Aims. Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis. Methods. The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently. Results. Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications. Conclusion. TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity. Cite this article: Bone Jt Open 2024;5(3):252–259

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. Methods. We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates. Results. The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes. Conclusion. The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results. Cite this article: Bone Jt Open 2024;5(3):227–235

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

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. 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

Aims

Involvement of the posterior malleolus in fractures of the ankle probably adversely affects the functional outcome and may be associated with the development of post-traumatic osteoarthritis. Anatomical reduction is a predictor of a successful outcome.

The purpose of this study was to describe the technique and short-term outcome of patients with trimalleolar fractures, who were treated surgically using a posterolateral approach in our hospital between 2010 and 2014.

Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. Methods. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Results. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. Conclusion. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229–1241

Introduction. The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Methods. We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system. Results. The PITFL insertion on the posterior aspect of the tibia is very large. The average size of insertion was 54.9×47.1mm across the posterior aspect of the tibia. Medially the PITFL blends into the sheath of tibialis posterior and laterally into the peroneal tendon sheath. 78 posterior lateral and 35 posterior medial fragments were measured. On average, the lateral to medial size of the posteromalleolar fragment was 24.5mm in the posterolateral fragment, and 43mm if there is a posteromedial fragment present also. The average distal to proximal size of the posterolateral fragment was 24.5mm and 18.5mm for the posteromedial fragment. Conclusion. The PITFL insertion on the tibia is broad. In comparison to the average size of the posterior malleolar fragments, the PITFL insertion is significantly bigger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur. This explains the finding by Mason and Molloy that only 49% of type 2 injuries had a syndesmotic injury on testing

Management of complex posterior malleolar fractures requires a detailed appreciation of ligamentous and bony anatomy for optimal fracture fixation and restoration of articular congruency. Pre operative planning is vitally important to determine the surgical strategy for complex ankle fractures. We evaluated pre operative planning strategy pre and post implementation of BOAST 12 guidelines (2016) focussing on pre operative CT scans prior to definitive fixation at a major trauma centre. A multi-surgeon retrospective review of prospectively collected data from 2013 to 2018 was performed at a major trauma centre. Patients who had sustained a posterior malleolar fracture and definitive fixation were identified. Information was collated from PICS, PACS, the trauma database and operative notes. 134 patients were identified over a 5 year period who had sustained a posterior malleolar fracture and had definitive fixation. (Pre BOAST guidelines = 61, Post BOAST guidelines = 73). Prior to the implementation of BOAST guidelines ¼ with posterior malleolar fractures did not have a pre operative CT scan (15/61). Post implementation of BOAST 12 90% (66/73)patients with fixation of posterior malleolus fractures had a pre operative CT scan. Posterior malleolus surgery most commonly took place In patients between 18–30 years. Following implantation of BOAST 12 guidelines there was a 15% increase in pre operative CT scanning for ‘complex ankle fractures'. Changes in national guidelines have heavily influenced pre operative planning strategy for ankle fractures at University Hospitals Birmingham. A detailed appreciation of fracture pattern pre operatively helps guide surgical strategy

Aims. The rationale for exacting restoration of skeletal anatomy after unstable ankle fracture is to improve outcomes by reducing complications from malunion; however, current definitions of malunion lack confirmatory clinical evidence. Methods. Radiological (absolute radiological measurements aided by computer software) and clinical (clinical interpretation of radiographs) definitions of malunion were compared within the Ankle Injury Management (AIM) trial cohort, including people aged ≥ 60 years with an unstable ankle fracture. Linear regressions were used to explore the relationship between radiological malunion (RM) at six months and changes in function at three years. Function was assessed with the Olerud-Molander Ankle Score (OMAS), with a minimal clinically important difference set as six points, as per the AIM trial. Piecewise linear models were used to investigate new radiological thresholds which better explain symptom impact on ankle function. Results. Previously described measures of RM and surgeon opinion of clinically significant malunion (CSM) were shown to be related but with important differences. CSM was more strongly related to outcome (-13.9 points on the OMAS; 95% confidence interval (CI) -21.9 to -5.4) than RM (-5.5 points; 95% CI -9.8 to -1.2). Existing malunion thresholds for talar tilt and tibiofibular clear space were shown to be slightly conservative; new thresholds which better explain function were identified (talar tilt > 2.4°; tibiofibular clear space > 6 mm). Based on this new definition the presence of RM had an impact on function, which was statistically significant, but the clinical significance was uncertain (-9.1 points; 95% CI -13.8 to -4.4). In subsequent analysis, RM of a posterior malleolar fracture was shown to have a statistically significant impact on OMAS change scores, but the clinical significance was uncertain (-11.6 points; 95% CI -21.9 to -0.6). Conclusion. These results provide clinical evidence which supports the previously accepted definitions. Further research to investigate more conservative clinical thresholds for malunion is indicated. Cite this article: Bone Jt Open 2022;3(10):841–849

