Between 1992 and 2000, 57 patients with 57 isolated fractures of the medial malleolus were treated conservatively by immobilisation in a cast. The results were assessed by examination, radiography and completion of the short form-36 questionnaire and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. Of the 57 fractures 55 healed without further treatment. The mean combined dorsi- and plantar flexion was 52.3° (25° to 82°) and the mean short form-36 and American Orthopaedic Foot and Ankle Society scores 48.1 (28 to 60) and 89.8 (69 to 100), respectively. At review there was no evidence of medial instability, dermatological complications, malalignment of the mortise or of post-traumatic arthritis. Isolated fractures of the medial malleolus can obtain high rates of union and good functional results with conservative treatment. Operation should be reserved for bi- or trimalleolar fractures, open fractures, injuries which compromise the skin or those involving the plafond or for patients who develop painful nonunion

We report the cases of three children with chronic injuries of the medial tibial malleolus caused by traction injuries during sport. All three had the triad of swelling of the medial malleolus, tenderness over its anterior part, and pain on forced valgus movement of the foot. Radiographs showed bilateral accessory ossification centres and MRI demonstrated partial avulsion or avulsion fracture of the apophyseal cartilage and fragmentation of the accessory centres. A review of 134 young basketball players showed that 25% had tenderness of the anterior medial malleolus. This high rate indicates that traction apophysitis of the medial malleolus is not uncommon in children as a sports-related disorder

Aims. This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton. Methods. A total of 20 patients with isolated, bimalleolar, or trimalleolar ankle fractures were recruited between July 2018 and October 2019. Fracture reduction was achieved through bioabsorbable Mg-based screws composed of pure Mg alloyed with zinc (Zn) and calcium (Ca) ( Mg-Zn0.45-Ca0.45, in wt.%; ZX00). Visual analogue scale (VAS) and the presence of complications (adverse events) during follow-up (12 weeks) were used to evaluate the clinical outcomes. The functional outcomes were analyzed through the range of motion (ROM) of the ankle joint and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Fracture reduction and gas formation were assessed using several plane radiographs. Results. The follow-up was performed after at least 12 weeks. The mean difference in ROM of the talocrural joint between the treated and the non-treated sites decreased from 39° (SD 12°) after two weeks to 8° (SD 11°) after 12 weeks (p ≤ 0.05). After 12 weeks, the mean AOFAS score was 92.5 points (SD 4.1). Blood analysis revealed that Mg and Ca were within a physiologically normal range. All ankle fractures were reduced and stabilized sufficiently by two Mg screws. A complete consolidation of all fractures was achieved. No loosening or breakage of screws was observed. Conclusion. This first prospective clinical investigation of fracture reduction and fixation using lean, bioabsorbable, REE-free ZX00 screws showed excellent clinical and functional outcomes. Cite this article: Bone Joint Res 2020;9(8):477–483

McFarland fractures of the medial malleolus in children, also classified as Salter–Harris Type III and IV fractures, are associated with a high incidence of premature growth plate arrest. In order to identify prognostic factors for the development of complications we reviewed 20 children with a McFarland fracture that was treated surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven children (35%) developed premature growth arrest with angular deformity. The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale for all patients was 98.3 (87 to 100) and the mean modified Weber protocol was 1.15 (0 to 5). There was a significant correlation between initial displacement (p = 0.004) and operative delay (p = 0.007) with premature growth arrest. Both risk factors act independently and additively, such that all children with both risk factors developed premature arrest whereas children with no risk factor did not. We recommend that fractures of the medial malleolus in children should be treated by anatomical reduction and screw fixation within one day of injury. Cite this article: Bone Joint J 2013;95-B:419–23

Aims. 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. Methods. We retrospectively analyzed patients who underwent hindfoot Charcot reconstruction with an intramedullary nail between January 2007 and December 2019 in our unit. Patient demographic details, comorbidities, weightbearing status, and postoperative complications were noted. Metalwork breakage, nonunion, 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 54 months (SD 26). Overall, 51 patients (72%) and 52 patients (74%) were fully weightbearing at one year postoperatively and at final follow-up, respectively. The overall hindfoot union rate was 83% (58/70 patients). Age, BMI, glycated haemoglobin, and prior revascularization did not affect union. The ratio of nail diameter and isthmus was greater in the united compared to the nonunited group (0.90 (SD 0.06) and 0.86 (SD 0.09), respectively; p = 0.034). In those with a supplementary hindfoot compression screw, there was a 95% union rate (19/20 patients), compared to 78% in those without screws (39/50 patients; p = 0.038). All patients with a miss-a-nail hindfoot compression screw went on to union. Hindfoot metalwork failure was seen in 13 patients (19%). An intact medial malleolus was found more frequently in those with intact metalwork ((77% (44/57 patients) vs 54% (7/13 patients); p = 0.022) and in those with union ((76% (44/58 patients) vs 50% (6/12 patients); p = 0.018). Broken metalwork occurred more frequently in patients with nonunions (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001) and midfoot deformity recurrence (69% (9/13 patients) vs 9% (5/57 patients); p < 0.001). Conclusion. Rates of hindfoot union and intact metalwork were noted in over 80% of patients. Union after hindfoot reconstruction occurs more frequently with an isthmic fit of the intramedullary nail and supplementary hindfoot screws. An intact medial malleolus is protective against nonunion and hindfoot metalwork failure. Cite this article: Bone Joint J 2022;104-B(6):703–708

