Introduction. In this cohort study, the TightRope® fixation technique has been compared with the traditional screw fixation for ankle syndesmosis injuries, with respect to the accuracy of the syndesmotic reduction and their clinical correlation. Patients and Methods. This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial CT scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. More than 2 mm widening of syndesmosis as compared to normal contra-lateral ankle was considered as significant malreduction. Clinical outcomes were measured using AOFAS and FADI Scores. Results. Forty-six out of 55 eligible patients attended for the study. Twenty three patients were in the tightRope group and 23 in the syndesmosis screw group. Mean follow-up was 2.5 (1.5–3.5) years. Average age was 41.6 years in tightrope group and 39.8 years in syndesmosis screw group. The mean width of normal syndesmosis was 4.01 + 0.89 mm. In tightRope group the mean width of syndesmosis was 4.37 + 1.12 mm (t-test, p = 0.30) as compared to 5.16 + 1.92 mm in screw group (t-test, p = 0.01). Five (21.7%) out of 23 ankles in screw group had syndesmotic mal reduction, while none of the tightRope group showed mal-reduction on CT scans (fisher's exact test, p = 0.04). There was no significant difference in mean post operative AOFAS score (89.56 and 86.52) and FADI score (82.42 and 81.22) between two groups. Conclusion. The results of this study indicate that tightRope provides more accurate method of syndesmosis stabilization as compared with screw fixation. Syndesmosis malreduction is the most important independent predictor of clinical outcomes; therefore care should be taken to reduce the syndesmosis accurately

Classical AO teaching recommends that a syndesmosis screw should be inserted at 25 to 30 degree angle to the coronal plane of the ankle. In practice accurately judging the 25/30 degree angle can be difficult, and there are several reports based on post operative CT scans demonstrating that a significant minority of patients have poorly operatively reduced syndesmotic injuries. The CT scans of 200 normal ankles in one hundred individuals which had been performed as part a CT angiogram were retrospectively examined. The centroid of the fibula and tibia in the axial plane 15mm proximal to the talar dome was calculated. Since a force vector between the centroid of the fibula and the tibia in the axial plane should not displace the fibula relative to the tibia, a line connecting the two centroids was therefore postulated to be the ideal syndesmosis line, and also the optimum position in which to place a compression clamp after reducing the syndesmosis. Where this ideal line passed through the lateral border of the fibula, and through the medial malleolus was then noted. The ideal syndesmosis line was shown to pass through the fibula with in 2mm of the lateral cortical apex of the fibula, and the anterior half of the medial malleolus in 100% of the ankles studied. The results support the concept that in the operatively reduced syndesmosis, the anterior half of the medial malleolus can be used as a reliable guide for aiming the syndesmosis drill hole, provided that the fibular entry point is at or adjacent the lateral fibular apex. The corollary of these findings is that a screw inserted through a plate on the standard antero-lateral border of the fibula, or a plate in the anti-glide position posteriorly, cannot lie in the centroidal axis of the ankle

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT. This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF. Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position. Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers

Flexible fixation techniques combined with anatomic (open) syndesmosis reduction have demonstrated improved functional outcomes and rates of malreduction. Suture-button devices allow physiologic motion of the syndesmosis without need for implant removal, which may lower the risk of recurrent syndesmotic diastasis. There is limited longer-term assessment of the maintenance of reduction between static and flexible syndesmotic fixation using bilateral ankle CT evaluation. This is an a priori planned subgroup analysis of a multi-centre, randomized clinical trial comparing static syndesmosis fixation (two 3.5 mm screws) with flexible fixation (single knotless Tightrope) for patients with AO- OTA 44-C injuries. Patients who completed bilateral ankle CT scans at 3- and 12-month follow-up were included. The primary outcome measure was syndesmotic malreduction based on bilateral ankle CT scans, using the uninjured, contralateral ankle as a control. Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance were calculated to measure syndesmosis reduction. Secondary outcomes included re-operation, adverse events and functional outcomes including the EQ5D, Olerud-Molander Ankle Score (OM), Foot and Ankle Disability Index (FADI), and Work Productivity Activity Impairment Questionnaire (WPAI). Paired samples t-tests were used to compare injured to control ankles (R, v 3.5.1). 42 patients (24 Group S, 18 Group T) were included. ASD for Group T was 5.22mm (95%CI 4.69–5.77) at 3 months compared to 4.26mm (95%CI 3.82–4.71; p=0.007) in controls and 5.38mm (95%CI 4.72–6.04) at 12 months compared to 4.44mm (95%CI 3.73–5.16; p=0.048) in controls. ASD for Group S was 4.63mm (95%CI 4.17– 5.10) at 3 months compared to 4.67mm (95%CI 4.24–5.10; p=0.61) in controls, but significantly increased to 5.73mm (95%CI 4.81–6.66) at 12 months compared to 4.65mm (95%CI 4.15–5.15; p=0.04) in controls. MSD results were similar; Group T had a larger MSD than control ankles at 3 months (p=0.03) and 12 months (p=0.01), while the MSD in Group S was not different at 3 months (p=0.80) but increased at 12 months (p=<0.01). 88% (21/24) of Group S had broken or removed screws by 12 months. Unplanned re-operation was 15% in Group S and 4% in Group T (p=0.02), with an overall re-operation rate of 30% in Group S. There was no significant difference between treatment groups for EQ-5D, OM, FADI or WPAI at 3- or 12-month follow-up. Tightrope fixation resulted in greater diastasis of the ASD and MSD compared to contralateral, uninjured ankles at 3- and 12-months post-fixation. Group S initially had syndesmotic reduction similar to control ankles, but between 3- and 12-months post-fixation, there was significantly increased syndesmosis diastasis compared to controls. The majority of Group S (88%) had either broken screws or scheduled screw removal, which may explain the increased tibio-fibular diastasis seen at 12-months

