Aims. To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. Methods. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. Results. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Conclusion. Ankle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients. Cite this article: Bone Jt Open 2023;4(3):188–197

Aims. To describe outcome reporting variation and trends in non-pharmacological randomized clinical trials (RCTs) of distal tibia and/or ankle fractures. Methods. Five electronic databases and three clinical trial registries were searched (January 2000 to February 2022). Trials including patients with distal tibia and/or ankle fractures without concomitant injuries were included. One reviewer conducted all searches, screened titles and abstracts, assessed eligibility, and completed data extraction; a random 10% subset were independently assessed and extracted by a second reviewer at each stage. All extracted outcomes were mapped to a modified version of the International Classification of Functioning, Disability and Health framework. The quality of outcome reporting (reproducibility) was assessed. Results. Overall, 105 trials (n = 16 to 669 participants) from 27 countries were included. Trials compared surgical interventions (n = 62), post-surgical management options (n = 17), rehabilitative interventions (n = 14), surgical versus non-surgical interventions (n = 6), and pre-surgical management strategies (n = 5). In total, 888 outcome assessments were reported across seven domains: 263 assessed body structure or function (85.7% of trials), 136 activities (68.6% of trials), 34 participation (23.8% of trials), 159 health-related quality of life (61.9% of trials), 247 processes of care (80% of trials), 21 patient experiences (15.2% of trials), and 28 economic impact (8.6% of trials). From these, 337 discrete outcomes were described. Outcome reporting was inconsistent across trials. The quality of reporting varied widely (reproducibility ranged 4.8% patient experience to 100% complications). Conclusion. Substantial heterogeneity in outcome selection, assessment methods, and reporting quality were described. Despite the large number of outcomes, few are reported across multiple trials. Most outcomes are clinically focused, with little attention to the long-term consequences important to patients. Poor reporting quality reduces confidence in data quality, inhibiting data synthesis by which to inform care decisions. Outcome reporting guidance and standardization, which captures the outcomes that matter to multiple stakeholders, are urgently required. Cite this article: Bone Jt Open 2022;3(10):832–840

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

Introduction:. In this cohort study, we present comprehensive injury specific and surgical outcome data from one of the largest reported series of distal tibial pilon fractures, treated in our tertiary referral centre. Methods:. A series of 76 pilon fractures were retrospectively reviewed from case notes, plain radiographs and computed tomography (CT) imaging. Patient demographics, injury and fracture patterns, methods and timing of fixation and clinical and radiological outcomes were assessed over a mean follow up period of 8.6 months (range 2–30). Results:. Definitive fixation was most commonly performed through an open technique with plate fixation. CT imaging was used to plan the most direct approach to access the fracture fragments. The majority of cases were classified as AO/OTA 43.C3. When definitive open fixation for closed fracture was performed within 48 hours, the rate of deep infection or wound complication was 0%. When performed on day 3–5, the deep infection rate was 0% but the superficial wound complication rate was 23.5%. From day six onwards, the deep infection rate was 4% and the superficial wound complication rate was 8%. The rate of wound complications after double plate fixation of the tibia using two separate incisions was 23.1%, compared to 11.7% after single incision and plating. The rate of non-union was 9.7%. Symptomatic post-traumatic arthritis requiring orthopaedic management occurred in 9.9%. Further surgery was required in 27.8% of all patients. Conclusion:. Outcomes from our unit compare favourably with those from large trauma centres worldwide. Our study supports the use of early definitive fixation, within 48 hours, to achieve low rates of wound complications. We support an “unsafe window” for definitive fixation of three to five days post injury due to the high rate of wound complications. The likelihood of developing post-traumatic arthritis and of requiring further surgery is high

