Aims. The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant. Methods. This is a single-centre retrospective review of patients who underwent primary total ankle arthroplasty (TAA) with a Vantage implant between November 2017 and February 2020, with a minimum of two years’ follow-up. Four surgeons contributed patients. The primary outcome was reoperation and revision rate of the Vantage implant at two years. Secondary outcomes included radiological alignment, peri-implant complications, and pre- and postoperative patient-reported outcomes. Results. There were 168 patients (171 ankles) included with a mean follow-up of 2.81 years (2 to 4.6) and mean age of 63.0 years (SD 9.4). Of the ten ankles with implant failure (5.8%), six had loosening of the tibial component. In the remaining four failed implants, one was due to periprosthetic joint infection (PJI), one was due to loosening of the talar component, and two were due to loosening of both the tibial and talar components. Seven patients underwent reoperation: irrigation and debridement for superficial infection (n = 4); bone grafting for cysts (n = 2); and open reduction internal fixation (n = 1). Asymptomatic peri-implant lucency/subsidence occurred in 20.1% of ankles, with the majority involving the tibial component (n = 25). There were statistically significant improvements in PROMs in all domains. Conclusion. Short-term results of this implant demonstrate early survival comparable to the reported survivorship of similar low-profile, non-stemmed implants. Radiological lucency occurred more commonly at the tibial component, and revisions occurred primarily due to loosening of the tibial component. Further research is needed to evaluate longer-term survivorship. Cite this article: Bone Joint J 2023;105-B(10):1099–1107

Aim. Surgical options for management of a failed ankle arthroplasty are currently limited; typically conversion to fusion is recommended with only a few patients being considered for revision replacement surgery. This paper presents our experience of revision ankle replacements in a cohort of patients with failed primary replacements. Method. A total of 18 revision TAR in 17 patients were performed in patients with aseptic loosening. The technique was performed by a single surgeon (CSK) over a 4 year period between July 2014 and August 2018 using the Inbone total ankle replacement system. Patient demographics and clinical outcomes were collected retrospectively using - MOXFQ, EQ5D, VAS pain score and patient satisfaction questionnaires. Results. 12 right and 6 left ankle replacements were revised in 17 patients (11 male/ 6 female). The mean age at revision was 69.1 years (range 56–81 years) with a mean BMI of 31. The mean surgical time was 171 minutes with 22% of cases requiring bone grafting. 6 patients had early wound complications, all superficial and settled with dressings. There were no deep infections, 2 patients had further surgery for exploration for possible nerve injuries. At a mean follow up of 20.6 months, 4 patients had mild/moderate ongoing pain with the majority of patients being satisfied with the outcome of their surgery. Conclusion. This study represents one of the largest group of patients reported to have undergone revision total ankle arthroplasty. Our experience shows that this results in acceptable level of complications and provides satisfactory function in most patients. We feel revision TAR is a viable option in patients with failed primary arthroplasty who wish to continue to maintain mobility at the ankle joint

Objective. To evaluate early mobilization with the ‘STRONG regime’ is safe after lateral ankle ligament repair with suture tape augmentation. Background. The ESSKA-AFAS ankle instability group presented in 2016 evidence-based guidelines for rehabilitation and return to activity after lateral ankle ligament repair. Early mobilization is considered an important element of postoperative rehabilitation. Patients have to be immobilized for approximately six weeks to protect the delicate repair. Lateral ankle ligament repair with suture tape augmentation results in greater strength compared with standard repairs and early mobilization proved to be successful in small sample size studies. Augmented surgery technique is getting increasingly popular. However, it is unknown which rehabilitation regimes are used. It is essential to establish a clear evidence-based guideline for rehabilitation after surgery. Methods. A systematic literature search was performed to obtain the best evidence research regarding this surgery. In cooperation between the orthopaedic- and physical therapy department a post-operative rehabilitation protocol with early mobilization was established. This STRONG protocol (figure 1) is based on milestones and three stages. Results. In February 2016 the first patients were selected for the early mobilization regime. In total 102 patients with a lateral ankle ligament repair were treated with the STRONG protocol. No re-ruptures were observed with a follow up of a year. In a subgroup of athletes hop tests showed a symmetry index of 100,5% for triple hop, 98,6 for side hop and 103,6 for figure of 8 hop. First return to sport was achieved between 9–12 weeks, with full return to competition after a mean of 4 months. Conclusions. An early postoperative mobilization regime based on supervised exercises seems to be a safe intervention after a lateral ankle ligament reconstruction. Clinical implications. Augmented ankle ligament surgery with early mobilization could be an important advancement in treating patients with chronic ankle injuries. For any figures or tables, please contact authors directly