Aims. The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. Methods. Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). Results. All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. Conclusion. This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68–75

The June 2024 Trauma Roundup. 360. looks at: Skin antisepsis before surgical fixation of limb fractures; Comparative analysis of intramedullary nail versus plate fixation for fibula fracture in supination external rotation type IV ankle injury; Early weightbearing versus late weightbearing after intramedullary nailing for distal femoral fracture (AO/OTA 33) in elderly patients: a multicentre propensity-matched study; Long-term outcomes with spinal versus general anaesthesia for hip fracture surgery; Operative versus nonoperative management of unstable medial malleolus fractures: a randomized clinical trial; Impact of smoking status on fracture-related infection characteristics and outcomes; Reassessing empirical antimicrobial choices in fracture-related infections; Development and validation of the Nottingham Trauma Frailty Index (NTFI) for older trauma patients

Aims. The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction. Methods. We retrospectively reviewed 537 consecutive cases of ankle fractures involving the medial malleolus treated in our institution. 3D fracture maps were produced by superimposing all the fracture lines onto a standard template. We sliced fracture fragments and the standard template based on selected sagittal and coronal planes to create 2D fracture maps, where angles α and β were measured. Angles α and β were defined as the acute angles formed by the fracture line and the horizontal line on the selected planes. Results. A total of 121 ankle fractures were included. We revealed several important fracture features, such as a high correlation between posterior collicular fractures and posteromedial fragments. Moreover, we generalized the fracture geometry into three recurrent patterns on the coronal view of 3D maps (transverse, vertical, and irregular) and five recurrent patterns on the lateral view (transverse, oblique, vertical, Y-shaped, and irregular). According to the fracture geometry on the coronal and lateral view of 3D maps, we subsequently categorized medial malleolar fractures into six types based on the recurrent patterns: anterior collicular fracture (27 type I, 22.3%), posterior collicular fracture (12 type II, 9.9%), concurrent fracture of anterior and posterior colliculus (16 type III, 13.2%), and supra-intercollicular groove fracture (66 type IV, 54.5%). Therewere three variants of type IV fractures: transverse (type IVa), vertical (type IVb), and comminuted fracture (type IVc). The angles α and β varied accordingly. Conclusion. Our findings yield insight into the characteristics and recurrent patterns of medial malleolar fractures. The proposed classification system is helpful in understanding injury mechanisms and guiding diagnosis, as well as surgical strategies. Cite this article: Bone Joint J 2021;103-B(5):931–938

Ensuring correct rotation of the femoral component is a challenging aspect of patellofemoral replacement surgery. Rotation equal to the epicondylar axis or marginally more external rotation is acceptable. Internal rotation is associated with poor outcomes. This paper comprises two studies evaluating the use of the medial malleolus as a landmark to guide rotation. We used 100 lower-leg anteroposterior radiographs to evaluate the reliability of the medial malleolus as a landmark. Assessment was made of the angle between the tibial shaft and a line from the intramedullary rod entry site to the medial malleolus. The femoral cut was made in ten cadaver knees using the inferior tip of the medial malleolus as a landmark for rotation. Rotation of the cut relative to the anatomical epicondylar axis was assessed using CT. The study of radiographs found the position of the medial malleolus relative to the tibial axis is consistent. Using the inferior tip of the medial malleolus in the cadaver study produced a mean external rotation of 1.6° (0.1° to 3.7°) from the anatomical epicondylar axis. Using the inferior tip of the medial malleolus to guide the femoral cutting jig avoids internal rotation and introduces an acceptable amount of external rotation of the femoral component

Aims. Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Methods. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Results. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. Conclusion. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended. Cite this article: Bone Joint J 2024;106-B(9):1008–1014

