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. Methods. A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods. Discussion. The two treatments being compared are the most commonly used for this injury, however there is uncertainty over which is most clinically and cost-effective. The Articular Pilon Fracture (ACTIVE) Trial is a sufficiently powered and rigorously designed study to inform clinical decisions for the treatment of adults with this injury. Cite this article: Bone Jt Open 2021;2(3):150–163

Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger patients. 9-14. . Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration. 15. , distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By mounting the fixator components to the bone on each side of the joint, and then lengthening the rods connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage regeneration during distraction are not yet understood. A possible negative consequence of joint fixation is cartilage degeneration due to immobilization during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be detrimental to articular cartilage. 16-18. . Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage cartilage regeneration. 19-22. Toward this end, considerable effort has been invested in the application of hinges to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in distraction treatment, as well. 10. This is borne out by data from an RCT comparing the use of a rigid vs motion external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of symptoms

Between 1985 and 1994, 1223 patients with malleolar fractures of the ankle were treated by open reduction and internal fixation with absorbable pins and screws, of whom 74 (6.1%) had an obvious inflammatory foreign-body reaction to the implants. Of these 74, ten later developed moderate to severe osteoarthritis of the ankle despite no evidence of incongruity of the articular surface. The implants used in these patients were made from polyglycolide, polylactide or glycolidelactide copolymer. The joint damage seemed to be due to polymeric debris entering the articular cavity through an osteolytic extension of an implant track. The ten patients had a long clinical course which included a vigorous local foreign-body reaction, synovial irritation and subsequent degeneration. At a follow-up of three to nine years, ankle arthrodesis had been necessary in two patients and is being considered for another two. The incidence of these changes in the whole series was 0.8%, which is not high, but awareness of this possible late complication is essential

Introduction. Lisfranc joint injuries are increasingly recognised in elite soccer and rugby players. Currently no evidence-based guidelines exist on timeframes for return to training and competition following surgical treatment. This study aimed to see whether return to full competition following surgery for Lisfranc injuries was possible in these groups and to assess times to training, playing and possible related factors. Material/Methods. Over 46-months, a consecutive series of fifteen professional soccer (6) and rugby(9) players in the English Premierships/Championship, was assessed using prospectively collected data. All were isolated injuries, sustained during competitive matches. Each had clinical and radiological evidence of injury and was treated surgically within thirty-one days. A standardised postoperative regime was used. Results. Follow-up was obtained in all fifteen cases. Eight cases were ligamentous injuries and seven were bony. Time from injury to fixation ranged from 10–31 days. One athlete retired following a ligamentous injury. All remaining fourteen returned to training and full competition. Excluding the retired case, mean return to training time was 20.2 weeks and to full competition was 25.6 weeks. No significant difference existed between the mean return to competition time for rugby (27.8 weeks) and soccer(24.7 weeks). A significant difference existed between the mean return to competition time for ligamentous (23.7 weeks) compared to bony(27.6 weeks) injuries(p = 0.012). Three patients suffered deep peroneal nerve sensation loss, two of which fully recovered. Discussion/Conclusion. Return to competitive elite-level soccer and rugby is possible following surgically treated Lisfranc injuries. Return to training can take up to 24 weeks and playing up to 31 weeks, with bony injuries taking longer. To our knowledge this is the largest series of its kind and whilst we recognise it contains small numbers, we feel it provides some guidance on rehabilitative timeframes for those who treat and those who sustain these injuries. Evidence Level: 4

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.