Summary. Quantification of Three-Dimensional Computed Tomography (Q3DCT) is a reliable and reproducible technique to quantify and characterise ankle fractures with a posterior malleolar fragment (. www.traumaplatform.org. ). This technique could be useful to characterise posterior malleolar fragments associated with specific ankle fracture patterns. Introduction. Fixation of posterior malleolar fractures of the ankle is subject of ongoing debate1. Fracture fixation is recommended for fragments involving 25–30% of articular surface1. However, these measurements -and this recommendation- are based on plain lateral radiographs only. A reliable and reproducible method for measurements of fragment size and articular involvement of posterior malleolar fractures has not been described. The aim of this study is to assess the inter-observer reliability of Quantification using Three-Dimensional Computed Tomography (Q3DCT) –modelling. 2,3,4,5. for fragment size and articular involvement of posterior malleolar fractures. We hypothesize that Q3DCT-modelling for posterior malleolar fractures has good to excellent reliability. Patients & Methods. To evaluate inter-observer reliability of Q3DCT-modelling, we included a consecutive series of 43 patients with an ankle fracture involving the posterior malleolus and a complete radiographic documentation (radiographs and computed tomography) Fractures of the tibial plafond (pilon type fractures) were excluded. These 43 patients were divided in 3 different types (Type I, II or III) as described by Haraguchi6. Five patients of each type were randomly selected for an equal distribution of articular fragment sizes. 3D models were reconstructed by 1) creating a mask for every respective slice; 2) select the appropriate dots that separate fracture from tibialshaft; 3) connect masks of each respective slice; and 4) reconstruct a 3D-mesh. After reconstruction of 3D-models, 1) fragment volume; 2) articular surface of the posterior malleolar fragment; 3) articular surface of intact tibia and 4) articular surface of the medial malleolus were calculated by all three observers. A summary of this technique is shown on . www.traumaplatform.org. The inter-observer reliability of these measurements was calculated using the ICC, which can be interpreted as the kappa coefficient. Results. Measurements of the volume of posterior malleolar fracture fragments ranged from 357 to 2904 mm3 with an ICC of 1.00 (Confidence interval (CI) 0.999 – 1.000) Measurements of the articular surface of the posterior malleolar fracture fragment ranged from 25 to 252 mm2 with an ICC of 0.998 (CI 0.996 – 0.999); the articular surface of the intact tibia plafond ranged from 375 to 1124 mm2 (ICC 0.998, CI 0.996 – 0.999); and the articular surface of the medial malleolus ranged from 79 to 149 mm2 (ICC 0.978, CI 0.978 – 0.911). The categorical ratings for all ICC's were defined as almost perfect according to the system of Landis7. Discussion/Conclusion. This study showed that our Q3DCT-modelling technique. 2,3,4,5. is reliable and reproducible to reconstruct ankle fractures, in order to assess fracture characteristics of posterior malleolar fracture fragments. Future research will focus on the association between overall ankle fracture patterns according to Lauge-Hansen, and characterization of posterior malleolar fragment morphology. We hypothesise that supination-exorotation type fractures are associated with smaller (in volume and involved articularsurface) “pull-off” fragments, while pronation-exorotation type ankle fractures are associated with larger (in volume and involved articular surface) “push-off” fragments. The clinical relevance might be that smaller “pull-off” type fractures benefit from positioning screws, while larger “push-off” type fractures require direct open reduction and internal fixation of the posterior malleolar fragment

