Aims. Accurate identification of the ankle joint centre is critical for estimating tibial coronal alignment in total knee arthroplasty (TKA). The purpose of the current study was to leverage artificial intelligence (AI) to determine the accuracy and effect of using different radiological anatomical landmarks to quantify mechanical alignment in relation to a traditionally defined radiological ankle centre. Methods. Patients with full-limb radiographs from the Osteoarthritis Initiative were included. A sub-cohort of 250 radiographs were annotated for landmarks relevant to knee alignment and used to train a deep learning (U-Net) workflow for angle calculation on the entire database. The radiological ankle centre was defined as the midpoint of the superior talus edge/tibial plafond. Knee alignment (hip-knee-ankle angle) was compared against 1) midpoint of the most prominent malleoli points, 2) midpoint of the soft-tissue overlying malleoli, and 3) midpoint of the soft-tissue sulcus above the malleoli. Results. A total of 932 bilateral full-limb radiographs (1,864 knees) were measured at a rate of 20.63 seconds/image. The knee alignment using the radiological ankle centre was accurate against ground truth radiologist measurements (inter-class correlation coefficient (ICC) = 0.99 (0.98 to 0.99)). Compared to the radiological ankle centre, the mean midpoint of the malleoli was 2.3 mm (SD 1.3) lateral and 5.2 mm (SD 2.4) distal, shifting alignment by 0.34. o. (SD 2.4. o. ) valgus, whereas the midpoint of the soft-tissue sulcus was 4.69 mm (SD 3.55) lateral and 32.4 mm (SD 12.4) proximal, shifting alignment by 0.65. o. (SD 0.55. o. ) valgus. On the intermalleolar line, measuring a point at 46% (SD 2%) of the intermalleolar width from the medial malleoli (2.38 mm medial adjustment from midpoint) resulted in knee alignment identical to using the radiological ankle centre. Conclusion. The current study leveraged AI to create a consistent and objective model that can estimate patient-specific adjustments necessary for optimal landmark usage in extramedullary and computer-guided navigation for tibial coronal alignment to match radiological planning. Cite this article: Bone Jt Open 2022;3(10):767–776

We undertook a retrospective review of 24 arthroscopic procedures in patients with symptomatic ossicles around the malleoli of the ankle. Most of the patients had a history of injury and localised tenderness in the area coinciding with the radiological findings. Contrast-enhanced three-dimensional fast-spoiled gradient-echo MRI was performed and the results compared with the arthroscopic findings. An enhanced signal surrounding soft tissue corresponding to synovial inflammation and impingement was found in 20 patients (83%). The arthroscopic findings correlated well with those of our MRI technique and the sensitivity was estimated to be 91%. At a mean follow-up of 30.5 months (20 to 86) the mean American Orthopaedic Foot and Ankle Society score improved from 74.5 to 93 points (p < 0.001). Overall, the rate of patient satisfaction was 88%. Our results indicate that symptomatic ossicles of the malleoli respond well to arthroscopic treatment

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding. Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement. Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed. Results: The mean preoperative BMD within the medial malleolus improved from 0.58g/cm2 to mean 6 months postoperative BMD of 0.59g/cm2 and 0.60g/cm2 at 12 months. The mean preoperative BMD within the lateral malleolus decreased from 0.40g/cm2 to a mean 6 months postoperative BMD of 0.34g/cm2. However the BMD over the lateral malleolus increased to 0.36g/cm2 at 12 months. The mean alignment of the tibial component was 88.5° varus (85° varus to 94° valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865). Conclusion: The absence of stress shielding around the medial malleolus indicates that TAR implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus

Introduction: There is limited literature looking into the circumstances surrounding the development of stress fractures of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD) and the phenomenon of stress shielding. Aim: To assess the effect of TAR loading othe medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility TAR. Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 and 12 months after surgery. The bone mineral density of a 2 cm square area within the medial and lateral malleoli was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed. Results: The mean preoperative BMD within the medial malleolus increased from a mean of 0.57g/cm2 to 0.58g/cm2 at six months and 0.60g/cm2 at 12 months postoperatively. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to 0.34g/cm2 at six months postoperatively. However the BMD over the lateral malleolus increased to 0.356g/cm2 at 12 months. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). There was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865). Conclusion: The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus