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

Abstract. The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512–521

Aims. The aims of this study were to evaluate the morphology of the ankle in patients with an osteochondral lesion of the talus using 3D CT, and to investigate factors that predispose to this condition. Patients and Methods. The study involved 19 patients (19 ankles) who underwent surgery for a medial osteochondral lesion (OLT group) and a control group of 19 healthy patients (19 ankles) without ankle pathology. The mean age was significantly lower in the OLT group than in the control group (27.0 vs 38.9 years; p = 0.02). There were 13 men and six women in each group. 3D CT models of the ankle were made based on Digital Imaging and Communications in Medicine (DICOM) data. The medial malleolar articular and tibial plafond surface, and the medial and lateral surface area of the trochlea of the talus were defined. The tibial axis-medial malleolus (TMM) angle, the medial malleolar surface area and volume (MMA and MMV) and the anterior opening angle of the talus were measured. Results. The mean TMM angle was significantly larger in the OLT group (34.2°, . sd. 4.4°) than in the control group (29.2°, . sd. 4.8°; p = 0.002). The mean MMA and MMV were significantly smaller in the OLT group than in the control group (219.8 mm. 2. , . sd. 42.4) vs (280.5 mm. 2. , . sd. 38.2), and (2119.9 mm. 3. , . sd. 562.5) vs (2646.4 mm. 3. , . sd. 631.4; p < 0.01 and p = 0.01, respectively). The mean anterior opening angle of the talus was significantly larger in the OLT group than in the control group (15.4°, . sd. 3.9°) vs (10.2°, . sd. 3.6°; p < 0.001). Conclusion. 3D CT measurements showed that, in patients with a medial osteochondral lesion of the talus, the medial malleolus opens distally, the MMA and MMV are small, and the anterior opening angle of the talus is large. This suggests that abnormal morphology of the ankle predisposes to the development of osteochondral lesions of the talus. Cite this article: Bone Joint J 2018;100-B:1487–90

Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being recognised that the integrity of the ‘medial column’ is essential for the stability of the fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external rotation (SER) fractures of the lateral malleolus remains controversial. We provide a rationale as to how to classify SER distal fibular fractures using weight-bearing radiographs, and how this can help guide the management of these common injuries. Cite this article: Bone Joint J 2017;99-B:851–5

Osteochondrosis juvenilis is caused by a dysfunction of endochondral ossification. Several epiphyses and apophyses can be affected, but osteochondrosis juvenilis of the medial malleolus has not been reported. We describe a 12-year-old boy with bilateral pes planovalgus who was affected by this condition. Conservative management was successful. The presentation, aetiology and treatment are described and the importance of including it in the differential diagnosis is discussed

We describe the reconstruction of a defect of the medial malleolus which was the result of an accident in a ten-year-old child. A graft from the iliac crest, with the apophyseal cartilage and perichondrium, was used for reconstruction of the medial malleolus, the growth plate and the adjacent metaphyseal defect, respectively. The soft-tissue defect was covered with a free scapular flap with microvascular anastomosis. Three years after the injury stability of the ankle is excellent with adequate growth of the reconstructed epiphyseal plate

We have compared the results at a mean follow-up of 13 years (11 to 14) of two groups of supination-external rotation type-4 fractures of the ankle, in one of which there was a fracture of the medial malleolus and in the other the medial deltoid ligament had been partially or completely ruptured. Of 66 patients treated operatively between 1993 and 1997, 36 were available for follow-up. Arthroscopy had been performed in all patients pre-operatively to assess the extent of the intra-articular lesions. The American Orthopaedic Foot and Ankle Society hind-foot score was used for clinical evaluation and showed a significant difference in both the total and the functional scores (p < 0.05), but not in those for pain or alignment, in favour of the group with a damaged deltoid ligament (p < 0.05). The only significant difference between the groups on the short-form 36 quality-of-life score was for bodily pain, again in favour of the group with a damaged deltoid ligament. There was no significant difference between the groups in the subjective visual analogue scores or in the modified Kannus radiological score. Arthroscopically, there was a significant difference with an increased risk of loose bodies in the group with an intact deltoid ligament (p < 0.005), although there was no significant increased risk of deep cartilage lesions in the two groups. At a mean follow-up of 13 years after operative treatment of a supination-external rotation type-4 ankle fracture patients with partial or complete rupture of the medial deltoid ligament tended to have a better result than those with a medial malleolar fracture

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm. 2. (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm. 2 . (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm. 2. (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region. Cite this article: Bone Joint J 2013;95-B:1662–6

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications. We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months). Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble)

