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Background: We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning., Methods: In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated., Results: In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle ( P  = .03), dislocated peroneal tendons ( P  < .001), calcaneal fracture-dislocation ( P  < .001), SPR avulsion fracture ( P  < .001), and Sanders type IV of calcaneal fracture ( P  = .02). There was no statistically significant relationship between PTI and the mechanism of injury ( P  = .98), side of fracture ( P  = .30), uni- or bilateral calcaneal fractures ( P  = .27), a fracture at the tip of lateral malleolus ( P  = .69), shape of the retromalleolar groove ( P  = .78), or excessive displacement of the lateral calcaneal wall ( P  = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%)., Conclusion: Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures., Level of Evidence: Level III, retrospective case control study.

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens., Methods: Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures., Results: At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints., Conclusion: The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma., (© 2022. The Author(s).)

Purpose: The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism., Methods: The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings., Results: The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients., Conclusion: Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle., (© 2021. Springer-Verlag GmbH Germany, part of Springer Nature.)

»: Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures., »: The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT)., »: The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN., »: Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome., »: Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A804)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature., Methods: Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores., Results: Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed., Conclusion: When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury., Level of Evidence: Level IV, retrospective case series.

Even minor residual fragment malpositioning after internal fixation of ankle fractures is associated with a worse prognosis. Frequent causes for non-anatomical reduction are fibular shortening due to comminuted fractures or poor bone quality, translational or rotational malpositioning of the distal fibula within the tibial incisura with unstable syndesmosis injuries, and inadequately addressed bony avulsions of the tibiofibular syndesmosis. After operative treatment of fracture dislocations with syndesmotic fixation, in case of complex fracture pathoanatomy, and with suspected non-anatomic reduction in postoperative radiographs, computed tomography imaging of both ankles should be performed. Correction of relevant malreductions should be performed as early as possible in order to speed up rehabilitation and to avoid late sequelae due to a load shift or instability in a weight-bearing joint., Competing Interests: Christine Marx, Klaus-Dieter Schaser and Stefan Rammelt received travel and accommodation costs from the AO Foundation. This does not result in any conflicts of interest for the content presented in the present work./Christine Marx, Klaus-Dieter Schaser und Stefan Rammelt erhielten Reise- und Unterbringungskosten von der AO Foundation. Hieraus resultieren keine Interessenkonflikte für die in der vorliegenden Arbeit dargestellten Inhalte., (Thieme. All rights reserved.)

Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.

"Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise.", Competing Interests: Disclosure Dr S. Rammelt is a paid consultant for KLS Martin and has received travel support by AO Trauma as a member of the AO Foot & Ankle Expert Group and AO Foot & Ankle Education Task Force. Dr S. Rammelt has no conflict of interest resulted for the purpose of this review. Dr A. Boszczyk provided paid training for Arthrex and Stryker as well as received financial support from Johnson and Johnson devoted to continued education. Dr A. Boszczyk has no conflict of interest resulted for the purpose of this review., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective of Surgery: Joint-spanning transfixation of the ankle joint aims at mostly temporary retention of the reduction, i.e. restoring length and axial alignment and stabilization of the ankle mortise in highly unstable fractures around the ankle and under critical soft tissue conditions. In selected cases, external fixation serves as an additional stabilization also following completed internal fixation or the fracture can be treated in the external fixator. The goal of surgery is to allow quick soft tissue recovery, prevention of redislocation and stabilization of the ankle and adjacent structures., Indications: a) Fractures of the tibial pilon; b) very distal, extra-articular lower leg fractures (without the option for pin positioning in the distal fragment); c) highly unstable malleolar fractures with tendency to subluxation and dislocation fractures; d) critical soft tissue conditions around the ankle; e) dislocation fractures of the talus, Chopart and Lisfranc joints (if necessary with additional transarticular transfixation)., Contraindications: Missing consent to surgery by the conscious patient, life-threatening general condition by other prioritized injuries., Surgical Technique: Percutaneous pin placement of the appropriate caliber into so-called safe zones of the tibia, metatarsus and calcaneus, as needed. Additional transfixation of the Chopart and Lisfranc joints with K‑wires as needed. Fixation of the struts with the foot in a neutral position. Besides consideration of biomechanical principles, pin placement must be done in anticipation of the definitive stabilization and future approaches respecting the anatomical structures while achieving maximum stability and soft tissue protection., Postoperative Management: Following initial transfixation, elevation of the injured leg for soft tissue protection, local cooling and bed rest are indicated. In cases of compartment syndrome and open fractures with temporary soft tissue coverage, second look surgery after 24-72 h is mandatory. For exact fracture analysis and optimal planning of the definitive surgical strategy, the indications for CT imaging should be generously considered. The timing of definitive care depends on the local soft tissue status and the overall condition of the patient., Results: The presence of a dislocation at the time of the accident represents a negative prognostic factor for ankle fractures. Higher rates of posttraumatic arthrosis are also found in pilon fractures and trimalleolar fractures, direct cartilage damage and rupture of the syndesmosis. In cases of anatomic reconstruction of the mortice and ankle joint congruence, good to excellent results can be achieved in 75-89%.

