Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3° (25° to 82°) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis. Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion

McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury. Cite this article: Bone Joint J 2013;95-B:419–23

Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended. Cite this article: Bone Joint J 2024;106-B(9):1008–1014

Aims. The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. Methods. We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes. Results. A total of 121 ankle fractures were included. We revealed several important fracture features, such as a high correlation between posterior collicular fractures and posteromedial fragments. Moreover, we generalized the fracture geometry into three recurrent patterns on the coronal view of 3D maps (transverse, vertical, and irregular) and five recurrent patterns on the lateral view (transverse, oblique, vertical, Y-shaped, and irregular). According to the fracture geometry on the coronal and lateral view of 3D maps, we subsequently categorized medial malleolar fractures into six types based on the recurrent patterns: anterior collicular fracture (27 type I, 22.3%), posterior collicular fracture (12 type II, 9.9%), concurrent fracture of anterior and posterior colliculus (16 type III, 13.2%), and supra-intercollicular groove fracture (66 type IV, 54.5%). Therewere three variants of type IV fractures: transverse (type IVa), vertical (type IVb), and comminuted fracture (type IVc). The angles α and β varied accordingly. Conclusion. Our findings yield insight into the characteristics and recurrent patterns of medial malleolar fractures. The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. Cite this article: Bone Joint J 2021;103-B(5):931–938

Aims. This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton. Methods. A total of 20 patients with isolated, bimalleolar, or trimalleolar ankle fractures were recruited between July 2018 and October 2019. Fracture reduction was achieved through bioabsorbable Mg-based screws composed of pure Mg alloyed with zinc (Zn) and calcium (Ca) ( Mg-Zn0.45-Ca0.45, in wt.%; ZX00). Visual analogue scale (VAS) and the presence of complications (adverse events) during follow-up (12 weeks) were used to evaluate the clinical outcomes. The functional outcomes were analyzed through the range of motion (ROM) of the ankle joint and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Fracture reduction and gas formation were assessed using several plane radiographs. Results. The follow-up was performed after at least 12 weeks. The mean difference in ROM of the talocrural joint between the treated and the non-treated sites decreased from 39° (SD 12°) after two weeks to 8° (SD 11°) after 12 weeks (p ≤ 0.05). After 12 weeks, the mean AOFAS score was 92.5 points (SD 4.1). Blood analysis revealed that Mg and Ca were within a physiologically normal range. All ankle fractures were reduced and stabilized sufficiently by two Mg screws. A complete consolidation of all fractures was achieved. No loosening or breakage of screws was observed. Conclusion. This first prospective clinical investigation of fracture reduction and fixation using lean, bioabsorbable, REE-free ZX00 screws showed excellent clinical and functional outcomes. Cite this article: Bone Joint Res 2020;9(8):477–483

There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. Current ankle classification systems do not account for differences in fracture patterns or injury mechanisms, and as such, the clinical outcomes of these fractures are difficult to interpret. The aim of this study was to analyse our posterior malleolar fractures to better understand the anatomy of the fracture. In a series of 42 consecutive posterior malleolar, who all underwent CT imaging, we have described anatomically different fracture patterns dictated by the direction of the force and dependent on talus loading. We found 3 separate categories. Type 1 – a rotational injury in an unloaded talus resulted in an extraarticular posterior avulsion of the posterior ligaments. This occurred in 10 patients and was most commonly associated with either a high fibular spiral fracture or a low fibular fracture with Wagstaffe fragment avulsion. The syndesmosis was usually disrupted in these patients. Type 2 – a rotational injury in a loaded talus resulting in a posterolateral articular fracture, of the posterior incisura. This occurred in 16 patients and was most commonly associated with a posterior syndesmosis injury, low fibular spiral fracture and an anterior collicular fracture of the medial malleolus. Type 3 – axially loaded talus in plantarflexion causing a posterior pilon. This occurred in 16 patients and was most commonly associated with a long oblique fracture of the fibular and a Y shape fracture of the medial malleolus. The syndesmosis was usually intact in these patients. In conclusion, the anatomy of the posterior malleolar should not be underestimated and requires careful consideration during treatment and categorisation in outcome studies to prevent misinterpretation

