Background. Supination-external rotation (SER) injuries make up 80% of all ankle fractures. SER stage 2 injuries (AITFL and Weber B) are considered stable. SER stage 3 injury includes disruption of the posterior malleolus (or PITFL). In SER stage 4 there is either medial malleolus fracture or deltoid injury too. SER 4 injuries have been considered unstable, requiring surgery. The deltoid ligament is a key component of ankle stability, but clinical tests to assess deltoid injury have low specificity. This study specifically investigates the role of the components of the deep deltoid ligament in SER ankle fractures. Aim. To investigate the effect of deep deltoid ligament injury on SER ankle fracture stability. Methods. Four matched pairs (8 specimens) were tested using a standardised protocol. Specimens were sequentially tested for stability when axially loaded with a custom rig with up to 750N. Specimens were tested with: ankle intact; lateral injury (AITFL and Weber B); additional posterior injury (PITFL); additional anterior deep deltoid; additional posterior deep deltoid; lateral side ORIF. Clinical photographs and radiographs were recorded. In addition, dynamic stress radiographs were performed after sectioning the deep deltoid and then after fracture fixation to assess tilt of the talus in eversion. Results. All specimens with an intact posterior deep deltoid ligament were stable when loaded and showed no talar tilt on dynamic assessment. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Surgical stabilisation of the lateral side prevented talar shift but not talar tilt. Conclusion. If the posterior deep deltoid ligament is intact SER fractures may be managed without surgery in a plantigrade cast. Without immobilisation the talus may tilt, risking deltoid incompetence

Introduction. Deltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury. Aim. Our objective was to establish if there was a difference in pes planus deformity in patients who underwent DLR during their ankle fracture fixation compared to those who did not. Methods. A retrospective analysis of post-operative weight bearing radiographs was performed of patients who underwent ankle fracture fixation. Inclusion criteria were confirmed deltoid instability presurgery without medial malleolar fracture and post operative weightbearing radiographs at least 6 weeks post-fixation. Patients were categorised into no deltoid ligament reconstruction (nDLR) and having DLR. Radiographic pes planus parameters involved Meary's Angle assessment. Other fracture morphology was classified. Results. A total 723 ankle fractures were screened. 122 patients were included for further analysis. There were 94 patients in the nDLR group and 28 patients in DLR group. The mean Meary's Angle was 15.81 (95% CI 14.06, 17.56) degrees in the nDLR group and −.2 (95% CI −3.86, 3.82) in the DLR group. This was statistically significant (p<.001). There was no significant difference in medial clear space measurements (2.90mm v 3.19mm, p = 0.145). There were significantly more pes planus patients in the nDLR than the DLR group (p<.001, 90.5% vs 25%). Conclusion. In this study there was significantly greater pes planus parameters in patients not undergoing DLR. Patients undergoing DLR had on average normal parameters, whilst those not undergoing DLR had on average severe pes planus. The benefits of DLR are not only maintaining ankle stability but maintaining medial arch integrity, and this should be taken into account in a future study on DLR

Deltoid ligament insufficiency has been shown to decrease tibiotalar contact area and increase peak pressures within the lateral ankle mortise. Sectioning of the deltoid ligament has been shown to decrease tibiotalar contact area by 43%. This detrimental effect may create an arthritic ankle joint if left unresolved. Reconstructive efforts thus far have been less than satisfactory. Pankovich and Shivaram described the deltoid ligament as having superficial and deep components based on insertion sites. The superficial layer originates from the anterior colliculus of the medial malleolus and inserts on the navicular, calcaneus and talus. The deep layer originates from the intercollicular groove and posterior colliculus and inserts on the talus. Boss and Hintermann noted that the most consistent and strongest bands of the deltoid were the tibiocalcaneal and posterior deep tibiotalar ligaments. Chronic deltoid ligament insufficiency may be seen in several disorders including trauma and sports injuries, posterior tibial tendon disorders, prior triple arthrodesis with valgus malunion, or total ankle arthroplasty with improper component positioning or pre-existing ligament laxity. The reconstruction of the deltoid ligament in these settings may be critical to the prevention of tibiotalar arthrosis or failure of ankle prostheses from edge loading and polyethylene wear. The reconstructive technique we describe, under low torque, was able to restore eversion and external rotation stability to the talus, which was statistically similar to the native deltoid ligament. In addition, though we maximally tension this graft to give the most secure repair possible, we did not note any increased stiffness in the ankle joint through our measurement techniques. This unusual, positive secondary effect is different from that noted in studies of lateral ligament reconstruction, where ligament tensioning by all methods attempts to reproduce the native tension and not exceed it. All medial ankle ligament repairs of substance involve some type of tendon-weave (whether autograft or allograft) to achieve reconstruction. Our technique develops its strength not only from the anatomic orientation of the reconstructed ligament, but the strength of the components chosen to fix the tendon graft to the bone. The use of Endobuttons allows the entire graft to sit within the tunnels, without the potential violation of the graft ends achieved through techniques utilizing interference screw fixation. Tensioning the graft proximally through the tibia against a rigid distal construct allows greater tension to be placed on the graft at the deltoid ligament site itself than techniques which employ distal tensioning while holding the ankle into inversion. Finally, the use of a looped graft proximally secured with a post that may be moved even further proximally at the surgeon's discretion creates superior tension to achieve medial column rigidity in grossly unstable situations. Thus, given the critical importance of the deltoid ligament and the relative paucity of repair/reconstruction options available, we believe this novel approach will assist the clinician in anatomically reconstructing this challenging condition. Deltoid ligament reconstruction technique using semitendinosis allograft, with superimposed line drawing demonstrating orientation of looped graft