Abstract. Introduction. Controversy exists regarding the optimal tibial coronal alignment in total knee arthroplasty. Many believe navigation or robotics are required to set kinematic alignments or to ensure they remain within ‘safe’ limits e.g. maximum 5° varus on the tibia. Given most navigation or robotic systems require the surgeon to identify the ankle malleoli, this study aimed to radiographically analyse standardly used intra-operative landmarks around the ankle, assessing their value in achieving kinematic alignment / setting safety boundaries. Materials and Methods. Long leg alignment radiographs were analysed independently by two orthopaedic surgeons at two time points, eight weeks apart. Angles were measured between the long axis of the tibia (TB) and: 1. lateral malleolus (TB-LM), 2. lateral border of the talus (TB-LT) and 3. medial aspect of the medial malleolus (TB-MM). Intra- and inter-rater reliabilities were assessed. Results. One hundred and sixty-seven radiographs in 119 patients were analysed; mean age 71.6 years. Mean angles (95% CI) were: TB-LM 4.8° (4.7°- 4.8°), TB-LT 2.6° (2.5° - 2.6°) and TB-MM 4.2° (4.1° - 4.2°). Interrater reliability was good for TB-LM (ICC = 0.72) and TB-MM (ICC=0.67), and fair for TB-LT (ICC= 0.50). Intra-rater reliability was excellent for all measures (ICC >0.85). Conclusion. There are consistent angles between tibial alignment and ankle landmarks. Using these landmarks, with standard instrumentation and alignment checks, allows surgeons to define safe limits, e.g. maximum 4.8° tibial varus if aligned to the tip of the lateral malleolus or set a 2.5° varus cut, without the need for added technology

Aims. Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results. There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion. Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352–8

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

There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding. We aimed to assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the Bone Mineral Density (BMD) of the medial and lateral malleoli before and after Mobility total ankle replacement. Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and postoperative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed. The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865). The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus

Introduction: There is limited literature available looking into circumstances surrounding the development of stress fracture of the medial and lateral malleoli after ankle replacement. We present the preliminary results of a prospective study examining the effect of ankle replacement upon local bone mineral density and the phenomenon of stress shielding. Aim: To assess the effect of ankle replacement loading of the medial and lateral malleoli, by analysing the BMD of the medial and lateral malleoli before and after Mobility total ankle replacement. Methodology: Ten consecutive patients undergoing Mobility total ankle replacement for osteoarthritis had pre-operative bone densitometry scans of the ankle, repeated at 6 months after surgery. The bone mineral density of a 2 cm square area within the medial malleolus and lateral malleolus was measured. The pre-operative and post-operative bone densitometry scans were compared. The relation between the alignment of the tibial component and the bone mineral density of the malleoli was also analysed. Results: The mean preoperative BMD within the medial malleolus improved from 0.57g/cm2 to mean 6 months postoperative BMD of 0.62g/cm2. The mean preoperative BMD within the lateral malleolus decreased from 0.39g/cm2 to a mean 6 months postoperative BMD of 0.33g/cm2. The mean alignment of the tibial component was 88.50 varus (range 850 varus to 940 valgus). However, there was no correlation between the alignment of the tibial component and the bone mineral density on the medial malleolus (r = 0.09, p = 0.865). Conclusion: The absence of stress shielding around the medial malleolus indicates that ankle replacements implanted within the accepted limits for implant alignment, load the medial malleolus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in the lateral malleolus

We present a series of 16 patients treated between 1993 and 2006 who had a failed total ankle replacement converted to an arthrodesis using bone grafting with internal fixation. We used tricortical autograft from the iliac crest to preserve the height of the ankle, the malleoli and the subtalar joint. A successful arthrodesis was achieved at a mean of three months (1.5 to 4.5) in all patients except one, with rheumatoid arthritis and severe bone loss, who developed a nonunion and required further fixation with an intramedullary nail at one year after surgery, before obtaining satisfactory fusion. The post-operative American Orthopaedic Foot and Ankle Society score improved to a mean of 70 (41 to 87) with good patient satisfaction. From this series and an extensive review of the literature we have found that rates of fusion after failed total ankle replacement in patients with degenerative arthritis are high. We recommend our method of arthrodesis in this group of patients. A higher rate of nonunion is associated with rheumatoid arthritis which should be treated differently

We assessed the long-term (20 years) outcome of closed reduction and immobilisation in 19 patients with an isolated fracture of the posterior malleolus of the ankle treated at a single hospital between 1985 and 1990. The assessments used were an Olerud functional questionnaire score, physical examination using a loaded dorsal and plantar range of movement measurement, radiological analysis of medial joint space widening, the Cedell score for anatomical alignment of all three malleoli, and the radiological presence of osteoarthritic change. . There were excellent or good results in 14 patients (74%) according to the Olerud score, in 18 patients (95%) according to loaded dorsal and plantar range of movement assessment, in 16 patients (84%) as judged by the Cedell score, and for osteoarthritis 18 patients (95%) had an excellent or good score. There were no poor outcomes. There was no correlation between the size of the fracture gap and the proportion of the tibiotalar contact area when compared with the clinical results (gap size: rho values -0.16 to 0.04, p ≥ 0.51; tibiotalar contact area: rho values -0.20 to -0.03, p ≥ 0.4). Conservative treatment of ‘isolated’ posterior malleolar fractures resulted in good clinical and radiological outcome in this series at long-term follow-up.