Revision options for a failed Total ankle arthroplasty (TAA) have historically been limited to complex hindfoot fusions, bespoke ankle arthroplasty revision or amputation. The patient outcomes of these procedures has been felt to be poor. The introduction of the INBONE-II and INVISION ankle arthroplasty revision systems has created a range of revision arthroplasty options, with the possibility of improved patient outcomes. We aim to report on the early results of 20 sequential revision TAA. All patients undergoing revision TAA with INBONE-II or INVISION had prospective collection of pre-operative and post-operative MOx-FQ and EQ-5D scores. Between September 2013 and June 2019 23 patients underwent revision TAA with mean time from implantation of 35 months (6 to 74). Those with greater than 1 year follow-up had scores included. Other outcomes included radiographic assessment for loosening and revision. 13 patients had INBONE-II and 10 INVISION. None required revision at the time of review. Pre-operative MOx-FQ averaged 40.6 (13.4 pain, 21 walking, 6.2 social). Post-operative MOx-FQ averaged 17.4 (6.2 pain, 8.1 walking, 3.1 social). Average EQ-5D improved from 8 to 6.6 and average EQ-VAS from 60 to 80. On radiograph review one patient had radiolucent lines around their INBONE-II stem evident at 1 year. This had not progressed by 4 years total follow-up. Another patient had uncoupling of part of the stem of her INBONE-II but had not required revision. This was attributed to surgeon error. Revision TAA using the INBONE-II and INVISION systems shows promising early results relating to loosening and revision and good maintained improvement in MOx-FQ and EQ-5D scores. This provides further evidence that patients with a failed TAA can safely have revision rather than having to commit to complex ankle/hindfoot fusion. This provides surgeons with flexibility particularly in those patients with other hindfoot arthritis or arthrodesis

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. Methods. Patients were recruited from 11 specialist centres between June 2016 and November 2019. Demographic, radiological, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Questionnaire, and EuroQol five-dimension five-level score) were collected preoperatively, at six months, one year, and two years. The Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system was used to stratify deformity. Early and late complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts, and/or subsidence. Results. In all, 500 patients reached six-month follow-up, 420 reached one-year follow-up, and 188 reached two-year follow-up. The mean age was 67.8 years (23.9 to 88.5). A total of 38 patients (7.5%) presented with inflammatory arthritis. A total of 101 (20.0%) of implantations used patient-specific instrumentation; 167 patients (33.1%) underwent an additional procedure at the time of surgery. A total of seven patients died of unrelated causes, two withdrew, and one was lost to follow-up. The mean follow-up was 16.2 months (6 to 36). There was a significant improvement from baseline across all functional outcome scores at six months, one, and two years. There was no significant difference in outcomes with the use of patient-specific instrumentation, type of arthritis, or COFAS type. Five (1.0%) implants were revised. The overall complication rate was 8.8%. The non-revision reoperation rate was 1.4%. The 30-day readmission rate was 1.2% and the one-year mortality 0.74%. Conclusion. The early experience and complications reported in this study support the current use of the INFINITY TAA as a safe and effective implant in the treatment of end-stage ankle arthritis. Cite this article: Bone Joint J 2021;103-B(7):1270–1276

Aims. This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme. Methods. A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed. Results. Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported. Conclusion. The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe. Cite this article: Bone Joint J 2024;106-B(9):949–956