Background. There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. In our previous multicenter study (Powell, BOFAS 2016) we showed that the Olerud-Molander Ankle Score (OMAS) was 79 for unimalleolar fractures and 65 for bi malleolar fractures, however it dropped significantly to 54 in trimalleolar fractures. In creating a treatment guiding classification, we report our results in a system change in management of posterior malleolar fractures in our unit. Method. All fractures were classified according to Mason and Molloy classification (BOFAS 2015, FAI 2017) based on CT scans obtained pre-operatively. This dictated the treatment algorithm. Type 1 fractures underwent syndesmotic fixation. Type 2A fractures underwent ORIF through a posterolateral incision, and type 2B and 3 fractures underwent ORIF through a posteromedial incision. The patient remained NWB for 6 weeks postoperative. Data was collected from December 2014 to July 2017. Results. Patient related outcome measures were obtained in 50 patients with at least 6 month follow up (mean 18 months). According to Mason and Molloy classification there were 17 type 1, 12 type 2A, 10 type 2B and 11 type 3. The mean OMAS for type 1 was 75.9 (Range 30–100, SD 18.4), type 2A 75.0 (range 35–100, SD 21.3), type 2B 74.0 (range 55–100, SD 13.7) and type 3 70.5 (Range 35–100, SD 17.1). An increase in OMAS of 4 is clinically significant. Conclusion. We have been able demonstrate an improvement in OMAS for all posterior malleolar fractures with the treatment algorithm applied using the Mason and Molloy classification. Compared to our previous study we have successfully increased our OMAS scores to what would be expected from unimalleolar fractures. Mason and Molloy type 3 fractures have marginally poorer outcomes, which correlates with a more significant injury, however this does not reach statistical significance

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture, who underwent a CT. The Mason and Molloy posterior malleolus fracture classification system was used. Results. 764 diaphyseal tibial fractures were analysed, 300 had a CT. 127 were intra-articular fractures. 83 (27.7%) were classifiable using Mason and Molloy classification. There were 8 type 1 (9.6%), 43 type 2 (51.8%), 5 type 2B (6.0%) and 27 type 3 (32.5%). 90.4% (n=75) of the posterior malleolar fractures, were undisplaced. The majority of PM fractures occurred in type 42A1 (65 of 142 tibia fractures) and 42B1 (11 of 16). Conclusions. Most PM fractures occurred after a rotational mechanism. Unlike, the PM fractures of the ankle, the majority of PM fractures associated with tibia fractures are undisplaced. We theorise that unlike the force transmission in ankle fractures where the rotational force is in the axial plane in a distal-proximal direction, in the PM fractures related to fractures of the tibia, the rotational force in the axial plane progresses from proximal-distal. Therefore, the force transmission which exits posteriorly, finally dissipates the force and thus unlikely to displace

Abstract. Objectives. Ankle fractures have an incidence of around 90,000 per year in the United Kingdom. They affect younger patients following high energy trauma and, in the elderly, following low energy falls. Younger patients with pre-existing comorbidities including raised BMI or poor bone quality are also at risk of these injuries which impact the bony architecture of the joint and the soft tissues leading to a highly unstable fracture pattern, resulting in dislocation. At present, there is no literature exploring what effect ankle fracture-dislocations have on patients’ quality of life and activities of daily living, with only ankle fractures being explored. Methods. Relevant question formatting was utilised to generate a focused search. This was limited to studies specifically mentioning ankle injuries with a focus on ankle fracture-dislocations. The number of patients, fracture-dislocation type, length of follow up, prognostic factors, complications and outcome measures were recorded. Results. 939 fractures were included within the studies. Eight studies looked at previously validated foot and ankle scores, two primarily focused on the American Orthopaedic Foot and Ankle Society score (AOFAS), three on the Foot and Ankle Outcome Score (FAOS), and one study on the Olerud–Molander Score (OMAS). Patient, injury, and management factors were identified as being associated with poorer clinical outcomes. Conclusions. Not only are age and BMI a risk factor for posttraumatic osteoarthritis but they were also identified as prognostic indicators for functional outcome in this review. Patients sustaining a concurrent fracture-dislocation were found to have poorer clinical outcomes, and the timing and success of reduction further influenced outcomes. This review found that the quality of reduction was directly related to the patients’ functional outcomes post-follow up, and the risk of developing posttraumatic osteoarthritis, which was more frequent in patients sustaining Bosworth fractures, posterior malleolar fractures, and in patients over 35 years old

