Introduction. Positive reports from implant designer centres on the use of fibular nails in the complex ankle fractures has resulted in a marked increase in their use nationally. Our aim in this study was to report on the outcomes of the use of all fibular nails in two major trauma centres. Methods. All patients who underwent ankle fracture fixation using a fibular nail in two major trauma centres, were included for analysis. MTC 1 included patients from April 2013 to May 2015, and MTC 2 included patients February 2015 to March 2018. A minimum follow up of 1 year was achieved for all patients. Radiographic reduction was confirmed by Pettrones criteria at time of operation and at 6 weeks and 1 year post-operatively. Kellgren Lawrence radiographic criteria was used to classify osteoarthritis. All complications and further surgery were recorded. Results. Forty-four patients underwent fibular nail fixation in the two centres. The average age was 59 (range 21–91). Using Pettrones criteria, 86% were malreduced at time of operation. A further 34% deteriorated by at least 1 grade by 6 weeks and an additional 16% (n=7) deteriorated by at least 1 grade by 1 year. 57% had developed radiographic evidence of osteoarthritis by 1 year. Only 4.5% (2ankles) maintained complete reduction by 1 year. Other significant complications were reported in 43% of patients. Conclusion. Both major trauma centres report the same experience in the use of fibular nails for ankle fracture fixation. As previously reported in smaller number studies, initial reduction is challenging. Worryingly, the majority of well-reduced lose position with time. We suggest that the fibula nail is used with caution and as part of an appropriately approved audit

Introduction:. Inadequate reduction and fixation of ankle fractures leads to poor clinical outcomes although there are no well-established criteria to evaluate the quality of surgical fracture fixation of the ankle. The aim of our study was to validate Pettrone's criteria that can be used in the radiological assessment of the quality of ankle fracture fixation that predict the functional outcome. Methods:. A retrospective study was completed following the operative management of ankle fractures at a University teaching hospital between 1. st. January 2009 and 31. st. December 2009 were included in the study. Exclusion criteria were paediatric fractures, polytrauma, and fractures involving the tibial plafond. The fracture pattern was classified using the AO classification system. Three independent Foot and Ankle Consultants assessed the quality of surgical ankle fracture fixation using Pettrone's criteria. Approximately one year following the surgery, functional outcome was obtained using Lower Extremity Function Score (LEFS) and a modified American Orthopaedic Foot and Ankle Society score (AOFAS). The Mann-Whitney test was used for the LEFS and AOFAS functional scores. Logistic regression was performed upon age and gender with regards to functional outcome. Given that the Kappa coefficient is a pair wise statistic, the average pair wise agreement for each category of the Pettrone criteria was also determined. Results:. Sixty-one consecutive patients were included in the study with a mean age of 51 years (17–74 years) and a mean follow-up of 17.41 months (13–24 months). Using Pettrone's criterias, mean interobserver agreement was 90.0% (89.4–92.6%) with inadequate reduction in 20 cases (32.5%). Mean LEFS following inadequate reduction was 47.5 (1–79) and following satisfactory reduction was 55.9 (9–80) p=0.03. Conclusion:. Pettrone's criteria has high interobserver agreement for the quality of surgical fracture fixation of the ankle which correlates with functional outcome

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

Aims. The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee. Patients and Methods. All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points. Results. A total of 179 patients were included with a median age of 50 years (interquartile range (IQR) 37 to 60), of whom 71 patients (39.7%) were male. With a median score of 60 before IR (IQR 45 to 72) and 66 after IR (IQR 51 to 76) on the LEFS, there was a statistically significant improvement in functional outcome (p < 0 .001). A total of 31 surgical site infections (17.3%) occurred. Conclusion. Although IR led to a statistically significant improvement of functional outcome, the minimal clinically important difference was not reached. In conclusion, this study shows that IR does not result in a clinically relevant improvement in functional outcome. These results, in combination with the high complication rate, highlight the importance of carefully reviewing the indication for IR. Cite this article: Bone Joint J 2019;101-B:447–453

Introduction

Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published.

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.