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

Aims. The purpose of this study was to assess the success rate and functional outcomes of bone grafting for periprosthetic bone cysts following total ankle arthroplasty (TAA). Additionally, we evaluated the rate of graft incorporation and identified associated predisposing factors using CT scan. Methods. We reviewed a total of 37 ankles (34 patients) that had undergone bone grafting for periprosthetic bone cysts. A CT scan was performed one year after bone grafting to check the status of graft incorporation. For accurate analysis of cyst volumes and their postoperative changes, 3D-reconstructed CT scan processed with 3D software was used. For functional outcomes, variables such as the Ankle Osteoarthritis Scale score and the visual analogue scale for pain were measured. Results. Out of 37 ankles, graft incorporation was successful in 30 cases. Among the remaining seven cases, four (10.8%) exhibited cyst re-progression, so secondary bone grafting was needed. After secondary bone grafting, no further progression has been noted, resulting in an overall 91.9% success rate (34 of 37) at a mean follow-up period of 47.5 months (24 to 120). The remaining three cases (8.1%) showed implant loosening, so tibiotalocalcaneal arthrodesis was performed. Functional outcomes were also improved after bone grafting in all variables at the latest follow-up (p < 0.05). The mean incorporation rate of the grafts according to the location of the cysts was 84.8% (55.2% to 96.1%) at the medial malleolus, 65.1% (27.6% to 97.1%) at the tibia, and 81.2% (42.8% to 98.7%) at the talus. Smoking was identified as a significant predisposing factor adversely affecting graft incorporation (p = 0.001). Conclusion. Bone grafting for periprosthetic bone cysts following primary TAA is a reliable procedure with a satisfactory success rate and functional outcomes. Regular follow-up, including CT scan, is important for the detection of cyst re-progression to prevent implant loosening after bone grafting. Cite this article: Bone Joint J 2024;106-B(5):475–481

Background. The use of a knotless TightRope for the stabilisation of a syndesmotic injury is a well-recognised mode of fixation. It has been described that the device can be inserted using a “closed” technique. This presents a risk of saphenous nerve entrapment and post-operative pain. Aim. We aimed to establish the actual risk of injury to the Saphenous Nerve using a “closed” technique for the insertion of a TightRope. Method. 20 TightRopes were inserted into Fresh Frozen Cadavers. This was done using the senior authors preferred technique of divergent tightropes with the distal implant directed slightly anterior to the fibula-tibia axis and the proximal implant slightly posterior in order to simulate the greatest risk to the nerve. This was done under image Intensifier guidance to simulate an intraoperative environment. The medial side of the distal tibia was then dissected to directly record and measure the relationship of the TightRope to the Saphenous Nerve. Measurements were taken using digital calipers from the centre of the button on the medial side of the TightRope to the centre of the nerve at the point of closest proximity. Results. 12 TightRopes were found to exit posterior to the nerve, 7 anterior and 1 penetrated through the centre of the nerve. The mean distance from the centre of the button to the nerve was 6.99mm (range 0.72–14.52mm, standard deviation 4.33mm). In 9 of the 20 TightRopes, the nerve was found to be less than 5mm away. Conclusion. Our findings demonstrated that the risks of damaging or indeed entrapping the Saphenous nerve were high, and therefore we would advocate an open incision on the medial side with judicious exploration to ensure there is no damage to the medial neurological structures

Introduction. Fibula shortening with an intact anterior tibiofibular ligament (ATFL) and medial ligament instability causes lateral translation of the talus. Our hypothesis was that the interaction of the AITFL tubercle of the fibular with the tibial incisura would propagate lateral translation due to the size differential. Aim. To assess what degree of shortening of the fibular would cause the lateral translation of the talus. Methodology. Twelve cadaveric ankle specimens were dissected removing all soft tissue except for ligaments. They were fixed on a specially-designed platform within an augmented ankle cage allowing tibial fixation and free movement of the talus. The fibula was progressively shortened in 5mm increments until complete ankle dislocation. The medial clear space was measured with each increment of shortening. Results. The larger AITFL tubercle interaction with the smaller tibial incisura caused a significant increase in lateral translation of the talus. This occurred in most ankles between 5–10mm of fibular shortening. The medial clear space widened following 5mm of shortening in 5 specimens (mean=2.0725, SD=±2.5338). All 12 specimens experienced widening by 10mm fibula shortening (Mean=7.2133mm, SD=±2.2061). All specimens reached complete dislocation by 35mm fibula shortening. Results of ANOVA analysis found the data statistically significant (p<0.0001). Conclusion. This study shows that shortening of the fibula causes a significant lateral translation of the talus provided the ATFL remains intact. Furthermore, the interaction of the fibula notch with the ATFL tubercle of the tibia appears to cause a disproportionate widening of the medial clear space due to its differential in size. Knowledge of the extent of fibula shortening can guide further intervention when presented with a patient experiencing medial clear space widening following treatment of an ankle fracture