The syndesmosis ligament complex stabilizes the distal tibiofibular joint, while allowing for the subtle fibular motion that is essential for ankle congruity. Flexible fixation with anatomic syndesmosis reduction results in substantial improvements in functional outcomes. New dynamic CT technology allows real-time imaging, as the ankle moves through a range of motion. The aim of this study was to determine if dynamic CT analysis is a feasible method for evaluating syndesmosis reduction and motion following static and flexible syndesmosis fixation. This is a subgroup analysis of a larger multicenter randomized clinical trial, in which patients with AO 44-C injuries were randomized to either Tightrope (one knotless Tightrope, Group T) or screw fixation (two 3.5-mm cortical screws, Group S). Surgical techniques and rehabilitation were standardized. Bilateral ankle CT scans were performed at one year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). Three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: anterior, midpoint, and posterior tibiofibular distances. T-tests compared Group T and Group S, and injured and uninjured ankles in each group. Fifteen patients (six Group T [three male], nine Group S [eight male]) were included. There was no difference for mean age (T = 42.8 ± 14.1 years, S = 37 ± 12.6, P = 0.4) or time between injury and CT scan (T = 13 ± 1.8 months, S = 13.2 ± 1.8, P = 0.8). Of note in Group S, seven of nine patients had at least one broken screw and one additional patient had screws removed by the time of their dynamic CT. There was no significant difference between treatment groups for tibiofibular distance measurements in maximal PF or DF. Group T showed no significant difference between the injured and uninjured side for tibiofibular measurements in maximal PF and DF, suggesting anatomic reduction. For Group S, however, there was a significantly larger distance for all three measurements at maximal PF compared to the uninjured ankle (all P < 0 .05). In all but one Group S patient, screws were broken or removed prior to their dynamic CT, allowing possible increased syndesmotic motion, similar to Group T. Despite this, dynamic CT analysis detected increased tibiofibular distance in Group S as ankles moved into maximal PF when compared with the uninjured ankle. Given the importance of anatomic syndesmosis reduction, dynamic ankle CT technology may provide valuable physiologic information warranting further investigation

