Tibial pilon fractures are typically the result of high-energy axial loads, with complex intra- articular fractures that are often difficult to reconstruct anatomically. Only nine simultaneous pilon and talus fractures have been published previously, but we hypothesised the chondral surface of the dome is affected more frequently. Data was acquired prospectively from 154 acute distal tibial pilon fractures (AO/OTA 43B/C) in adults. Radiographs, photographs, and intra-operative drawings of each case were utilised to document the presence of any macroscopic injuries of the talus. Detailed 1x1mm maps were created of the injuries in each case and transposed onto a statistical shape model of a talus; this enables the cumulative data to be analysed in Excel. Data was analysed using a Chi-squared test. From 154 cases, 104 were considered at risk and their talar domes were inspected; of these, macroscopic injuries were identified in 55 (52.4%). The prevalence of talar dome injury was greater with B-type fractures (53.5%) than C-type fractures (31.5%) (ρ = .01). Injuries were more common in men than women and presented with different distribution of injuries (ρ = .032). A significant difference in the distribution of injuries was also identified when comparing falls and motor vehicle accidents (ρ = .007). Concomitant injuries to the articular surface of the dome of the talus are relatively common, and this perhaps explains the discordance between the post-operative appearance following internal fixation and the clinical outcomes observed. These injuries were focused on the lateral third of the dome in men and MVAs, whereas women and fall mechanism were more evenly distributed. Surgeons who operatively manage high-energy pilon fractures should consider routine inspection of the talar dome to assess the possibility of associated macroscopic osteochondral injuries

This study investigated concurrent talar dome injuries associated with tibial pilon fractures, mapping their distribution across the proximal talar dome articular surface. It compared the two main mechanisms of injury (MOI), falling from a height and motor vehicle accident (MVA), and whether the fractures were open or closed. From a previously compiled database of acute distal tibial pilon fractures (AO/OTA 43B/C) in adults of 105 cases, 53 cases were identified with a concurrent injury to the talar dome with a known mechanism of injury and in 44 it was known if the fracture was open or closed. Case specific 2D injury maps were created using a 1x1mm grid, which were overlayed in an Excel document to allow for comparative analyses. A two-way ANOVA was conducted that examined the effect of both MOI and if the fracture was open or closed on what percentage of the talar dome surface was injured. There was a statistically-significant difference between the average percentage of injured squares on the talar dome by both whether the fracture was open or closed (f(1)=5.27, p= .027) and the mechanism of injury (f(1)=8.08, p= .007), though the interaction between these was not significant (p= .156). Open injuries and injuries that occurred during an MVA were more likely to increase the surface area of the talar dome injuries. We have identified both MOI and if the fracture was either open or closed impacts the size of the injury present on the talar dome. Future research will investigate the aetiology of the differences noted, highlighting the clinical implications. Surgeons treating tibial pilon fractures caused by either a MVA or an open fracture, should be aware of an increased risk of large injuries to the surface of the talar dome

Introduction. Pilon fractures are complex, high-energy, intra-articular fractures of the distal tibia. Achieving good outcomes is challenging due to fracture complexity and extensive soft tissue damage. The purpose of this study was to determine the long-term functional and clinical outcomes of definitive management with fine wire Ilizarov fixation for closed pilon fractures. Materials and Methods. 185 patients treated over a 14-year period (2004–2018) were included. All patients had Ilizarov frames applied to restore mechanical axis and fine wires to control periarticular fragments. CT scans were performed post operatively to confirm satisfactory restoration of the articular surface. All frames were dynamized prior to removal. Patients' functional outcome was assessed using the validated Chertsey Outcome Score for Trauma (“COST”). Review of clinical notes and imaging was used to determine complications and time to union. Results. The mean functional outcome in the studied cohort was determined to be “average” on the “COST” score. Poorer functional outcomes were associated with younger age at time of injury and multi-fragment fracture patterns. Mean time in frame was 170 days. Complication rates were low. There were no deep infections, no amputations and only 8 patients went on to have ankle fusions. Conclusions. Good functional results and low complication rates can be achieved by managing pilon fractures with fine wire Ilizarov fixation. Nonetheless, at time of injury patients should be counselled as to the severity of the injury and impact on their functional status

