Treatment of posterior malleolar (PM) ankle fractures remain controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the medium-to-long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation. A retrospective cohort study of patients aged 18–55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013 with PM ankle fractures was performed. Inclusion criteria were that all patients must mobilise independently pre-trauma, have no pre-existing ankle pathologies, and had satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale, visual analogue scale (VAS) and patient satisfaction ratings. Osteoarthrosis was assessed using modified Kellgren-Lawrence scale on updated weightbearing ankle radiographs. 61 participants were included. Mean follow-up was 10.26 years. Average PM size was 16.19±7.39%. All participants were evaluated for clinical outcomes, demonstrating good functional outcomes (FAAM-ADL 95.48±7.13; FAAM-Sports 86.39±15.52) and patient satisfaction (86.16±14.42%), with minimal pain (VAS 1.13±1.65). Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthrosis in 36/52 (69.23%), mild osteoarthrosis in 14/52 (26.92%) and moderate osteoarthrosis in 2/52 (3.85%). Clinical outcomes were not associated with PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off and dislocation were associated with worse radiographical osteoarthrosis. Other published medium-to-long term studies reported overall good outcomes, with no differences after small fragment fixation. The unfixated smaller posterior malleolus fragment demonstrated overall satisfactory clinical and radiographical outcomes at 10-year follow-up and may be considered a valid treatment strategy

The use of patient reported outcome measures (PROMs) of function is increasing in popularity. Self reported outcome instruments are used to measure change in health status over time allowing for the collection of accurate and relevant data on the quality of healthcare services. With recent changes outlined by the government, it will become increasingly important for surgeons to be able to demonstrate, with quantitative data, positive benefit of the surgery they perform. This study demonstrates the effectiveness of, and issues involved with setting up a PROMs database in a busy orthopaedic unit. We have previously shown that a high proportion of our orthopaedic patients have access to the Internet. Suitable patients were identified at foot and ankle clinics or from surgical lists, and the well validated Foot and Ankle Ability Measure (FAAM) regional scoring system was used. The FAAM is a self-reported, region specific, instrument consisting of 21-item activities of daily living (ADL) subscale and an eight-item sports subscale. This was completed pre-operatively and also online at six-months post operatively, using limesurvey, a free online survey with internet/email based responses. The software was simple to use and took about 4 hours to develop. 77% of the patient cohort for the period of study had email access and the majority of patients without email were happy to have the questionnaire completed over the phone. This took approximately ten minutes per survey. Patients who did not conduct the study prior to their admission were able to fill it in on the ward using a laptop. This project has demonstrated that the initiation and continuation of a PROMs data collection system is feasible in a busy orthopaedic unit, producing reliable data which will enable us to monitor and improve standards of clinical practice. We discuss the issues involved with its introduction and usage

Background. Many scoring systems exist that assess ankle function, none of them are validated for use in a group of higher demand patients. This group of patients there have potential problems with ceiling effects, not being able to detect change or that a sports-subscale is not included. This study was to create a validated self-administered scoring system for ankle injuries in athletes by studying existing scoring systems and key-informant interviews. Methods. The Sports Athlete Foot and Ankle Score (SAFAS) was developed from interviews with athletes as well as expert-opinions. Initially 26 patients were interviewed before creating the scoring system, this was modified from the Foot and Ankle Outcome Score, this had been partially validated previously and the subjects regarded the content as relevant but incomplete. Secondly, SAFAS the content was validated in a group of 25 patients with a range of injuries and 14 athletes without ankle injury. It is a self-administered region specific sports foot and ankle score that containing four subscales assessing the levels of symptoms, pain, daily living and sports. Results. Spearman correlation coefficients between SAFAS and the Foot and Ankle Ability Measure (FAAM) are 0.88 for activities of daily living and 0.78 for sports. Content validity gave high satisfaction at 75%. There was good internal consistency of each subscale; symptoms 0.77, pain 0.92, daily living 0.92 and sports 0.88. SAFAS has shown to be able to differentiate between injured and non-injured athletes. Conclusion. SAFAS is a measurement a suitable tool to assess differences in ankle function and disability between injured and non-injured athletes. It is valid to be used as a score in those clinical conditions which affect the high levels of ankle and hind foot function

Purpose. Identifying optimal treatment strategies for inpatients with traumatic foot and ankle injuries has been hampered by a wide variety of outcome measures with unproven reliability and validity. It remains plausible that the choice of functional outcome measures may influence measurement of treatment effects. This prospective observational study aims to measure the correlation and agreement across six functional outcome measures in patients with traumatic foot and ankle injuries. Methods. Patients 18 years of age or older with a traumatic foot or ankle injury completed the Short Form-12 (SF-12), Short Musculoskeletal Functional Assessment (SMFA), Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS) Foot and Ankle Questionnaire and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale at a single follow-up visit. Raw scores were calculated and transformed to a functional level of excellent, very good, good, fair or poor. Pearson correlation co-efficients providing measures of correlation and agreement between functional levels were assessed. Results. Fifty-two patients were enrolled at a mean follow-up of 15.5 months. Moderate to strong correlations were found for most pair-wise comparisons of raw scores and functional levels (?=0.43-0.92, p< 0.002). The strongest correlations were found between the SMFA, FFI, FAAM and AAOS Foot and Ankle Questionnaire. Despite significant correlation between scores, considerable disagreement between functional levels was observed. None of the 52 subjects attained the same functional level on all 6 outcome measures. Conclusion. High correlations between scores and functional level suggest it is unnecessary to use more than one outcome measure when examining functional outcome in patients with foot and ankle trauma. However, inconsistencies between functional levels attained with the different instruments suggest a need for further validation and scrutiny