Malreduction of the syndesmosis is a poor prognosticator following ankle fracture and has been documented in as many as 52% of patients following fracture fixation. The current standard for assessment of reduction of the syndesmosis is bilateral computed tomography (CT) scan of the ankle. Multiple radiographic parameters are utilized to define malreduction, however, there has been limited investigation into the accuracy of these measurements to differentiate malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles. Bilateral lower extremity CT scans including ankles were screened. Studies were excluded if the patient was skeletally immature, had pathology below the knee or if they had congenital neuromuscular syndromes. The resulting cohort consisted of 207 patients. The indication for bilateral CT scan was femoral acetabular impingement in 110 patients (53%), rotation assessment following arthroplasty in 32 patients (15%), rotation assessment following femoral fracture in 30 patients (14%), rotational assessment for patellar instability in 30 patients (14%) and five miscellaneous indications (2%). Fifty patients were reviewed by three observers independently and to determine inter-observer reliability. A single observer repeated the measurements within the same cohort four weeks later to evaluate intra-observer reliability. Three observers then measured the anterior syndesmotic distance, posterior syndesmotic distance, central syndesmotic distance, fibular rotation and sagittal fibular translation at 1cm from the distal tibial articular surface. Overall side to side variability between the left and right ankle were assessed. Previously studied malreduction standards were evaluated. These included: anterior to posterior syndesmotic distance > 2mm, central syndesmotic difference > 1.5mm, average syndesmotic distance > 2mm, fibular rotational difference > 10o and sagittal translational difference > 2mm. The inter- and intra-observer reliability was good to excellent for anterior, posterior and central syndesmotic distance, and fibular rotation measurements. Sagittal fibular translation had an ICC of 0.583, and thus was only of fair reliability. Side to side comparison revealed statistically significant difference in only anterior syndesmotic difference (p=0.038). A difference of anterior to posterior syndesmotic distance of greater than 2mm was observed in 43 patients (20.2%). Thirty eight patients (17.8%) had a central syndesmotic difference of greater than 1.5mm. A fibular rotational difference of greater than 10o was observed in 49 patients (23%). The average difference between the anterior and posterior syndesmosis was greater than 2mm in 17 patients (8.2%). Nine patients (4.2%) had sagittal translation of greater than 2mm. Eighty one patients (39%) demonstrated at least one parameter beyond previously set standards for malreduction. Only one parameters was anomalous in 54 patients (26%), 18 patients (8%) had two positive parameters, while eight patients (4%) had three. One patient was asymmetrical in all measured parameters. In this study there was no statistically significant asymmetry between ankles. However, 39% of native syndesmoses would be classified as malreduced on CT scan using previously studied malreduction limits. Current radiographic parameters are not sufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis

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

Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain. Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity. 153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture. We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly

We report on the first clinical cases of the Arthrex Ankle Syndesmosis TightRope (winner of 2003 BOA Technological Achievement Award and 2004 Cutlers' Prize), which has recently been licensed for use where classically a syndesmosis screw would be used. Twelve patients with Weber C ankle fractures treated with Arthrex TightRope syndesmosis fixation have a minimum of six months follow-up. The syndesmosis was fixed with the ankle in plantarflexion to aid reduction. Patient demographics, including fracture classification and mode of injury were obtained. Parameters measured at follow-up included ankle range of motion, maintenance of reduction and fibular length, and AOFAS ankle outcome score. The patient cohort showed a typical bimodal distribution of age. Age over 65 years was associated with a poorer outcome. Five patients had ankle fracture-dislocations, which was a factor for a poorer outcome. Nine patients had fibular plate fixation in addition to syndesmosis fixation, whilst three patients with Maisonneuve injuries had syndesmosis fixation only. There were no major complications, loss of reduction, wound problems, implant loosening or osteolysis. Ankle dorsiflexion was not restricted and mean total ankle range of motion was comparable to the uninjured side. No patient required secondary surgery for any reason, including hardware removal. Arthrex TightRope fixation is a simple, safe and effective method of ankle syndesmosis fixation, which allows physiological micromotion. Fixation in plantarflexion provides optimum syndesmosis compression for reduction, and does not compromise ankle range of motion. The Arthrex Ankle Syndesmosis TightRope may become the treatment of choice in Weber C ankle fractures

Introduction. It is recommended that the ankle be held in dorsiflexion at the time of placement of syndesmosis screw. We assessed the validity of this recommendation. Materials and methods. A two-part roentgenographic and computerised analysis of distal tibiofibular syndesmosis. The first part involved recruitment of 30 healthy adult volunteers. The second part involved 15 ankle fractures with syndesmotic injury requiring syndesmosis screw placement. In the first part individuals maximally dorsiflexed and plantarflexed their ankles in a specialised jig for standardisation. Mortice views were taken and intermalleolar distance measured. In the second part mortice views were taken in plantarflexion and dorsiflexion before and after the placement of syndesmosis screw in theatre. The intermalleolar distance was then measured. Results. In both parts of the study we found the change in intermalleolar distance between the positions of plantarflexion and dorsiflexion was not more than 0.9 mm. This change is significantly less than the calculated difference between the anterior and posterior talar body width of 3-5 mm. Conclusion. This study shows that the width of ankle mortice is independent of the position of the talus occupying it and hence dorsiflexion of the ankle at the time of syndesmosis screw placement is totally unwarranted