Introduction: The SonicPin technology uses ultrasonic energy to weld polymer into bone (BoneWelding), thus forming a bond between implant and bone. The aim of this study was to determine the mechanical capabilities of the SonicPin in comparison to conventional techniques using generic mechanical load conditions. Methods: Blocks of cancellous bone served as test specimens for generic tests. Two blocks respectively were fixed using either the SonicPin, a titanium cancellous bone screw (ASNIS) or a PLLA pin-screw system (Inion OTPS). The samples were then clamped into a test device and mechanically tested. Tests included pull-out, shear and 4-point-bending. To examine the mechanical performance of the Son-icPin in a realistic fracture model 12 fresh frozen tibiae were osteotomized through the medial apex of the pla-fond, simulating a horizontal fracture of the medial malleolus. The tibiae were treated with either the Son-icPin or with 4.0-millimeter partially threaded titanium screws. Mechanical testing was performed by applying a compressive load 17 degrees from the long axis of the tibia to simulate supination-adduction loading. Results: The bond between implant and bone exceeded the strength of the SonicPin itself. Using 2 SonicPins load levels were similar to those obtained with the cancellous screw or the PLLA fixation (p> 0,05). Discussion: Ultrasonic welding of polymer into bone seems to be a promising technology to be used in orthopaedic surgery. Applying the SonicPin in fractures of the medial malleolus may be considered after slight modifications such as larger diameter or longer pins

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured. Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score. Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups. At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture

Medial malleolar stress fractures are uncommon even in the sporting population. They tend to occur almost exclusively in athletes involved in sports involving running and jumping. We believe that stress fractures of the medial malleolus may be the end stage of chronic anteromedial ankle impingement in elite running and jumping athletes. Anterior impingement spurs are thought to be caused by repetitive microtrauma at the limit of dorsiflexion causing subperiosteal haemorrhage and subsequent ossification. More specifically the lower surface of the anterior tibia and the anterior part of the medial malleolus undergo similar trauma during severe supination injuries. Repetitive trauma to the cartilage from the kicking action in soccer is also thought to play a part, the cartilage responding by the formation of scar tissue and subsequent calcification. We present five cases of elite athletes (three AFLplayers, one sprinter and one A Grade cricketer) who presented to our establishment with vertical stress fractures of the medial malleolus over a three year period (2004–7). In each case preoperative imaging revealed an anteromedial bony spur on the tibia. All patients had the fractures internally fixed and at the same sitting had arthroscopic debridement of the impingement spur. Average time to union was 10.2 weeks (6–16). At most recent review (average 18 months (8–37)) all fractures had united and all patients had resumed sporting activity. No patient had suffered a further fracture of the medial malleolus. We believe this region of impingement causes premature abutment of the talus on the tibia in the supination-adduction motion that in severe trauma leads to the vertical fracture through the medial malleolus according to the Lauge-Hansen classification. We therefore feel it should be addressed at the time of fracture fixation to reduce the re-fracture rate

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm. 2. (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm. 2 . (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm. 2. (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region. Cite this article: Bone Joint J 2013;95-B:1662–6

Introduction and Objective. Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures. Materials and Methods. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies. MEDLINE (via PubMed), Embase and the Cochrane Library electronic databases were searched inclusive of all date up to the search time. We included all studies that investigated the effect of weight-bearing following adults ankle fracture fixation by any means. All ankle fracture types, including isolated lateral malleolus fractures, isolated medial malleolus fractures, bi-malleolar fractures, tri-malleolar fractures and Syndesmosis injuries, were included. All weight-bearing protocols were considered in this review, i.e. immediate weight-bearing (IMW) within 24 hours of surgery, early weight-bearing (EWB) within three weeks of surgery, non-weight-bearing for 4 to 6 weeks from the surgery date (or late weight-bearing LWB). Studies that investigated mobilisation but not weight-bearing, non-English language publications and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomised controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. Results. After full-text review, fourteen studies (871 patients with a mean age ranged from 35 to 57 years) were deemed eligible for this systematic review; ten randomised controlled trials and four comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There is no important difference in the infection rate between protected EWB and LWB groups (696 patients in 12 studies). The risk ratio (RR) is 1.30, [95% CI 0.74 to 2.30], I. 2. = 0%, P = 0.36). Other complications were rare. The Olerud-Molander Ankle Score (OMAS) was the widely used patient-reported outcome measure after ankle fracture fixation among the studies. The result of the six weeks OMAS analysis (three RCTs) was markedly in favour of the early weight-bearing group (MD = 10.08 [95% CI 5.13 to 15.02], I. 2. = 0%P = <0.0001). Conclusions. The risk of postoperative complications is an essential factor when considering EWB. We found that the overall incidence of surgical site infection was 6%. When comparing the two groups, the incidence was 5.2% and 6.8% for the LWB and EWB groups. This difference is not clinically important. On the other hand, significantly better early functional outcome scores were detected in the EWB group. These results are not without limitations. Protected early weight-bearing following open reduction and internal fixation of ankle fractures is potentially safe and improve short-term functional outcome. Further good-quality randomised controlled trials would be needed before we could draw a more precise conclusion