Background. Ankle fractures are extremely common but unfortunately, over 20% fail to obtain good to excellent recovery. For those requiring surgical fixation, usual-care post-surgery has included six-weeks cast immobilisation and non-weightbearing. Disuse atrophy and joint stiffness are detrimental sequelae of this management. While rehabilitation, starting at two-weeks post-surgery is viewed as safe, the literature contains methodological flaws and a lack of focus on early exercise, perpetuating the controversy over the effectiveness of early exercise interventions. Objectives. Our objectives were to determine if following operative fixation for Weber B fracture, the physiotherapy intervention, early motion and directed exercise (EMADE), applied in the clinical setting, were superior to Usual-care at 12-weeks (primary outcome) and 24-weeks. Design and Methods. We undertook a pragmatic-RCT, recruiting 157 surgically fixed Weber B ankle fracture patients, to establish if EMADE was superior to the Usual-care of 6-weeks immobilisation. The EMADE physiotherapy intervention (between week-2 and 4 post-surgery) utilised a removable cast and combined non-weightbearing progressive home exercises with manual therapy, advice and education. The primary outcome measure was the OMAS at 12-weeks. Results. 130 participants returned their 12-weeks post-surgery data, exceeding the 60/group threshold set by the a-priory power calculation. Group OMAS means were; 62.0 and 48.8 (SD 21, 22.5) EMADE, Usual-care respectively, yielding a clinically meaningful mean difference of 13.2 on the OMAS and a statistical difference (95% CI p< 0.001, 5.66 to 20.73). Both clinically meaningful and statistically significant findings were maintained at week-24. There were no intervention related or unexpected adverse events, including instability. Conclusions. This clinic set pragmatic-RCT yielded both clinical and statistical outcomes at week-12 in favour of the EMADE physiotherapy intervention over the Usual-care of 6-weeks immobilisation, in surgically fixed Weber B ankle fracture patients. These positive findings were maintained at week-24 and justify EMADE physiotherapy as a viable treatment option

Introduction

Hindfoot intramedullary nail fixation (HFN) or fibula pro-tibial screw fixation (PTS) are surgical options for ankle fractures in patients with multiple co-morbidities; we compared their outcomes.

The Zenith. TM. total ankle replacement (Corin, Cirencester) is a mobile-bearing implant based on the Buechal Pappas design. Key features are the simple fully-jigged instrumentation aiming to improve accuracy and reproducibility of implant positioning, cementless calcium phosphate coated surfaces for improved early osseointegration, and titanium nitride-coated bearing surfaces to resist wear. We present early to mid-term survival data for 155 total ankle replacements implanted by three surgeons in our institute. Case records of all patients undergoing Zenith. TM. Total Ankle Replacement by three senior surgeons, including a member of the design team, between 2007 and 2014 were examined. Patients were examined clinically and radiographically annually after the early postoperative period. The primary outcome measure was implant survival. Secondary outcome measures included complication rates, parameters of radiographic alignment, and radiographic evidence of cysts and loosening. One hundred and fifty-five cases were performed for a mixture of primary pathologies, predominantly primary or posttraumatic arthrosis. Mean follow-up was 50 months. Implant survival was 99.0% at 3 years (n=103), 94.0% at 5 years (n=50), and 93.8% at 7 years (n=16). One patient was revised to arthrodesis for aseptic loosening, one arthrodesis was performed for periprosthetic infection with loosening, and one below-knee amputation was performed for chronic pain. Three cases underwent further surgery to address cysts, and 7 malleolar fractures were reported. Medial gutter pain was experienced by 9% of patients. Overall, our data show excellent early and mid-term survivorship for the Zenith. TM. Total Ankle Replacement. Simple fully-jigged instrumentation allows accurate and reproducible implant alignment