Treatment of syndesmotic injuries is a subject of ongoing controversy. Locking plates have been shown to provide both angular and axial stability and therefore could potentially control both shear forces and resist widening of the syndesmosis. The aim of this study is to determine whether a two-hole locking plate has biomechanical advantages over conventional screw stabilisation of the syndesmosis in this pattern of injury. Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. The limbs were then mounted on a servo-hydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Each limb was compared with its pair; one receiving stabilisation of the syndesmosis with two 4.5mm quadricortical cortical screws, the other a two-hole locking plate with 3.2mm locking screws (Smith and Nephew). Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening or axial migration >2mm. Both constructs effectively stabilised the syndesmosis during the cyclical loading within 1mm of movement. However the locking plate group demonstrated superior resistance to torque compared to quadricortical screw fixation (40.6Nm vs 21.2Nm respectively, p value <0.03). Conclusion. A 2 hole locking plate (3.2mm screws) provides significantly greater stability of the syndesmosis to torque when compared with 4.5mm quadricortical fixation

Introduction. Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging. Method. Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura. Results. When compared to the normal side, eight out of nineteen (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis, However, if a standard value of G(2mm) was used for the injured leg only, all of the nineteen cases would have abnormal values of ‘G’ following reduction. The value of G for the injured side was poorly correlated with the mean inter-limb diastasis (MD, R=0.23). Discussion. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of ‘G’ of 2mm as the normal limit cannot be applied universally as apparent from the data presented in this study

There have been few reports with efficient treatments for neglected distal tibiofibular syndesmosis disruption. Here we will report four cases of successful anatomical reconstruction with autologous gracilis tendon, using the interference fit anchoring (IFA) system. All four cases were males between 20 and 58 years of age at the time of surgery (mean age 36 years). The post-injury period to surgery was between 7 and 59 months (mean 20.1 months), with the consultation period being from 5 to 19 months (mean 9.5 months). Radiographs at the time of injuries were all malleolar fractures of pronation-external rotation (PE) stage 3 in the Lauge-Hansen classification. Stress tests for distal tibiofibular syndesmosis were positive in all cases (dilation more than 2 mm). Arthroscopic drilling was conducted in two cases with a cartilaginous injury of trochlea of talus. Distal tibiofibular syndesmosis was anatomically repositioned and was fixed with screws after bony and soft tissues within the tibiofibular syndesmosis were removed and fibular adhesion was dissected. Ipsilateral autologous gracilis tendon was passed through foramen in the insertion of the anterior inferior tibiofibular tendon on tibia and fibula, and was fixated using the IFA system. The preoperative Japanese society for surgery of the foot (JSSF) score was from 26 to 74 points (mean 43.5) and postoperative JSSF score was from 67 to 100 (mean 89.5). In a case where there was a poor outcome, five years of post injury had passed before the surgery. Although the JSSF score improved to 67 points postoperatively (from the preoperative score of 26) in this case, arthroscopic arthrodesis was conducted 5 months postoperatively due to persistent pain. Anatomical reconstruction with autologous gracilis tendon using the IFA system showed a favorable functional prognosis overall. However, there was a case with progressive degenerated changes of injured distal tibiofibular syndesmosis due to a prolonged post-injury period resulted in a poor outcome

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

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

Purpose. The anterior inferior tibiofibular ligament (AiTFL) is the primary lateral ligamentous stabilizer of the ankle syndesmosis. Current syndesmosis repair techniques traverse the tibia and fibula, but do not anatomically reconstruct the AiTFL. We compared a novel AiTFL anatomic repair technique (ART) to rigid syndesmosis screw fixation (SCREW). Method. Twelve cadaveric below knee specimens were compared radiographically and using a biomechanical testing protocol. All specimens underwent a CT scan of the ankle joint prior to testing. Next, the AiTFL, interosseous membrane and deltoid ligament were sectioned, and the posterior malleolus osteotomized, to recreate a trimalleolar-equivalent ankle fracture. The posterior malleolus was repaired with the posterior ligamentous insertions intact and functional (PMALL). Ankles were examined under fluoroscopy with an external rotation stress exam and the medial clear space (MCS) measured. Specimens were then randomized to receive either a conventional syndesmosis screw (SCREW), or the novel anatomic repair technique (ART). External rotation stress fluoroscopy was repeated. A second CT was completed and the fibular position compared to the pre-injury CT. Each specimen was then loaded in external rotation until failure using a custom biomechanical jig. Results. The MCS during stress examination increased by 1.04 0.31mm in the PMALL group. MCS increased significantly less at only 0.300.07mm (p=0.002) in the ART group. The SCREW fixation method demonstrated a delta MCS of 0.280.16mm (p=0.008). Post repair CT showed that 33% of specimens were subluxed from the SCREW group compared to 0% for the ART. Mean torque at failure for ART was 24.85.5Nm compared to 16.85.8Nm for SCREW (p=0.01). Conclusion. Repair of the posterior malleolus alone demonstrated a greater than 1mm of medial clear space widening and is not sufficient to re-establish syndesmotic stability. Addition of the ART or SCREW technique restored syndesmotic stability. None of the ART specimens demonstrated fibular subluxation, while 33% of SCREW specimens were subluxed anteriorly on CT. Biomechanical strength of the ART was found to be greater than that of rigid screw fixation