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

Pilon fractures are associated to significant soft tissue injury, as well as soft tissue complications. The soft tissue on the medial side of the distal tibia is often involved, likely due to a lack of muscle investment. Medial approaches and medial plate application may well add to the soft tissue trauma. The objective of this study was to examine the relationship between medial plating and soft tissue complications in our center. This is a retrospective study based on a prospective database. Pilon cases treated with plate and screw fixation were identified between 2011 and 2014. Injury characteristics, patient demographics, and soft tissue complications were collected from chart review. Soft tissue complications recorded included any wound or skin problem, as well as patient complaints of hardware irritation leading to hardware removal. Logistic regression was employed. Independent variables for the model included medial plating, the presence of open fracture, smoking status and diagnosis of diabetes. Two models were created, one with the dependent variable as presence of any soft tissue complication, and the second model with the dependent variable as presence of a wound complication, which required surgical intervention. The study included 91 patients, 89 of whom had full data with an average follow up of 11.6 months (1–33 months). The incidence of soft tissue complications, including hardware irritation, was 26% (n=23), and 13% (n=12) required surgical treatment. Smoking status was the only predictor of soft tissue complications with an odds ratio of 3.6 (95%CI 1.2, 10.4; p=0.02), while controlling for other independent variables. The model explained 12% of the variation in soft tissue complications (Cox and Snell 0.119, p=0.028). In the second model, presence of a medial plate predicted soft tissue complications requiring surgical intervention with an odds ratio of 8.8 (95%CI 1.1, 73.7; p=0.045), while controlling for the other independent variables. The model explained 10% of the variation in soft tissue complications requiring surgical intervention (Cox and Snell 0.095, p=0.035). The use of a medial plate does not appear to correlate to general soft tissue complications in pilon fractures. Smoking status increased the odds of a soft tissue complication more than three fold. The use of medial plating did increase the odds of soft tissue complications that required surgical treatment almost nine fold. It appears medial plating is not related to soft tissue complications, however treating soft tissue compilations in the presence of a medial plate may require more invasive methods

We describe a new surgical approach designed for use with minimally invasive fixation and a circular frame. Tibial pilon injuries are often associated with significant soft tissue injury, which may not be evident at the time of injury. In such cases standard surgical approaches can lead to problems with wound healing, thus increase the risk of deep infection. AO Type C valgus fractures are commonly associated with fibula fractures. We found that the anterior syndesmotic ligaments are often disrupted with sparing of the lateral soft tissue envelope. Our technique utilizes a direct lateral approach to expose the lateral malleolus/distal fibula, which is reflected postero-laterally through the fracture and intact posterior syndesmotic ligaments. This creates a direct view of posterolateral and anterolateral comminution and talar dome allowing direct fixation of fragments with minimal internal fixation. Fibula fixation is performed with a 1/3. rd. tubular plate and the anterior syndesmotic ligaments are repaired. From 2007–2009, we used this approach in 12 patients (Male 9: Female 3; age 19–42) with AO Type C3 fractures with significant soft tissue injury (open = 2/ closed = 10; Tscherne Grade 1 = 4; Grade 2 = 8). We used circular frame stabilization in all cases (in four patients an additional foot frame was applied to protect the articular surface). All fractures united in satisfactory alignment. Wound healed well in all cases. One case of gouty arthritis developed superficial infection, which went on to heal after wound wash out and oral antibiotic therapy. Follow-up (minimum 3 months and maximum 2 years) showed no ankle instability. Clinical evaluation revealed a mean dorsiflexion of 10° (5–15°) and mean plantar flexion of 35° (15–60°). We conclude that transfibular approach gives good exposure of lower tibial articular surface in selected cases of pilon fractures with least soft tissue disruption

Background. The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy. Methods. A cohort of 95 patients with AO type C tibial pilon fractures underwent primary ORIF. Of these patients, 21 had open fractures. Sixty-eight fractures were sustained in falls, 21 in motor vehicle collision, 5 in crushes and one in an aircraft crash. The principal outcome measure was wound dehiscence or infection requiring surgery. Radiological and functional outcomes were assessed at a mean of five years using the SF36 and the Foot and Ankle Outcome Score. Results. Primary ORIF was performed within 48 hours of admission in 98% cases. Reduction was anatomical in 90% cases. Six (6%) patients developed a wound infection or dehiscence that required surgical débridement, giving a wound complication rate of 4/21 (19%) for open fractures and 2/74 (2.7%) for closed fractures. Of the two closed fractures, one occurred in a patient with local scarring from previous trauma, insulin-dependent diabetes mellitus and chronic alcohol abuse, and the other in a patient with schizophrenia, diabetes and peripheral neuropathy. Radiographic follow-up revealed 74% patients had normal appearances or mild osteoarthritic degeneration only. Functional outcomes revealed a reduced level of general health and mild disability. Conclusions. Provided surgery is performed expeditiously by experienced orthopaedic trauma surgeons, AO type C pilon fractures can be stabilised safely and effectively by primary ORIF, with very low rates of wound complications, a high quality of reduction, and a good long term outcome. These results compare favourably with the published results for all other methods of treatment