Introduction:. We present the early results of 220 Rebalance Total Ankle Replacements performed in 6 centres in 4 different countries. Methods:. The Rebalance Total Ankle Replacement is a new 3 component uncemented mobile bearing prosthesis with a surface coating of ‘bonemaster’ and an ‘e’ poly bearing. The prosthesis was released in a limited way in May 2011. Since then 220 replacements have been implanted in 218 patients in 6 centres in 4 different countries (UK, Sweden, Canada, Czech Republic). All the x-rays and case notes were reviewed.63 prostheses have a minimum follow up of 2 years. Outcome measures included revision of the prosthesis, and the incidence of progressive and non-progesssive radiolucent lines around the prosthesis. Results:. 7 patients underwent revision or are awaiting revision of their prosthesis. Reasons for revision included loosening(2), infection(1), malposition(2), periprosthetic fracture(1), impingement(1). 9 patients had non-progressive radiolucent lines and 2 patients had progressive radiolucent lines. 1 patient with progressive radiolucent lines is waiting revision for suspected infection. 8 patients suffered fractures to the lateral malleolus and 4 to the medial malleolus. There were no cases of balloon osteolysis. 29 patients had pre-op AOFAS scores= 41(12–67). 21 had 1 year post-op AOFAS scores= 73.5(26–100). 12 had 2 year AOFAS scores= 75.5(50–100). Conclusion:. The early results are encouraging and we believe support its wider use

Introduction:. Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritic complaints of the ankle. Glazebrook et al proposed a three grade classification of complications to assist prediction of early implant failure. We have compared the experience of a tertiary referral centre in the UK to Glazebrook's proposed system. Method:. A retrospective review of the Sheffield Foot and Ankle Unit TAR database was performed from 1995 to 2010. All complications were recorded and categorised using Glazebrook's proposed system. Glazebrook described eight main complications of increasing severity. Low grade complications; Post operative bone fracture, Intra-operative bone fracture and wound healing problems were very unlikely to lead to revision. Medium grade complications; technical error and subsidence, lead to failure < 50% of the time. High grade complications; deep infection, aseptic loosening and implant failure lead to revision > 50% of the time. Results:. 217 TAR were implanted in 198 patients with a minimum follow up of 30 months. The complication rate was 23% with a revision rate of 17%. All complications recorded in our study except intraoperative bone fracture and wound healing had a failure rate of at least 50%. Conclusion:. The proposed classification system of Glazebrook et al was the first step towards an international system of classifying TAR complications. Most complications associated with TAR have a significant impact on the lifespan of a TAR. Glazebrook et al's proposed three tier system did not reliably reflect our experience. We would categorise complications as either high or low risk for early failure of TAR

Minimally Invasive foot surgery remains controversial. Potential benefits include a reduced incidence of wound complications, faster return to employment and normal footwear. There are no studies published regarding the results of minimally invasive dorsal cheilectomy. Patients and Methods. Thirty eight patients with painful grade I hallux rigidus underwent dorsal cheilectomy between April 2006 and June 2010. Minimally invasive cheilectomy (MIC) was introduced in August 2009. AOFAS scores, satisfaction, return to normal shoes and employment were assessed. Results. Twenty two patients had open cheilectomy (OC) whilst 16 had MIC. Mean follow-up was 6 months for the MIC group and 35 months for the OC group. Mean AOFAS score was 75/100 (SD 17) in the MIC group and 70/100 (SD 18). Patients rated their satisfaction as 9.1/10 for MIC and 8.6/10 for OC. There was no significant difference in time to return to normal shoes (P = 0.32) or employment (P = 0.07). Two patients (one MIS, one OC) had a superficial wound infection which resolved with oral antibiotics. One patient had a first metatarsophalangeal joint fusion in the MIS group. Two patients in the OC group went on to have a first metatarsophalangeal joint fusion and one underwent joint resurfacing. Discussion. These results suggest MIC has comparable early results to OC. Larger studies are required to further establish the benefits of MIC. Conclusion. Minimally invasive dorsal cheilectomy seems to offer a safe alternative to open cheilectomy with promising early results. Patient satisfaction with this procedure is very high