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures. We developed clinical criteria for potential instability and applied them to a prospective series of patients. Criteria included: medial clear space of < 4mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; a high-energy fracture mechanism. A consecutive, prospectively documented series of 37 patients chose functional brace treatment of potentially unstable fractures. Weightbearing radiographs were performed in the brace before treatment, and free of brace at clinical union (6–9 weeks in all patients). Patients were encouraged to bear full weight and actively exercise their ankles in the brace. All fractures healed without displacement. The risk of displacement was 0% (95% CI 0–11.2%). This preliminary series gives support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures

Aim. To determine the preferable treatment for congenital pseudarthrosis of the tibia, we retrospectively reviewed 19 patients (20 limbs) treated consecutively over a 22 year period (1988–2007). Fifteen were followed up to maturity. The patients were assessed for union, leg length discrepancy (LLD), ankle valgus, range of ankle movement and distal tibial physeal injury. Results. The median age at surgery was 3 years. At surgery nineteen of the tibiae had a dysplastic constriction with a fracture (Crawford II-C or Boyd II) lesion. To obtain union in the 20 tibiae, 29 procedures were done. Nine failed primarily and required a second procedure to obtain union. Older patients (≥ 5 years) had a significantly higher success rate. Excision, intramedullary rodding and bone graft (IMR) was done in 14 tibiae: 10 (71.4%) were successful. Six of 10 primary operations and all 4 secondary operations after a previous failed procedure were successful. Ipsilateral vascularized fibula transfer (IVFT) was successful in 5 tibiae (3 primary and 2 secondary). Ilizarov with bone transport only, failed in two patients. Ilizarov with excision, intramedullary rodding and bone graft with lengthening was successful in 2 of 5 cases (40%); two sustained fractures at the proximal lengthening site. A median leg length discrepancy (LLD) of 3 cms occurred post surgery which was treated with contralateral epiphysiodesis. At maturity 3 patients had a LLD of ≥ 2cms. Six limbs had ankle valgus and were treated with stapling and tibio-fibular syndesmosis. Decreased range of movement of the ankle (< 50%) occurred in 7 patients. Distal tibial physeal injury occurred in 4 patients and was associated with repeated rodding. Conclusion. We concluded that surgery should be delayed as long as possible. If there is adequate tibial purchase for the rod distally, IMR is the best option. If purchase is inadequate, Ilizarov with rodding will avoid ankle stiffness. Epiphysiodesis is preferable to lengthening because of the risk of fracture above the rod. IVFT is a good option as a secondary procedure. NO DISCLOSURES

Introduction. Foot and ankle injuries are a common occurrence amongst all footballers. The aim of this study was to establish the frequency and variation of foot and ankle injuries within one English Premier League (EPL) professional football club over the course of a season and attempt to identify any factors associated with the injuries. Method. Data was collected prospectively for all foot and ankle injuries suffered by first team players over the 2008–09 and 2009–10 EPL season at one EPL club. Each player's demographics were recorded along with various factors concerning or influencing the injury including ground conditions, foot posture index score (FPIS), type of injury, ability to continue playing, recovery time, mechanism of injury and footwear type. Results. The most common injury was 5th metatarsal fracture seen in 33%. Lateral ligament sprain was seen in 28% and syndesmosis injury in 17%. The mean recovery time following 5th metatarsal fractures was 76 days. 67% of all injuries (100% of 5th metatarsal fractures) were sustained while wearing blade footwear, 17% wearing the more traditional studded footwear. Supination was the most common FPIS, present in 43%. 56% of injuries were in the dominant (kicking) side while 50% of injuries were sustained in the tackle. There were no ankle fractures observed. Conclusion. 5th metatarsal fractures are the most common foot & ankle injury amongst professional footballers, ankle fractures are relatively rare in comparison. Injuries occur more frequently with blade footwear, with supination being the most common foot posture at the time of injury