Ankle osteomyelitis after open pilon-fractures remain one of the most challenging scenarios. Ankle-fusion using an external frame is a classical option but in some cases of non-compliance patients could be not ideal. The purpose of this report was to evaluate our results using a new staged salvage protocol in cases where an external-frame arthrodesis is not recommended due to the issue of a non-compliance patient. During the first stage we resect all the infected tissues and an antibiotic-loaded cement spacer is used to obliterate the dead space, to reach some kind of stability and to achieve a high concentration of local antibiotic. A free or keystone flap is used if needed and a posterior splint is placed. After a course of targeted systemic antibiotics the second stage is schedule. During the second stage after the spacer removal, a self-made antibiotic coating retrograde hindfoot arthrodesis nail is used in order to achieve ankle fusion. We use a bone-substitute loaded with gentamicin (Cerament-G®) to fill the bone defects and to achieve high concentration of local gentamicin, to protect bone healing and to decrease the risk of relapse. We present four patients with ankle-osteomyelitis after open pilon fracture treated by such protocol. We receive all patients > 6 months after the initial fracture. In all cases type III-B open pilon fracture was the initial injury. All the patients presented psychological disturbances and the possibility of perform an external frame reconstruction was considered not indicated. At presentation, all patients have compromised skin around the distal tibia area. According to the Cierny/Mader osteomyelitis classification all patients were Type IV-Blocal. Compromises soft tissues were treated with an ALT free flap in two cases and with a Keystone flap in two cases. 10 mL paste of Cerament-G® was used in each case with a single case where a white-draining event was present without further complication. Tibiotalocalcaneal fusion was achieved after 4 months in all cases. At average of 7 months of follow-up, none of the four fused ankles has required further surgery and no infection relapse was observed. The use of this salvage treatment protocol has proven safe and useful for such difficult problem in these difficult patients, with a relatively low associated complication rate. Cerament-G® is a useful tool in order to fill all the bone voids, promote bone healing and simultaneously to protect the surgical area due to the high local concentration of gentamicin

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). Conclusion/Significance. In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion

Introduction. Ashford and St Peter's Hospital (ASPH) is a district general hospital in Chertsey, Surrey. It is a tertiary referral unit offering a circular frame service to manage complex trauma patients in the South East of England. This study analyses the patient pathway in 66 consecutive tertiary referrals from 2015–2020. All patients were managed with an Ilizarov frame for either a tibial plateau fracture or pilon fracture. Materials and Methods. The patient journey of 66 consecutive tertiary referrals for tibial plateau and pilon fractures were analysed. The following data was captured: patient demographics; type of injury; referring centre; date of injury; date of referral; date of arrival at ASPH; date of surgery and date of discharge. Using this data we aimed to identify areas of the pathway that can be improved. In addition, the 66 patients were split into two groups of 33 patients. 33 patients were referred via an electronic referral platform and 33 patients were referred verbally prior to the implementation of the electronic referral platform. The groups were compared to see the impact of an electronic referral platform on the patient's journey. Results. Average age 45 (range 17–88 years), Male percentage 54.55%, 45 tibial plateau patients, 21 pilon patients. Injury to Admission at ASPH- 6 days (median), Injury to Surgery 8 days (median), Surgery to Discharge 4 days (median), Total stay in ASPH 6 days (median). Conclusions. The biggest delay in our tertiary referral pathway is from referral to arrival at ASPH. The implementation of an electronic referral pathway has not improved times from referral to arrival at ASPH. Ring fenced beds for tertiary referrals would be the greatest way to improve flow through the pathway and reduce the complications related to delayed surgery

Introduction. We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy. Materials & Methods. A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate. Results. Developing an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate. Conclusions. Infection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures. This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up. We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up. We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle

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

Decreased ankle dorsiflexion is common after injury and may result in patient complaints of stiffness and subsequent injury. The weight-bearing lunge test (WBLT) is a simple clinical measure of dorsiflexion. Previous study has defined a 2.0cm side-to-side discrepancy in WBLT as likely significant. With review of current literature, ankle stiffness is a concept largely undefined; we aim to relate patient complaints of stiffness to WBLT. This was a population-based inception cohort with longitudinal follow-up. Patients between ages 18–65 receiving surgical fixation for ankle fracture were screened. Pilon/plafond fractures, bilateral injuries, or polytrauma were excluded. At 6-weeks, 6-months, and 1-year WBLT was measured along with non-weight-bearing goniometry; and an Olerud-Molander ankle score completed. 155 patients were recruited (90 female, 65 male; mean age 42, range 20–67). 47% of injuries were unimalleolar, 17% bimalleolar, and 36% trimalleolar; 35% received syndesmotic fixation. 89% of patients reported feeling stiff at 6-weeks, 82% at 6-months, and 74% at 1-year. 98% of patients had ≥2.0cm discrepancy of WBLT at 6-weeks, 78% at 6-months, and 72% at 1-year. Different thresholds of WBLT (larger discrepancy or absolute negative measurement) had worse correlation with patient reported stiffness. Our population had high incidence of stiffness at 1-year. The proportion of patients complaining of stiffness after ankle fracture was similar to that measured with ≥2.0cm discrepancy of WBLT. This is the first study that we are aware of that relates the WBLT and the previously reported threshold of 2.0cm to stiffness. This measurement may give clinicians a better objective idea regarding patient perception of a “stiff” ankle. Reducing side to side discrepancy in range of motion should be considered in rehabilitation rather than total range of motion

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

Purpose of the study:. Is circular external fixation a safe and effective method of managing closed distal third tibia fractures. These fractures are conventionally treated with plaster casts, intramedullary nails or plate fixation. These treatment modalities have complication rates in the literature of up to 16% malunion, 12% non-union, and 17% deep infections. Description and Methods:. Retrospective review of 18 patients with closed distal third tibia fractures, with or without extension into the ankle joint, treated with circular fixator systems and minimal percutaneous internal fixation of the intra-articular fragment if required. Patients were followed up for time to union, malunion incidence as well as incidence of pin tract and deep infection. Distal third fractures which were extra articular or with simple intra articular extension were included. (AO 43 A, B1, C1, C2 + AO 42 in distal third) Patients with pilon fractures (AO 43 B2, B3 and C3) were excluded. Summary of results:. The average time to union in these patients was 16 weeks (11–33 weeks). The non-union rate was 11.1% in comparison to 12% with conventional treatment. The malunion rate was 0% compared to 16% with conventional treatment. The incidence of pin tract infection was 16.6%, but no deep infections were noted, whilst conventional treatment shows deep infection in up to 17%. Conclusion:. Circular external fixation is a safe and efficient option in the treatment of distal tibia fractures. The incidence of complications is significantly reduced in comparison to conventional treatment

Introduction. The optimal treatment of high-energy tibia fractures remains controversial. The role of external fixators has been shown to be crucial. This study aimed to compare the effectiveness of using either Taylor Spatial Frame (TSF) or Ilizarov frames in treatment of high-energy tibia fractures in a tertiary trauma referral centre. Methodology. Retrospective review of consecutive series identified two treatment groups; Group 1(TSF) and Group 2 (Ilizarov). Time in frame (healing time) was defined as time from insertion to removal of frame. All patients with incomplete data secondary to loss to follow-up or death were eliminated. Results. Data was available for 112 patients (Group 1 N37 and Group 2 N85) with average ages for of 46.43 and 44.64 years respectively and a male to female ratio of 23:14 and 63:22. 7 open tibial fractures and 24 distal tibia fractures were treated in Group 1 with 18 open tibia fractures and 24 pilon fractures in Group 2. Average healing time was 174.35 (124–340) and 176.41 (102–555) days respectively. Smoker's average healing time was 181.86 and 213.86 days per group. Non-smokers average healing time was 161.86 and 174 days for the two groups. N5 and N26 patients were recorded as high-energy injuries with associated other multiple fractures or visceral injuries with average frame times of 192.2 and 194.69 days respectively. All fractures went to union with only one infection in the Ilizarov group. Conclusion. Smoking and associated high-energy injuries lead to an increase in healing time for both groups. Despite the rigid nature of TSF, healing time is similar to Ilizarov frame

Aims

The exact risk to patients undergoing surgery who develop COVID-19 is not yet fully known. This study aims to provide the current data to allow adequate consent regarding the risks of post-surgery COVID-19 infection and subsequent COVID-19-related mortality.