Determination of ankle stability is straightforward when the injury involves both the medial and lateral malleolus. However it can be challenging when the medial injury involves the deltoid ligament. Radiographic diagnosis of ankle instability highly depends on the measurement of medial clear space. As the shape of talus has been postulated akin to a trapezoid, the medial clear space may be influenced by the portion of talus occupying the mortise. Hence the medial clear space may be influenced by the position of the ankle. We sought to evaluate the impact of ankle plantarflexion and division of the deltoid ligament on the medial clear space. For the study 10 fresh-frozen cadaveric lower limbs were used. Mortise radiographs were taken at neutral, 15 and 30 degrees of plantarflexion and neutral external rotation. These measurements were repeated after dividing the deltoid ligament. To ensure consistent ankle position, the ankle was placed in a specially constructed rig, which recreated the above positions. The medial clear space and talar tilt were measured. Differences in the means between the groups were determined with the paired ‘t’ test and ANOVA within the groups. Statistical significance was set a p-value of 0.05. Increasing the plantarflexion from neutral to 30 degrees in both groups resulted in increase in the medial clear space and talar tilt. The mean increase in medial clear space became statistically significant at 30 degrees when compared to neutral. Between the groups there was a significant difference in medial clear space at 30 degrees plantarflexion. Dividing the deltoid ligament also had a significant effect on talar tilt. Plantarflexion has an influence on the medial clear space in ankle mortise views therefore pre and post ankle fixation radiographs must be interpreted with caution

This study investigated athletes presenting with grade II syndesmosis injuries and identified the clinical and radiological factors important in differentiating a stable from dynamically unstable injury and those findings associated with a longer recovery and return to sport. Sixty-four athletes were prospectively assessed with an average follow-up of 37 months (range 24–66 months). Athletes with an isolated distal syndesmosis (+/− medial deltoid ligament) injury were included. Those athletes with a concomitant ankle fracture were excluded. Those considered stable (grade IIa) were treated conservatively with a boot and progressive rehabilitation. Those with clinical signs of instability underwent arthroscopy and if instability was confirmed (grade IIb) the syndesmosis was stabilized surgically. The clinical assessment of injury to individual ligaments of the ankle and syndesmosis were recorded along with MRI findings, complications and time to return to play. All athletes returned to the same level of professional sport – 28 with IIa injuries returned at a mean of 45 days whereas the 36 with grade IIb injuries returned to play at a mean of 64 days (p< 0.001). Clinical assessment of injury to the ligaments of the syndesmosis correlated well with MRI findings. Those with a positive squeeze test were 9.5 times as likely and those with a deltoid injury 11 times more likely to have an unstable syndesmosis confirmed arthroscopically. The combination of injury to the AITFL and deltoid ligament was associated with a delay in return to sport. Concomitant injury to the ATFL indicated a different mechanism of injury with the syndesmosis less likely to be unstable and was associated with an earlier return to sport. Clinical and MRI findings may differentiate stable from dynamically unstable grade II injuries and identify which athletes may benefit from early arthroscopic assessment and stabilization. It also suggests the timeframe for expected return to play

Aims

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Introduction. Postoperative pain following the 3 component ankle arthroplasty (AA) (Mobility™) is a recognised problem without any apparent cause. This study aimed to determine pattern of postoperative pain following Total Ankle Arthroplasty (TAA) and its management options. Materials and methods. In prospective observational study 167 patients who had (AA) and minimum follow-up of 24 months were included. FAOS ankle score, patients' satisfaction, SF36 and diagrammatic mapping of postoperative pain among other parameters were collected preoperatively and postoperatively at 3 months, 6 months and the annually. 20 Patients (12%) had moderate to severe postoperative ankle pain following the ankle arthroplasty. Results. Most of patients with mild pain and low AOFAS score during first year improved by the 2 year review. The pain was localised to the medial aspect of the ankle in 10 patients, lateral side in 8 patients, and both medial and lateral side in 1 patient and global in 1 patient with complex regional pain syndrome. 8 patients with medial or lateral pain needed a re-operation. 5 patients with medial pain were treated by complete release of deltoid ligament along with bony decompression of the medial compartment. None of the above implants were loose intra-operatively. 2 AA with lateral pain needed subtalar arthrodesis. 1 patient needed removal of metalwork from the calcaneum for relief of symptoms. A significant improvement of pain and AOFAS scores was observed in 3 out of the 5 patients who underwent medial compartment decompression and both patients who underwent subtalar arthrodesis. Conclusion. There are 10–13% of low AOFAS scores following Ankle Arthroplasty due to pain. In our series, the pain did not co-relate to implant loosening. Our treatment protocol of mapping of pain and re-do surgery could improve the long term outcome in a significant proportion of the patients

Aims

This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

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The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction.