We report a new technique of talectomy for patients with Hawkins group III fracture-dislocation of the talus. Talectomy is performed through a medial incision, the foot is displaced anteriorly, and the fractured or osteotomised medial malleolus is moved laterally and fixed to the tibia with a malleolar screw. Full weight-bearing is allowed after six weeks. In four patients at 36 to 57 months after operation the results were excellent in three and good in one, with no pain or early evidence of degenerative arthritis in the remaining joints of the foot

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

Ankle fractures are among the most common injuries treated by orthopaedic surgeons, and surgical treatment is often required to optimise the results. This retrospective study was undertaken to assess the effectiveness of the TRIMED ankle fixation system in the treatment of malleolar fractures. During the last ten months, fifteen patients with an average age of 63 years underwent open reduction and internal fixation of a bimalleolar ankle fracture with the TRIMED fixation system. A standart surgical approach was used for both the medial and lateral malleolus. Regarding the lateral malleolus, a TRIMED Sidewinter plate which requires no additional interfragmentary screw was applied. Based on the morphology of the fracture of the medial malleolus, either interfragmentary screws or the sled- like medial malleolus fixation system was applied. One patient underwent in addition open reduction and internal fixation of the posterior malleolus. All fractures proceeded to uncomplicated union in an average healing time of 6 weeks. Excellent functional restoration of the ankle joint, comparable to the ipsilateral ankle, was achieved. The TRIMED ankle fixation system represents a good alternative method in malleolar fracture fixation which simplifies the fracture reduction and obliterates the need for a lag screw, thus preserving the biology of the fracture site. Furthermore, it can be used for the reconstruction of distal fractures of the lateral malleolus. However, further long-term studies are recommended to evaluate the success of the TRIMED fixation system

Introduction: Operative fixation of unstable ankle fractures is a well recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 85 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures. Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. The mechanism of injury, fracture pattern, and medical co morbidities were recorded. A standard postoperative rehabilitation programme was followed. 5 patients were excluded as complete medical records were unavailable. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed. Results: There were 71 women and 16 men in the study. The most common fracture pattern was pronation external rotation type. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 5.7% (5 cases) which settled with oral antibiotic treatment for 1–2 weeks. The deep infection rate was 4.6% (4 cases) which required surgical debridement and implant removal. The 30 day postoperative mortality was 4.6 % (4 cases). Most patients demonstrated radiological fracture union with medial malleolus possessing slightly a higher risk of non union. 88.1 % (74 out of 84 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery. Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with good functional recovery and return to pre injury mobility status in most cases. The surgical fixation is technically challenging and careful attention must be given to the osteopenia and soft tissue factors

Purpose. Total Ankle Replacement (TAR) is increasingly being offered to patients as an alternative to arthrodesis for the operative management of debilitating end-stage ankle arthritis. The Mobility Total Ankle System is a third-generation design consisting of a three component, cementless, unconstrained, mobile-bearing prosthesis. This study reports the early results of a multi-centre prospective study of the Mobility prosthesis. This is the first such report by independent researchers. Method. The senior authors implanted 86 consecutive Mobility prostheses. The underlying diagnosis was primary OA in 24 ankles, secondary OA in 47 ankles and inflammatory arthritis in 15 ankles. There were 41 males (Mean age 67 / Range 51–87) and 44 females (Mean age 60 / Range 29–72). The mean BMI was 28 (Range 22–36) for males, and 28 (Range 20–39) for females. Previous ankle operations were performed in 24 patients, 22 of which were for fracture fixation. Ankles were classified according to the COFAS end-stage ankle arthritis classification system. Coronal plane deformity was quantified pre-operatively. Clinical outcome was assessed using the AOFAS hindfoot score. Radiological assessment was performed from weight-bearing radiographs, documenting post-operative alignment, osseous integration, edge-loading and heterotopic bone formation. The mean follow-up time was 40 months (Range 30–60). Survival analysis was calculated according to the Kaplan-Meier method. Failure was defined as exchange of any component of the TAR, arthrodesis or amputation. Results. Type 1 ankle arthritis was demonstrated in 54 ankles (63%). No patient had pre-operative coronal plane angulation > 20. In 30 ankles (35%), the pre-operative coronal alignment was neutral, and in 32 ankles (37%), the deformity was < 10. The mean AOFAS hindfoot score improved from 37.4 (Range 12–59) pre-operatively to 77.9 (Range 51–100) post-operatively. 78 (90%) of prosthetic components were implanted within 5 of the optimal position. Bone-implant interface abnormalities were identified in 16 ankles (18%). In total, 5 TARs required revision, 4 for aseptic loosening and one for component malpositioning. There was one conversion to arthrodesis, and one BKA for CRPS. 30 simultaneous procedures were performed in 28 patients. The most common was gastrocnemius recession. There were 8 re-operations, most commonly for impingement due to peri-articular ossifications. Delayed wound healing occurred in 3 patients, and there was one case of deep infection. There were 5 patients that sustained fractures of the medial malleolus: 2 were intra-operative, and underwent internal fixation. There are 6 patients being investigated for ongoing pain. The 2-year survival was 96.4% (95% CI 89.4–99.1) and 3-year survival was 91.7% (95% CI 83.3–96.3). Conclusion. Although early results of the Mobility TAR are encouraging for independent researchers, they do not match those reported by designer surgeons. Most patients achieve good pain relief and improved function post-operatively