Introduction. The position and orientation of the lower extremities are fundamental for planning and follow-up imaging after arthroplasty and lower extremity osteotomy. But no studies have reported the reproducibility of measurements over time in the same patient, and experience shows variability of the results depending on the protocols for patient positioning. This study explores the reproducibility of measurements in the lower extremity with the patients in “comfortable standing position” by the EOS® imaging system. Materials and Methods. Two whole-body acquisitions were performed in each of 40 patients who were evaluated for a spine pathology. The average interval between acquisitions was 15 months (4–35 months). Patients did not have severe spine pathology and did not undergo any surgery between acquisitions. The “comfortable standing position” is achieved without imposing on the patient any specific position of the lower limbs and pelvis. All the measurements were performed and compared in both 2- and 3-dimensional images. Distances between the centers of the femoral heads and between the centers of the knees and ankles were measured from the front. The profile is shown by the flexion angle between the axis of the femur (center of the femoral head and the top of the line Blumensaat) and the axis of the tibia. Results. The average radiation dose was 0.80 mGy (0.5–1.11). For the first acquisition, the mean distance between the femoral heads was 17.9 cm (15.8–20.2), the mean distance between the middle of the knee joints was 16.7 cm (11.2–23.1) and the mean distance between the medial malleoli was 13.1 cm (0 to 18). For the second acquisition, the mean distance between the femoral heads was 17.9 cm (14.9–21.5), the mean distance between the middle of the knee joints was 16.9 cm (11.4–23.1) and the mean distance between the medial malleoli was 13.6 cm (0–19.4). For all comparisons no significant difference was demonstrated in related samples by Wilcoxon rank test and paired Student t test. Discussion. Two- and 3-dimensional data are not affected by repeated acquisitions several to many months apart in “comfortable standing position.” This work shows the reproducibility of measurements of the lower extremity in the “comfortable standing position” by the EOS® imaging system. Additional research should be considered for combined measures in the face-profile position of each patient

Background Computer navigation is increasingly being recognized as a valuable tool in restoring the mechanical axis post TKR. Its use is as yet not universal due to the costs involved, its availability and the fact that it can be cumbersome and time consuming to use. Additionally it requires the insertion of Schanz pins in the femur as well as the tibia which can be a matter of concern as regards stress fracture and infection. However, it is able to reliably locate the center of the femoral head which is an elusive landmark in the standard method. The center of the ankle involves registration for the medial and lateral malleoli which are subcutaneous and easily palpable. We decided to navigate only the distal femoral cut with a specialized navigation unit called Articular Surface Mounted navigation which does not require the insertion of additional pins through the femur or the tibia. We purposely did not use navigation for the rest of the bony cuts as all the other landmarks i.e. femoral epicondyles, tibial malleoli, and tuberosity etc are all easily palpable. This dramatically reduced the surgical time and increased its user friendliness. We are presenting our results. Aim. To analyse the radiographic results obtained with selective femoral navigation and compare with. standard navigational results from the literature. Non-navigated Knees form personal series. Materials and Methods. We have utilized the ASM navigation for distal femoral cut in 112 knees and obtained long X-rays (scanograms) and routine knee X-rays (AP, Lateral and skyline) to study the mechanical axis and component positioning. We measured the mechanical axis deviation, femoral and tibial angle on AP and lateral films and patellar tilt or subluxation on post-operative X-rays by a digital imaging programme called Image–J. (As suggested by the Knee Society roentgenographic Score). We have compared our results with other navigated series from literature and our own series of non-navigated knees. (113 knees) We also noted the surgical time to perform the operation and the occurrence of any complications. Results. Selective femoral navigation is able to restore the mechanical axis as reliably as other methods of navigation and more reliably than non-navigated knees. On an average, it adds less than 10 minutes to surgical time. Femoral angle, tibial angle patellar tilt and subluxation are similar in both navigated and non-navigated series. Navigation use was not associated with any increased complications and no complication could be ascribed to its use. Selective femoral navigation reduced the outliers in mechanical axis restoration when compared with standard femoral intrameduallry instrumentation. Discussion. Selective distal femoral navigation is a reliable tool in restoring mechanical axis post TKR. It is particularly valuable in knees that have pronounced femoral bowing