The April 2012 Trauma Roundup. 360 . looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries

The August 2015 Foot & Ankle Roundup. 360 . looks at: Is orthosis more important than physio in tibialis posterior deficiency?; Radiographic evaluation of ankle injury; Sciatic catheter quite enough!; A fresh look at avascular necrosis of the talus; Total ankle and VTE; Outcomes of posterior malleolar fracture; Absorbable sutures in the Achilles tendon; Lisfranc injuries under the spotlight

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

1. A method of treatment of posterior malleolar fracture is described which restores the proximal surface of the ankle joint to its normal position. 2. Reduction is achieved with a special clamp and the position held with a strong plate. Early ankle movements may therefore be encouraged without fear of redisplacing the fracture. 3. Perfect reduction is necessary to avoid the later onset of arthritis, and this was achieved in five of six patients reported

Introduction. Posterior malleolar fractures are present in up to 44% of all ankle fractures. Those involving > 25% of the articular surface have a higher rate of posterior ankle instability which may predispose to post traumatic arthritis. The posterolateral approach to the distal tibia allows direct reduction and stabilization of the posterior malleolus and concomitant lateral malleolus fractures. An anatomical study was performed to establish the safe zone of proximal dissection to avoid injury to the peroneal vessels in this uncommon approach. Methods. 26 unpaired adult lower limbs were dissected using the posterolateral approach to the distal tibia as described by Tornetta et al. The peroneal artery was identified coursing through the intraosseous membrane on deep dissestion as the flexor hallucis longus muscle was reflected medially. The level of its bifurcation was also noted over the tibia. Perpendicular measurements were made from the tibial plafond to these variable anatomical locations. Results. The peroneal artery bifurcated at 83+/−21 mm (41–115mm) proximal to the tibial plafond and perforated through the interossoeus membrane 64+/−18 mm (47–96mm) proximal to the tibial plafond. Conclusion. The safe zone for the posterolateral approach to the distal tibia is described. Caution is advised as the bifurcation and perforating artery may be as little as 41mm from the tibial plafond. This is important during deep dissection when the belly of the flexor hallucis longus muscle is reflected medially from the medial edge of the fibula. Once the peroneal artery was mobilized a buttress plate could easily be placed beneath it

The posterolateral approach to ankle joint is well suited for ORIF of posterior malleolar fractures. There are no major neurovascular structures endangering this approach other than the sural nerve. The sural nerve is often used as an autologous peripheral nerve graft and provides sensation to the lateral aspect of the foot. Hence every attempt must be made to protect the sural nerve. The aim of this paper is to measure the precise distance of the sural nerve from surrounding soft tissue structures. This is a retrospective image review study including patients with MRI of their ankle from January 09 - Nov 2010. We indentified 78 MRI scans out of which 64 were deemed eligible for assessment. All measurements were made from Axial T1 slices. Measurements were made from the lateral aspect of the TA to the central of the sural nerve, central of sural nerve to the posterior aspect of the peronei muscles and central of the sural nerve to the posterior aspect of fibula. Data were collected on a Microsoft Excel spreadsheet and the descriptive statistics calculated. The key findings of the paper is the safety window for the sural nerve from the lateral border of TA is 7mm, 1.3cm and 2cm at 3 cm above ankle joint, at the ankle joint and at the distal tip of fibula respectively. Similarly the safety window for the nerve from the posterior aspect of fibula is 2cm, 1.6cm, 1.6cm at 3cm above ankle, at the ankle joint and the distal tip of fibula respectively. Our study demonstrates the close relationship of the nerve in relation to tendoachilles, peronei and fibula in terms of exact measurements. The safety margins established in this study should enable the surgeon in preventing endangerment of the sural nerve encountered in this approach