Introduction. The Mobility™ prosthesis [Depuy] is the most extensively used TAR in the UK, though there are few published results. We present our complete experience of the Mobility prosthesis in a diverse population. Methods. From March 2005 to December 2009, 84 consecutive Mobility ankle replacements were performed by the senior author, in 79 patients (28 female, 51 male) with mean age 64.5 years (43–80). This complete cohort included the first and last cases with this implant. Mean follow-up was 50.1±18.2 months (range 14–86). Patients with ankle replacements in situ, were reviewed clinically and radiologically. Clinical outcome measures were: AOFAS score, MOXFQ (adapted for the ankle), and VAS for pain. Post-operative radiographs were reviewed to assess component position and examine for zones of lucency. Results. At final review, 1 patient had died (unrelated), 13 had been revised as follows: . Arthrodesis 7. Further TAR 2. Talus only revised 1. Tibia only revised 1. Amputation 2 (one for an unrelated problem). Exchange of bearing had been carried out in 4. Intra-operative malleolar fractures occurred in 4.8% and were internally fixed. 62 patients attended for clinical review and 8 completed postal questionnaires. At follow up:. Mean AOFAS hindfoot score was 72.4±17.5 (0–100). Mean MOXFQ scores were:. Walking/Standing 40.8±28.4. Pain 31.6±20.8. Social 23.1±23.0. Mean VAS 2.7±2.3. Survival of the implant was:. 91.7 (CI 83.4–96.0) at 2 years. 89.2 (CI 80.2–94.2) at 3 years. 84.1 (CI 73.4–90.8) at 4 years. 84.1 (CI 73.4–90.8) at 5 years. 78.9 (CI 62.6–88.7) at 6 years. Conclusion. This study is a complete review and our failure rate is comparable to other publications. Early failures included some poor case selections with large pre-operative deformity and reflects the initial period of the learning curve of TAR. Longer term follow up is needed to evaluate for ongoing failures and monitor progressive radiolucency

Introduction. Peri prosthetic fracture is a recognised complication following Total ankle arthroplasty (TAA). There is limited literature on post operative management following TAA and controversies exist based on surgeon preferences. This project reports the incidence of peri- prosthetic fractures in patients managed with 2 different post-operative protocols. Materials and Methods. Patients undergoing primary TAA with a diagnosis of Osteoarthritis (OA) or Post-traumatic Osteoarthritis (PTOA) were recruited into a randomized controlled trial. These patients did not require any additional procedures. Patients were consented for the trial and randomized to one of two treatment groups (Early mobilisation after surgery vs. immobilisation in a plaster cast for 6 weeks post operatively). Plaster group patients underwent a graduated physiotherapy program from 6-12 weeks and early mobilisation group patients from 1-12 weeks. Complications any were recorded at 2, 4, 6 and 12 weeks post-operatively. Results. A total of 16 ankle replacements were done for a diagnosis of OA (10) and PTOA (6). Mean age was 58 years (±11.75) for the plaster group and 64 years (± 9.32) for the early mobilisation group. 7 patients were randomized to the plaster group and 9 patients were randomized to the early mobilisation group. Of the plaster group 1 patient sustained an intra-operative fracture tibia and 2 patients reported with a fractured medial malleolus. Of the early mobilisation group, 1 patient reported with a peri prosthetic fracture tibia at 6 weeks and 3 patients reported a fractured medial malleolus at 3 months follow up. The percentage of fracture incidence between plaster versus early immobilisation group was 42.8% and 44.4 % respectively. Conclusions. These early results demonstrate no significant differences in the incidence of fracture rates between groups. Further studies of post-operative management are needed to study the correlation with peri-prosthetic fracture rates after TAA