Background. RHF nail is an important tool for simultaneous ankle and subtalar joint stabilisation +/− fusion. Straight and curved RHF nails are available to use, but both seem to endanger plantar structures, especially the lateral plantar artery and nerve and Baxter's nerve. There is a paucity of literature on the structures at risk with a straight RHF nail inserted along a line bisecting the heel pad and the second toe (after Stephenson et al). In this study, plantar structures ‘at risk’ were studied in relation to a straight nail inserted as above. Methods. Re-creating real-life conditions and strictly following the recommended surgical technique with regards to the incision and guide-wire placement, we inserted an Orthosolutions Oxbridge nail into the tibia across the ankle and subtalar joints in 6 cadaveric specimens. Tissue flaps were then raised to expose the heel plantar structures and studied their relation to the inserted nail. Results. The medial plantar artery and nerve were always more than 10mm away from the medial edge of the nail, while the Baxter nerve was a mean 14mm behind. The lateral plantar nerve was a mean 7mm medial to the nail, while the artery was a mean 2.3mm away with macroscopic injury in one specimen. The other structures ‘at risk’ were the plantar fascia and small foot muscles. Conclusion. Lateral plantar artery and nerve are the most vulnerable structures during straight RHF nailing. The risk to heel plantar structures could be mitigated by making incisions longer, blunt dissection down to bone, meticulous retraction of soft tissues and placement of the protection sleeve down to bone to prevent the entrapment of plantar structures during guide-wire placement, reaming and nail insertion

Introduction. We report the functional outcome and survivorship of the Hintegra Total Ankle Replacement (TAR), in consecutive cases by multiple surgeons in a single UK institution. Between 2010–2014 the Hintegra TAR held 7.1% UK market share and surgeons should be aware of failure mechanisms. Methods. We conducted a retrospective review of prospectively collected data for 70 consecutive Hintegra TAR cases in a single institution between 2010–2014. Data collected included patient demographics, complications, reoperations, patient reported outcome measures (PROMS: AOS, MOX-FQ, pain VAS) and patient satisfaction. Results. The 70 patients (54 male/ 16 female) had an average age of 69 (range 48–84 years). Mean follow up was 76 months (range 60–04), 10 patients died during the follow up. Implant survivorship was 81.4% at most recent follow up. The commonest radiographic finding was periprosthetic cysts (n=28, 40%), size range (7–40mm), location of cysts: isolated talus (n=14), isolated tibia (n=6), mixed (n=8). 10 failed TARs were revised to Inbone TAR at a mean of 48 months (range 9–69). 3 Failed TARs were revised to arthrodesis (2 tibiotalar fusions, 1 hindfoot nail). 11 patients required reoperation with implant retention: 8 periprosthetic cyst debridement and grafting at a mean of 61 months (range 27–91), 1 lateral gutter debridement and 1 periprosthetic fracture ORIF. PROMS data was available for all patients. Overall patients showed marked improvement in functional outcome scores between pre-operative and final follow up questionnaires. Mean pre-op AOS: 62, MOX-FQ: 68 and pain VAS: 67.5 with mean final follow up scores of: AOS: 35, MOX-FQ: 36 and pain VAS: 30. Conclusion. Our experience demonstrates improved PROMS following ankle arthroplasty for patients with a mean follow up of 6.4 years. Implant survivorship is similar to other TAR studies. We have identified a high incidence of periprosthetic cysts and would recommend ongoing surveillance of these patients