Introduction. Despite costing up to 5X more than a one-third tubular plate (TTP) and no absolute indications, distal fibula locking plates (DFLP) are becoming increasingly popular in the fixation of ankle fractures, particularly in the elderly. We reviewed all our distal fibula fracture fixations, over the course of one year, in order to rationalise DFLP use. Methods. Patient demographics, Weber classification, use of DFLP or TTP and the mode of fixation were recorded. Open fractures and tibial plafond fractures were excluded. Results. 51/84 (61%) of patients had DFLP fixation of their distal fibula fracture, the majority (44/51) of which were for Weber B fractures. The DFLP was used in bridge mode for 12 Weber B fractures and in neutralisation mode for remaining 32. There was a significant difference in age between the DFLP and TTP groups for all fractures (p< 0.005) and for Weber B fractures treated in bridge mode (p=0.036), but not for Weber B fractures treated with a lag screw/ neutralisation plate (p=0.09). Discussion. In 32/44 of our cases, we used the DFLP to neutralise a lag screw. However DFLP are only of mechanical benefit when adequate fracture compression is not obtained either due to fracture comminution or due to osteoperotic bone, often seen in the elderly. All 32 of these Weber B fractures were amenable to a lag screw and were not comminuted. There was also no significant age difference between this group and the group of Weber B fractures that were treated with a lag screw/ neutralisation plate. In these cases therefore, the DFLP did not offer any mechanical advantage. Conclusion. We propose limiting the use of the DFLP to fibula fractures where intra-fragmentary compression cannot adequately be obtained, thus reducing our use by over 60% and significantly reducing our implant costs for such injuries

Aims

Management of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications.

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.

Conventionally, medial malleolus fractures are treated surgically with anatomical reduction and internal fixation using screws. There seems to be no consensus, backed by scientific study on the optimal screw characteristics in the literature. We retrospectively examined case notes and radiographs of 48 consecutive patients taken from our trauma database (21 male, 27 female) with an average age of 50 years (range 16-85) who had undergone medial malleolus fracture fixation with screws at the Royal Free Hospital, London between January 2009 and June 2010. The most commonly used screw was the AO 4.0 mm diameter cancellous partially-threaded screw in 40, 45 and 50 mm lengths (40 mm n = 28, 45 mm n = 26, 50 mm n = 23) with the threads passing beyond the physeal scar in all cases. Incomplete reduction defined as > 1mm fracture displacement was observed on post-operative x-rays in 12 out of 48 cases (25%), all of which relied on partially-threaded screw fixation. In 5 cases where AO 4.0 mm diameter fully-threaded screws engaging the physeal scar had been used, no loss of reduction was observed. This unusual, occasional use of fully-threaded screws prompted us to investigate further using a porcine model and adapted pedo-barographic transducer. We compared pressures generated within the fracture site using AO 4.0 mm partially-threaded cannulated screws, 4.0 mm partially-threaded cancellous screws and 4.0 mm fully-threaded cancellous screws. Fully-threaded cancellous 4.0 mm diameter screws generated almost 3 times the compression of a partially-threaded cancellous screw with superior stability at the fracture. Partially-threaded screws quickly lost purchase, compression and stability particularly when they were cannulated. We also observed that screw thread purchase seemed enhanced in the physeal region. We conclude that fully-threaded cancellous 4.0 mm AO screws are superior to longer partially-threaded screws and that use of cannulated 4.0 mm partially-threaded screws should be avoided in fixation of medial malleolus fractures

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

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

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

Background. Traditionally, the extended lateral approach (ELA) was the favoured approch for calcaneal fractures, but has been reported to have high incidence of wound complications. There has been a move amongst surgeons in the United Kingdom towards the sinus tarsi approach (STA) due to its minimally invasive nature, attempting to reduce such complications. Aims. To evaluate outcomes of ELA and STA for all consecutive calcaneal fracture fixation in our institution over a 10yr period. Method. Retrospective cohort study of all calcaneal fractures surgically treated with either approach between January 2008 and January 2018. Anatomic restoration was assessed radiologically by the change in Gissane's and Bohler's angles and calcaneal width. Post-operative complications including metalwork removal were recorded. Results. 35 calcaneal fractures were managed surgically via either approach during this period (21 STA and 14 ELA). There was a statistically significant improvement in the radiological makers when the post-operative films were compared to pre-operative ones. When the post-operative films from the 2 groups were compared against each other, there was no significant difference (p< 0.05) in any of the radiological markers. In the ELA group, 2 patients (14.3%) developed deep infections requiring metalwork removal and 1 had delayed wound healing (7.1%). No deep infections occurred with the STA; 1 patient (4.8%) had a superficial infection, treated with antibiotics. Of patients who had metalwork in situ for more than 1 year, 37.5% of the STA group required removal due to pain compared to only 16.7% with ELA. Conclusions. We have moved from ELA to STA. Our results have shown no difference in restoration of calcaneal anatomy but with a decrease in post-operative wound complications including infection. However, we have shown an increase in metalware removal in the STA group and it is important to ascertain the cause and significance of this

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

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.

Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

Introduction:. Early stabilization has the potential to expedite early return to function and reduce hospital stay thus reducing cost to health care. A clinical audit was performed to test the hypothesis that early surgical stabilization lowers the rate of soft tissue complications and is not influenced by choice of distal fibular implants used for stabilization of ankle fractures. Methods:. All surgically treated adult patients with isolated unstable ankle fracture were included from April 2012 to April 2013 at a MTC in UK. Patients with poly-trauma were excluded. All patients underwent a standard surgical protocol: aim for early definitive surgical fixation (ORIF) within 24 hours however if significantly swollen than temporary stabilization with an external fixation followed by a staged definitive fixation. Results:. In total 172 consecutive unstable ankle fractures were included in one-year study period. Definitive fixation (ORIF) was achieved in 91% patients with only 9% patients required temporary stabilization with external fixation. Fibular locking plates were used in 59(38%) patients compared to conventional one-third tubular plates in 91(60%) patients. In ORIF group 42% (73) patients were operated within 24 hours of admission whilst 58% (83) under went early fixation after 24–72 hours. At one year follow up complications were recorded in 18(11%) patients including metal irritation requiring removal of implant in 6(4%) patients. Wound complications and deep infection leading to a further surgical procedure in 8(5%) patients. There was no statistical difference between complication rates (p=0.016) in early versus delayed fixation groups. Fibular locking plates were associated with higher soft tissue complications (13%) as compared with conventional plates (2%) (p=0.004). Conclusion:. Our study showed that the timing of the surgery has less influence on the complications of the ankle fracture fixation. However choice of implants requires careful consideration and we suggest caution against use of current fibular locking plates

Background and objective. Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome. Material and Method. Retrospective study, January 2005 to December 2010. From a total of 324 patients with metatarsal fractures, 8 patients with peripheral neuropathy presented with second metatarsal non-traumatic fractures. Fractures were initially treated in cast for more than three months but failed to heal. Subsequently, this led to fractures of 3rd, 4th and 5th metatarsals. All patients remained clinically symptomatic due to fracture non-union. Operative treatment with bone graft and plating was used. Postoperatively below knee plaster and partial weight bearing for 12 weeks. Clinical and radiological surveillance continued until bone union. Results. There were 2 male and 6 female patients, age (24–83). 22 metatarsals had clinical and radiological union. 1 patient needed 1st tarsometatarsal joint fusion along with metatarsals fractures fixation. This patient developed deep infection and required below knee amputation. 2 patients required metalwork removal. Patient's satisfaction score was 8/10. Conclusion. Our review suggests low energy metatarsal stress fractures treated nonoperatively provide limited success. Timely surgical intervention and internal fixation proved to be a valid treatment option

Introduction. Venous thromboembolism (VTE) represents a major cause of morbidity, mortality and financial burden to the NHS. Acquired risk factors are well documented, including immobilisation, lower limb plaster cast and surgery. NICE guidance on VTE prophylaxis within orthopaedics currently excludes operative ankle fracture fixation (ankle ORIF). Aims. Ascertain the local incidence of VTE; compare our local VTE rates with published data from other institutions; review guidelines, scientific literature and other hospitals policies; formulate a local policy for VTE prophylaxis. Method. Retrospective analysis of records of all patients undergoing ankle ORIF in our hospital over a continuous 5 year period, identifying cases of VTE, individual risk factors and surgical duration. Results. 380 patients underwent ankle ORIF; 3 developed VTE; no mortality. VTE incidence 0.79% (0.26%DVT; 0.53%PE). Operative duration 88 +/− 34mins (mean +/− 1S.D); in those with VTE, duration was 35, 90&85min. There is no statistically significant difference (p=0.18) observed between our local and national VTE incidence rates. Operative duration was not a significant factor in those developing VTE. Additional risk factors were identified in one patient with VTE. Discussion. The incidence of heparin induced thrombocytopenia is 0.5%, its associated mortality 10% (i.e. 1:2000). To prevent one fatal PE in foot & ankle surgery, 10,000 must receive VTE prophylaxis. Therefore, heparin associated mortality exceeds VTE associated mortality in foot & ankle surgery. Conclusion. Our local VTE rates are comparable to national rates. Risk of pharmacological prophylaxis exceeds benefit; therefore routine use not justified. Individual risk should be assessed; higher risk patients may benefit