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Incorrect registration during computer assisted total knee arthroplasty (CA-TKA) leads to malposition of implants. Our aim was to evaluate the tolerable error in anatomic landmark registration. We incorrectly registered the femoral epicondyles, femoral and tibial centers, as well as the malleoli and documented the change in angulation or rotation. We found that the distal femoral epicondyles were the most difficult anatomic landmarks to register. The other bony landmarks were more forgiving. Identification of the distal femoral epicondyles has a high inter- and intra-observer variability. Our observation that there is less than 2 mm of safe zone in the anterior or posterior direction during registration of the medial and lateral epicondyles may explain the inability of CA-TKA to improve upon the outcomes of conventional TKA

Aims

Pelvic discontinuity is a challenging acetabular defect without a consensus on surgical management. Cup-cage reconstruction is an increasingly used treatment strategy. The present study evaluated implant survival, clinical and radiological outcomes, and complications associated with the cup-cage construct.

Traditional screw fixation of the syndesmosis can be prone to malreduction. Suture button fixation however, has recently shown potential in securing the fibula back into the incisura even with intentional malreduction. Yet, if there is sufficient motion to aid reduction, the question arises of whether or not this construct is stable enough to maintain reduction under loaded conditions. To date, there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress CT model. Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator frame that allows for the application of sustained torsional (5 Nm), axial (500 N) and combined torsional/axial (5Nm/500N) loads. Baseline CT scans of the intact ankle under unloaded and loaded conditions were obtaining. The syndesmosis and the deltoid ligament complex were then sectioned. The limbs were then randomised to receive a suture button construct tightened at 4 kg force (loose), 8 kg (standard), or 12 kg (maximal) of tension and CT scans under loaded and unloaded conditions were again obtained. Eight previously described measurements were taken from axial slices 10 mm above the tibiotalar joint to assess the joint morphology under the intact and repair states, and the three loading conditions: a measure of posterolateral translation (a, b), medial/lateral translation (c, g), a measure of anterior-posterior translation (f), a ratio of anterior-posterior translation (d/e), an angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula, and an angle (Angle 2) created between the medial surfaces of two malleoli. These measurements have all been previously described. Each measurement was taken at baseline and compared with the three loading scenarios. A repeated measures ANOVA with a Bonferroni correction for multiple comparisons was used to test for significance. Significant lateral (g, maximum 5.26 mm), posterior (f, maximum 6.42 mm), and external rotation (angle 2, maximum 11.71°) was noted with the 4 kg repair when compared to the intact, loaded state. Significant posterior translation was also seen with the both the 8 kg and 12 kg repairs, however the incidence and magnitude was less than with the 4 kg repair. Significant overcompression (g, 1.69 mm) was noted with the 12 kg repair. Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. If inserted too loosely, these constructs allow for supraphysiologic motion which may have negative implications on ligament healing. These constructs also demonstrate overcompression of the syndesmosis when inserted at maximal tension however the clinical effect of this remains to be determined

We present a simple seated dial test that can be used by a single examiner in the acute or chronic situation to diagnose posterolateral corner knee injury. In the acute setting a traditional prone dial test can be cumbersome and painful for patients. Therefore a supine technique can be utilised, however this requires an assistant in order to hold the knees together with the tibia in a reduced position. We therefore utilise a seated technique in which the patient sits with their knees flexed over the edge of the examination couch. The patient is then able to hold their knees together, negating the need for an assistant. The sensitivity of a dial test is improved if the knee is reduced and so with this technique the tibia will be held in the anatomical position by the examination couch. The patients' feet are grasped with both medial malleoli together and then an external rotation moment is exerted at 30 and 90 degrees of flexion measuring the thigh-foot angle or visualising the tibial tuberosities. A positive test being 10 degrees or more of increased external rotation in the affected knee. This test is similar to the Spin test however it relies on the tactile sensation of posterolateral tibial rotation. This can be difficult to elicit in the acute situation due to haemarthrosis. Simultaneous side-to-side comparison is also not possible. A further disadvantage of the Spin test is that it can only be performed at 90 degrees of flexion and so only applies in combined PCL and posterolateral corner repair. In conclusion we believe that this modification of the standard dial test is a simple to perform accurate method for assessing posterolateral corner knee injury in the acute and chronic setting