Introduction. Surgical reconstruction of deformed Charcot feet carries high risk of non-union, metalwork failure and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions. Methods. We retrospectively analysed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between 2007 and 2019 in our unit. Patient demographics, co-morbidities, weightbearing status and post-operative complications were noted. Metalwork breakage, non-union, deformity recurrence, concurrent midfoot reconstruction and the measurements related to intramedullary nail were also recorded. Results. There were 70 patients with mean follow up of 50±26 months. Seventy-two percent were fully weightbearing at 1 year post-operatively. The overall union rate was 83%. Age, BMI, HbA1c and peripheral vascular disease did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the non-united group (0.90±0.06 and 0.86±0.09, respectively; p = 0.03). Supplemental compression devices were used for 33% of those in the united compared to 8% in the non-united group (p = 0.04). All patients in the non-union group did not have a miss-a-nail screw. Metalwork failure was seen in 13 patients(19%). There was a significantly greater distal screw metalwork failure in those with supplementary bridging of tibia to midfoot (23% vs. 3%; p = 0.001). An intact medial malleolus was found more frequently in those with intact metalwork (77% vs. 54%, respectively; p = 0.02) and those with union (76% vs. 50%; p = 0.02). Broken metalwork occurred more frequently in patients with non-unions (69% vs. 8%; p < 0.001) and deformity recurrence (69% vs. 9%; p < 0.001). Conclusion. Satisfactory clinical and radiographic outcomes occur in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail, supplementary compression and miss-a-nail screws. An intact medial malleolus is protective against non-union and metalwork failure. Broken metalwork is linked to deformity recurrence and non-union

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

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The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

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Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

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Surgical reconstruction of deformed Charcot feet carries a high risk of nonunion, metalwork failure, and deformity recurrence. The primary aim of this study was to identify the factors contributing to these complications following hindfoot Charcot reconstructions.

Aims. There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. Patients and Methods. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs. Results. Postoperatively, the mean score for pain, using a visual analogue scale, decreased significantly from 4.3 to 2.5 points and the mean American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score improved significantly from 59 to 75 points (both p < 0.001). The mean TLS angle increased significantly by 6.6°; the mean TOR decreased significantly by 0.24 (p < 0.001). Radiological evaluation showed an improvement or no progression of sagittal ankle joint OA in 32 ankles (82%), while seven ankles (18%) showed further progression. Conclusion. A flexion osteotomy effectively improved the congruency of the ankle joint. In 30 patients (77%), the joint could be saved, whereas in nine patients (23%), the treatment delayed a joint-sacrificing procedure. Cite this article: Bone Joint J 2019;101-B:682–690

Aims

Treatment for delayed wound healing resulting from peripheral vascular diseases and diabetic foot ulcers remains a challenge. A novel surgical technique named ‘tibial cortex transverse transport’ (TTT) has been developed for treating peripheral ischaemia, with encouraging clinical effects. However, its underlying mechanisms remain unclear. In the present study, we explored the potential biological mechanisms of TTT surgery using various techniques in a rat TTT animal model.

Aims. Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views. Patients and Methods. A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation. Results. The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation. Conclusion. We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

During surgical reduction of ankle injuries with syndesmotic instability surgeons often use the anteroposterior (AP) and mortise radiographs to assess reduction. Current literature predicts 50% are malreduced mainly in the sagittal plane. Our aim was to develop a radiographic measure based on the lateral view to assess both the normal and abnormal fibula/tibia relationship after simulated syndesmotic malreduction and to evaluate the effect on commonly used AP and mortise measurements. Nine fresh-frozen cadaveric specimens were dissected to the level of the syndesmosis. AP, mortise and talar dome lateral radiographs were obtained before and following syndesmosis division and posterior fibula displacement. On the lateral radiograph a line was drawn (Orthoview) from the anterior border of the fibula bisecting a line drawn from the anterior to posterior lips of the distal tibia. The ratio of the anterior-posterior segments was calculated. Also a line was drawn from the posterior border of the fibula and the distance was measured to the posterior lip of the tibia. At 0, 2, 4 and 6mm of displacement the ratio measured 1.3±0.2, 1.1±0.2, 0.9±0.2 and 0.7±0.2 respectively with all pairwise comparisons being significantly different. Inter- and intra-observer variability varied from substantial to perfect. The only significant medial clear space (MCS) difference was on the mortise view between 0mm (2.0±0.3mm) and 6mm (2.4±0.4mm) displacement. Our new measure of syndesmotic reduction is reproducible and can detect from 2mm of saggital fibular displacement. At maximum fibular displacement the increase in MCS was less than 1mm. This demonstrates standard mortise radiographs are poor at detecting syndesmotic reduction. An interesting observation was in all specimens prior to any displacement, the posterior fibular line always bisected the posterior lip of the tibia or lay just anterior to it, never posterior. This could serve as a useful adjunct for surgeons when assessing syndesmotic reduction intra-operatively