We studied the vascular pattern of human posterior tibial tendons by injection techniques and immunohistochemically using antibodies against laminin. The intravascular volume of the posterior tibial tendon was determined using a new method of injection of a solution of . 99m. Tc and gelatin ink into the lower legs of cadavers. Three segments of 1 cm length from different regions of the human posterior tibial tendon were measured using a gamma well counter. The main blood supply arises from the posterior tibial artery. Blood vessels enter the paratenon of the posterior tibial tendon via a mesotenon from the posterior aspect. From the paratenon, the blood vessels penetrate the posterior tibial tendon and anastomose with a longitudinally orientated intratendinous network. The number of vessels in the substance of the tendon is consistently less than that in the surrounding paratenon. The distribution of blood vessels within the posterior tibial tendon is not homogeneous. In the retromalleolar region the intravascular volume was significantly reduced with a mean value of 15 μl/g of tendon tissue. There was no significant difference between the mean intravascular volumes of the proximal and distal areas (distal, 27.7 μl/g tendon tissue; proximal, 30 μl/g tendon tissue). The immunohistochemical investigation showed that there was no immunostaining for laminin in the anterior part of the tendon in the region where it passes behind the medial malleolus. This region is avascular. The most frequent site of rupture of the posterior tibial tendon is in the region behind the medial malleolus. A potential endogenous risk factor may be the limited healing potential of avascular tissue

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.

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.

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

Cite this article: Bone Joint J 2023;105-B(11):1135–1139.

Aims

The Chopart joint complex is a joint between the midfoot and hindfoot. The static and dynamic support system of the joint is critical for maintaining the medial longitudinal arch of the foot. Any dysfunction leads to progressive collapsing flatfoot deformity (PCFD). Often, the tibialis posterior is the primary cause; however, contrary views have also been expressed. The present investigation intends to explore the comprehensive anatomy of the support system of the Chopart joint complex to gain insight into the cause of PCFD.

Chronic instability of the ankle is frequently due to disruption of the fibres of the anterior talofibular ligament and the anterolateral capsule. This allows momentary subluxations at the ankle joint; the talus tilts into an abnormal varus position and rotates forwards and inwards about a vertical axis which passes through the medial malleolus. The use of a free tendon graft to reconstruct the anterior talofibular ligament restores the stability of the ankle without restricting movement at the subtalar level

We report a new technique of talectomy for patients with Hawkins group III fracture-dislocation of the talus. Talectomy is performed through a medial incision, the foot is displaced anteriorly, and the fractured or osteotomised medial malleolus is moved laterally and fixed to the tibia with a malleolar screw. Full weight-bearing is allowed after six weeks. In four patients at 36 to 57 months after operation the results were excellent in three and good in one, with no pain or early evidence of degenerative arthritis in the remaining joints of the foot

Aims

Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization.

Chronic non-specific tenosynovitis of the posterior tibial tendon is a well-known clinical entity, characterised by pain, swelling and tenderness behind the medial malleolus. There are no reports in the literature of any case associated with any radiological abnormality. Three such cases are discussed, each presenting with the clinical findings typical of the syndrome but with associated radiological changes. These changes may pose diagnostic problems and several primary conditions need to be excluded. Surgical decompression of the tendon may be necessary to relieve symptoms, to prevent erosion and rupture of the tendon, and to establish the diagnosis

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

We have evaluated prospectively the arthroscopic findings in acute fractures of the ankle in 288 consecutive patients (148 men and 140 women) with a mean age of 45.6 years. According to the AO-Danis-Weber classification there were 14 type-A fractures, 198 type B and 76 type C. Lesions of the cartilage were found in 228 ankles (79.2%), more often on the talus (69.4%) than on the distal tibia (45.8%), the fibula (45.1%), or the medial malleolus (41.3%). There were more lesions in men than in women and in general they were more severe in men (p < 0.05). They also tended to be worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05). Within each type of fracture the lesions increased from subgroups 1 to 3 (p < 0.05). The anterior tibiofibular ligament was injured with increased frequency from type-B.1 to type-C.3 fractures (p < 0.05), but it was not torn in all cases. While lateral ligamentous injuries were seen more often in type-B than in type-C fractures (p < 0.05), no difference was noted in the frequency of deltoid ligamentous lesions. Our findings show that arthroscopy is useful in identifying associated intra-articular lesions in acute fractures of the ankle

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

The goal was to evaluate tibiofemoral knee joint kinematics during stair descent, by simulating the full stair descent motion in vitro. The knee joint kinematics were evaluated for two types of knee implants: bi-cruciate retaining and bi-cruciate stabilized. It was hypothesized that the bi-cruciate retaining implant better approximates native kinematics.

The April 2023 Foot & Ankle Roundup³⁶⁰ looks at: Outcomes following a two-stage revision total ankle arthroplasty for periprosthetic joint infection; Temporary bridge plate fixation and joint motion after an unstable Lisfranc injury; Outcomes of fusion in type II os naviculare; Total ankle arthroplasty versus arthrodesis for end-stage ankle osteoarthritis; Normal saline for plantar fasciitis: placebo or therapeutic?; Distraction arthroplasty for ankle osteoarthritis: does it work?; Let there be movement: ankle arthroplasty after previous fusion; Morbidity and mortality after diabetic Charcot foot arthropathy.

Aims

Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care.

Aims

To identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.

Aims

Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA.

Aims

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

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.

Aims

The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.