Introduction. The dichotomy between surgical repair and conservative management of acute Achilles tendon ruptures has been eliminated through appropriate functional management. The orthoses used within functional management however, remains variable. Functional treatment works on the premise that the ankle/hindfoot is positioned in sufficient equinus to allow for early weight-bearing on a ‘shortened’ Achilles tendon. Our aim in this study was to test if 2 common walking orthoses achieved a satisfactory equinus position of the hindfoot. Methods. 10 sequentially treated patients with 11 Achilles tendon injuries were assigned either a fixed angle walking boot with wedges (FAWW) or an adjustable external equinus corrected vacuum brace system (EEB). Weight bearing lateral radiographs were obtained in plaster and the orthosis, which were subsequently analysed using a Carestream PACS system. The Mann-Whitney test was used to compare means. Results. Initial radiographs of all patients in cast immobilization showed a mean tibio-talar angle (TTA) of 55.67° (SD1.21) and a mean 1. st. metatarsal-tibia angle (1MTA) of 73.83° (SD9.45). There were 6 Achilles tendons treated in the FAWW. Their measurements showed a mean TTA of 27.67°(SD7.71) and 1MTA 37.00 (5.22). 5 tendons were treated using an EEB; there was a statistically significant (p< .05) increase in both the TTA 47.6° (SD5.90) and 1MTA 53.67 (SD5.77) compared to the FAWW group. Discussion. Plantar-flexion at the ankle was significantly greater in the EEB comparative to the FAWW, and very similar to the initial equinus cast. The use of wedges produced an equinus appearance through the midfoot, without producing equinus in the hindfoot as the heel pad rests on the top wedge. We express caution in the use of wedges for Achilles treatment as they do not shorten the Achilles tendon and may result in a lengthened tendon and reduced plantar-flexion power in the long-term

Introduction:. Cone Based CT (CBCT) scanning uses a point source and a planar detector with parallel data acquisition and volumetric coverage of the area of interest. The pedCAT (Curvebeam USA) scanner is marketed as a low radiation dose, compact, faster and inexpensive CT scanner that can be used to obtain both non- weightbearing and true 3 dimensional weightbearing views. Method:. A review of the first 100 CBCT scanning in our unit has been performed to assess ease of scanning, imaging time, radiation dose and value of imaging as opposed to conventional imaging. Results:. A pedcat CT scan was available within minutes of the request, similar to plain radiographs but much earlier than a 6 week delay for a patient to attend a new appointment for a conventional CT. All patients returned to see the clinician for a clinical decision in the same NHS clinic and did not require a new clinic visit; illustrative cases include fracture/subluxation detection, surgical planning, extent of arthritis and 3D assessment of union of arthrodeses. All patients were able to transfer to the scanner with ease and the imaging time was 10 times than a conventional CT. The radiation dose to the patients was 9% that of a full gantry system. Weightbearing CT scanning enabled a 3D evaluation of reduction of joint space and ankle/hindfoot alignment. Anterior ankle and sesamoid impingement have been diagnosed in patients with previously obscure pain. Conclusion:. 3D Cone Beam imaging has been found to be easily accessible, rapidly performed and safer to the patient in providing a lower radiation dose. Weightbearing 3D imaging provides additional diagnostic information

Introduction. Total ankle replacement (TAR) surgery remains a reasonable alternative to arthrodesis in a select group of patients with end stage ankle joint arthritis. We describe the early results of a prospective study of the first 50 Zenith total ankle replacements performed by a single surgeon (SKG). Methods. Demographic details, Visual Analogue Score (VAS) for pain (0, no pain; 10, worst possible pain), AOFAS scores, ‘would have surgery again’ and satisfaction levels were collated, pre-operatively and at their most recent outpatient review. Any post-operative complications were noted. Radiographs were also assessed for evidence of loosening, progressive osteolysis, subsidence and overall alignment of the implant. Results. One patient died at 25 months following surgery from unrelated causes. No patients have been lost to follow up. A review of 50 patients (35 males, 15 females; mean age 65 years, range 44–88 years) with a mean follow up of 30 months (range 11–48) included 48 patients with osteoarthritis and two patients with rheumatoid arthritis. There was one medial malleolar fracture at the time of surgery which required fixation and one fracture of the lateral malleolus which was picked up at the six week review. At their latest review the VAS and AOFAS score had improved significantly and 46 patients were satisfied and 4 patients unsatisfied with the outcome of surgery. One patient has cyst formation around the tibial component but is pain free with a stable implant and does not wish further intervention. The components were satisfactorily aligned in the vast majority of patients. Conclusion. This non-inventor series of the Zenith TAR has shown excellent results in the short term. We feel that the instrumentation allows for more reproducible cuts which appear to be technically easier than with some other designs. However, studies looking at long term results will be necessary