Aims

The purpose of this study was to determine the functional outcome and implant survivorship of mobile-bearing total ankle arthroplasty (TAA) performed by a single surgeon.

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There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety.

Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:874–83.

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

Aims

Arthroscopically controlled fracture reduction in combination with percutaneous screw fixation may be an alternative approach to open surgery to treat talar neck fractures. The purpose of this study was thus to present preliminary results on arthroscopically reduced talar neck fractures.

Aims

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

Talonavicular and subtalar joint fusion through a medial incision (modified triple arthrodesis) has become an increasingly popular technique for treating symptomatic flatfoot deformity caused by posterior tibial tendon dysfunction.

The purpose of this study was to look at its clinical and radiological mid- to long-term outcomes, including the rates of recurrent flatfoot deformity, nonunion and avascular necrosis of the dome of the talus.

A total of 84 patients (96 feet) with a symptomatic rigid flatfoot deformity caused by posterior tibial tendon dysfunction were treated using a modified triple arthrodesis. The mean age of the patients was 66 years (35 to 85) and the mean follow-up was 4.7 years (1 to 8.3). Both clinical and radiological outcomes were analysed retrospectively.

In 86 of the 95 feet (90.5%) for which radiographs were available, there was no loss of correction at final follow-up. In all, 14 feet (14.7%) needed secondary surgery, six for nonunion, two for avascular necrosis, five for progression of the flatfoot deformity and tibiotalar arthritis and one because of symptomatic overcorrection. The mean American Orthopaedic Foot and Ankle Society Hindfoot score (AOFAS score) at final follow-up was 67 (between 16 and 100) and the mean visual analogue score for pain 2.4 points (between 0 and 10).

In conclusion, modified triple arthrodesis provides reliable correction of deformity and a good clinical outcome at mid- to long-term follow-up, with nonunion as the most frequent complication. Avascular necrosis of the talus is a rare but serious complication of this technique.

Cite this article: Bone Joint J 2015; 97-B:668–74.

Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations.

We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of > 4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10).

We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle.

We performed a retrospective review of a consecutive series of 178 Mobility total ankle replacements (TARs) performed by three surgeons between January 2004 and June 2009, and analysed radiological parameters and clinical outcomes in a subgroup of 129 patients. The mean follow-up was 4 years (2 to 6.3). A total of ten revision procedures (5.6%) were undertaken. The mean Ankle Osteoarthritis Scale (AOS) pain score was 17 (0 to 88) and 86% of patients were clinically improved at follow-up. However, 18 patients (18 TARs, 14%) had a poor outcome with an AOS pain score of > 30. A worse outcome was associated with a pre-operative diagnosis of post-traumatic degenerative arthritis. However, no pre- or post-operative radiological parameters were significantly associated with a poor outcome. Of the patients with persistent pain, eight had predominantly medial-sided pain. Thirty TARs (29%) had a radiolucency in at least one zone.

The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. However, there is a significant incidence of persistent pain, particularly on the medial side, for which we were unable to establish a cause.

Cite this article: Bone Joint J 2013;95-B:1366–71.

Large osteochondral lesions (OCLs) of the shoulder of the talus cannot always be treated by traditional osteochondral autograft techniques because of their size, articular geometry and loss of an articular buttress. We hypothesised that they could be treated by transplantation of a vascularised corticoperiosteal graft from the ipsilateral medial femoral condyle.

Between 2004 and 2011, we carried out a prospective study of a consecutive series of 14 patients (five women, nine men; mean age 34.8 years, 20 to 54) who were treated for an OCL with a vascularised bone graft. Clinical outcome was assessed using a visual analogue scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score. Radiological follow-up used plain radiographs and CT scans to assess graft incorporation and joint deterioration.

At a mean follow-up of 4.1 years (2 to 7), the mean VAS for pain had decreased from 5.8 (5 to 8) to 1.8 (0 to 4) (p = 0.001) and the mean AOFAS hindfoot score had increased from 65 (41 to 70) to 81 (54 to 92) (p = 0.003). Radiologically, the talar contour had been successfully reconstructed with stable incorporation of the vascularised corticoperiosteal graft in all patients. Joint degeneration was only seen in one ankle.

Treatment of a large OCL of the shoulder of the talus with a vascularised corticoperiosteal graft taken from the medial condyle of the femur was found to be a safe, reliable method of restoring the contour of the talus in the early to mid-term.

Cite this article: Bone Joint J 2015;97-B:1242–9.