Purpose: The purpose of this work was to assess results of total ankle arthroplasty (TAA) for rheumatoid arthritis and determine the technical difficulties. Material and methods: Between 1993 and 1999, 32 TAA were performed for rheumatoid arthritis: 26 women and 16 men, mean age at implantation 55 years, age range 32 – 81 years, disease duration 17 years (range 2 – 35 years), long-term corticosteroid treatment 18, metotrex-ate 17. Non-cemented prostheses with a mobile insert were implanted: Buechel-Pappas (n=7), STAR (n=5), Salto (n=20). For 21 patients, subtalar and mediotarsal arthrodesis was associated with the TAA because of associated subtalar deterioration or valgus tilt due to tendiopathy of the posterior tibial tendon. All patients were seen at three, six and twelve months then every year for physical examination and x-rays. None of the patients were lost to follow-up. Mean follow-up was 57 months (range 26 – 90 months). Clinical outcome was assessed with the AOFAS. Results: There were two failures requiring revision: one loose talar piece migrated four years after implantation requiring arthrodesis; one over-sized talar piece leading to pain had to be changed after one year with good results (AOFAS = 92). Among the other 30 patients, the mean overall score and the pain score were 82/100 (73–92) and 35/40 (20–40) respectively. Several complications were observed: wound necrosis (n=2), impaction of the talar piece (n=1), and impaction of the tibial piece (n=2) which developed at weight bearing then remained unchanged. One anterior translation of the tibial piece was asymptomatic at two years, fractures of the medial malleolus healed without difficulty. Discussion: TAA is the treatment of choice for rheumatoid tibiotarsal degeneration. Associated lesions of the hind foot influence prognosis and results. Preoperative analysis of the deformation and loss of bone stock must be achieved with careful physical examination and appropriate x-ray or computed tomography imaging. Subtalar valgus deformation or tendinopathy of the posterior tibial tendon require an associated subtalar and mediotarsal arthrodesis

Purpose: A prospective study was conducted in 160 children presenting varus trauma of the ankle. The purpose of the study was to validate the Ottawa ankle rules in children. Application of the Ottawa rules can reduce the number of x-rays by 25% but little work has been reported concerning their validation (Chande 1995). Material and methods: One hundred sixty children, 71 boys and 89 girls, mean age eleven years three months (range 3 – 15 years) were included in this study conducted between February 2001 and December 2001. Clinical presentations with an obvious diagnosis of ankle fracture were excluded (six patients). Epidemiological and clinical data and the initial Ottawa criteria were recorded on a data sheet with a specific number of assigned items. A standard radiographic work-up with an anteroposterior, lateral and oblique view of the ankle was obtained in all cases. All patients were seen at a second consultation on day 8 by another physician to confirm diagnosis. The x-rays were read three times: by the emergency care physician, and by a second physician and a paediatric orthopaedic surgeon at the 8-day consultation. Results: Diagnosis which were confirmed were: benign sprains (BS) (n=71), moderately severe sprains (MS) (n=47), severe sprains (SS) (n=2), type I epiphyseal detachment (ED) (n=21), fractures (n=13) (8 fifth metatarsal, 1 triple fracture line, 1 medial malleolus, 2 lateral malleolus, 1 tarsal scaphoid). For the Ottawa criteria, ankles positive for pain and at least one other criterion were: 64/77 BS, 43/47 MS, 2/2 SS, 21/21 DE and 13/13 fractures. All fractures were diagnosed at the first exam or at the 8-day exam. Discussion: Based on our findings, the clinical Ottawa rules cannot be considered to be validated for children. Using these rules, x-rays would have been performed in 143 patients to identify 13 fractures that were not clinically obvious. Because the Ottawa rules are insufficiently specific for children, we recommend, like Brooks (1981) to use more rigorous clinical criteria for the diagnosis of ankle trauma in children. The diagnostic criteria used in this study enabled correct first intention diagnosis in 129 patients with trauma. We propose ordering x-rays only for children with signs of moderate or severe sprain or pain in zone C (base of the fifth metatarsal: 8/8) or E (medial border of the foot: tarsal scaphoid fracture). For other cases (98/160) physical examination is sufficient. Conclusion: We do not consider the Ottawa clinical rules to be valid for varus ankle trauma in children. We propose clinical criteria which can limit the number of x-ray work-ups by 60% in children with this type of trauma

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.