A delay in operative intervention for ankle fracture in the presence of blistering at the operative site is generally considered to reduce problems with soft tissue complications including infection. No evidence exists to show an increased rate of complications. Previous work has characterised two types of blisters clear- and blood-filled. It has been suggested that the presence of a blood-filled blister confers a higher risk of wound healing complications compared with a clear-filled blister. We present a series of patients who underwent surgery for ankle fracture, in the presence of blisters at the operative site, without any change to standard management of the fracture. We also present a review of the literature. We prospectively followed six patients who underwent early internal fixation (no delay in surgical intervention) of ankle fracture in the presence of blisters at the operative site. In many cases the surgical incisions were made through the blistered skin. No patients had any additional treatment for their blisters. All patients were treated with the same postoperative protocol. All six patients with both blister types went on to fracture union with no soft tissue complications and no cases of infection. This initial observational study supports the treatment of ankle fractures with early internal fixation in the presence of soft tissue blisters at the operative site. It is possible that the stabilisation of underlying skeleton results in better healing of the skin and other soft tissues which is a concept often employed in the management of open fractures. We plan to carry out further prospective work on a larger number of patients as part of a randomized trial to confirm this finding

The purpose of this study was to evaluate the early functional outcome of this new modification of the Brostrom-Gould lateral ligament reconstruction using suture anchors and triple breasting of ATFL. AOFAS hindfoot scoring system was the primary outcome measure used. Between January 2008 and May 2011, data was collected prospectively, pre and postoperatively. Surgery for all patients included ankle arthroscopy plus whatever other minor procedure was indicated and was performed by the senior author. Postoperatively at 3 months and 12 months and in May 2011 patients were asked to attend a research clinic and their scores were obtained. Anterior drawer laxity and patient satisfaction, activity resumption and complications were some of the other information recorded. A mean follow up of 25 months on 18 ankles is presented which is amongst the longest in the literature for this procedure. Comparing pre and postoperative AOFAS scores revealed a statistically significant mean improvement of 39 points p < 0.05 with mean preoperative score being 53 and at 25 months being 89. All ankles felt clinically stable on repeated anterior drawer testing. 8 patients had resumed normal pre-injury level of activities (including sports), 8 had some reduction in normal level of activity and 2 did not carry out physical prior to operation. One patient complained of scar tenderness otherwise no complications were noted. 13 patients were extremely satisfied with results of surgery, 4 were very satisfied and 1 was moderately satisfied. The mid-term results of our modification show it to be safe, reproducible and highly successful in producing clinically and functionally stable ankles with high patient satisfaction. This includes a statistically significant improvement in AOFAS scores. This exceeds the results in the published literature

Injury to the syndesmosis occurs in approximately 10% of all patients with ankle fractures. Anatomic restoration of the syndesmosis is the only significant predictor of functional outcome. Several techniques of syndesmosis fixation are currently used such as cortical screws, bioabsorbable screws and more recently introduced suture-button fixation. No single technique has been shown to be superior to the others. The objective of this research project is to investigate whether treatment with a tightrope (suture-button fixation) gives superior results than the use of a cortical screw in the treatment of acute syndesmotic ankle injuries with regards to function, pain, satisfaction and return to normal activities. Research Ethics Committee approval was obtained. 40 patients with syndesmotic ankle injuries associated with diastasis were prospectively recruited, 20 in each group. Patients were randomized to one of the 2 groups. At 12 weeks, American Orthopaedic Foot and Ankle Society (AOFAS) scores and a computerized tomography (CT) scan of both the ankles was obtained. At 1 year, AOFAS scores and satisfaction was assessed. 32 patients have been recruited so far, 20 in the tightrope group and 12 in the cortical screw group. Mean AOFAS scores at 3 months post-op were 90.67 in the Tightrope group and 84 in the screw group. The difference was not significant (p= 0.096). CT scans revealed that the quality of syndesmosis reduction was equally good with both the techniques. Metalwork prominence was common with both the devices. Discussion and Conclusion. Both the devices achieved good reduction of the syndesmosis. Our CT scan protocol has insignificant radiation risk and allows more accurate assessment of the syndesmosis. Early clinical results do not show a significant difference in the functional outcome with the use of either device. Long-term (1 year) follow-up has been planned