In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

Ankle fractures and associated ligamentous injuries are the most common injuries of a load-bearing joint. There is still no general consensus with respect to the pathomechanism, the treatment indications and surgical techniques. The medium and long-term results are affected by a particularly high risk of posttraumatic arthritis in bimalleolar and trimalleolar fractures and fracture dislocations. There is consensus on the necessity of a thorough preoperative analysis and postoperative control of reduction for which 3D imaging is increasingly generously employed. This detects relevant pathologies, such as bony syndesmotic avulsion and partial impaction of the tibial plafond that may go unnoticed on plain radiographs. Anatomic reconstruction of the ankle mortise, the detection and treatment of syndesmotic instability, reconstruction of the tibial notch and exact placement of the distal fibula into the latter are important prognostic factors.

Background: The study aims at comparing the bony anatomy of the syndesmosis in patients who sustained a high fibular fracture with syndesmosis disruption and that of the non-injured population. We hypothesised that there are certain anatomical features making the syndesmosis susceptible to injury., Methods: The CT examinations of 75 patients who sustained a high fibular fracture with syndesmosis disruption and control group of 75 patients with unrelated foot problems were compared. The depth, fibular engagement and rotational orientation of the tibial incisura were analyzed., Results: With the median values of the control group as cutoff there were 71% shallow, 71% disengaged and 77% retroverted syndesmoses in the injury group. The differences between the groups were statistically significant for every measure (P<.002 to P>.0001)., Conclusions: Patients with a shallow, disengaged and retroverted bony configuration of the syndesmosis are overrepresented among patients with syndesmosis disruption., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options., Objective: The aim of this review is to summarize the current knowledge on syndesmotic instability and to present some recommendations for the clinical practice for acute an chronic injuries., Material and Methods: Analysis of the current literature concerning the anatomy, etiology, diagnostics and treatment of syndesmosis injuries., Results: Purely ligamentous injuries (high ankle sprains) are not associated with a latent or frank tibiofibular diastasis and can be treated with an extended protocol of physiotherapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments and requires surgical stabilization. Syndesmotic disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. The proposed means of fixation are one or more tibiofibular screws or suture button implants. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. The most frequent complication is syndesmotic malreduction and can be minimized with direct visualization and intraoperative 3D scanning. Other complications include hardware failure, adhesions, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis., Conclusion: The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.

Background: The anatomy of the syndesmosis is variable, yet little is known on the correlation between differences in anatomy and syndesmosis reduction results. The aim of this study was to analyze the correlation between syndesmotic anatomy and the modes of syndesmotic malreduction., Methods: Bilateral postreduction ankle computed tomography (CT) scans of 72 patients treated for fractures with syndesmotic disruption were analyzed. Incisura depth, fibular engagement into the incisura, and incisura rotation were correlated with degree of syndesmotic malreduction in coronal and sagittal planes as well as rotational malreduction., Results: Clinically relevant malreduction in the coronal plane, sagittal plane, and rotation affected 8.3%, 27.8%, and 19.4% of syndesmoses, respectively. The syndesmoses with a deep incisura and the fibula not engaged into the tibial incisura were at risk of overcompression, anteverted incisuras at risk of anterior fibular translation, and retroverted incisuras at risk of posterior fibular translation., Conclusions: Certain morphologic configurations of the tibial incisura increased the risk of specific syndesmotic malreduction patterns., Level of Evidence: Level III, comparative study.

Introduction: Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy., Methods: The majority of purely ligamentous injuries ("high ankle sprains") is not sassociated with a latent or frank tibiofibular diastasis and may be treated with an extended protocol of physical therapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments that require surgical stabilization. Syndesmosis disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists in anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. Proposed means of fixation are refixation of bony syndesmotic avulsions, one or two tibiofibular screws and suture button. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic., Results/complications: The most frequent complication is syndesmotic malreduction and may be minimized with open reduction and intraoperative 3D scanning. Other complications include hardware failure, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis., Conclusion: The single most important prognostic factor is anatomic reduction of the distal fibula into the tibial incisura.

Objective: Early reduction of the dislocation and anatomic reconstruction of axial alignment, ankle mortise and articular congruity with special focus on syndesmotic stability., Indications: Fracture-dislocations resulting from pronation injuries to the ankle with a highly incongruent and unstable mortise and either considerable internal pressure on the soft tissues by the displaced fragments or open soft tissue damage., Contraindications: General contraindications to surgery: closed reduction and cast immobilization or external fixation., Surgical Technique: Early preoperative closed reduction of complete dislocations is achieved through longitudinal traction and movements contrary to the original fracture mechanism. A cast or joint-spanning external fixator is applied temporarily. Ideally, definite anatomic reduction of the posterior tibial fragment, the distal fibula and medial malleolus and stable internal fixation is achieved within the first hours after the injury. Congruity of the ankle mortise and syndesmotic stability is controlled intraoperatively and a syndesmotic screw is inserted if necessary. In these cases, the correct positioning of the distal fibula within the tibial incisura is verified with three-dimensional fluoroscopy or postoperative computed tomography scanning., Postoperative Management: Early range of motion exercises of the ankle and subtalar joints are initiated the second postoperative day or after soft tissue consolidation and removal of the external fixation. Patients are mobilized with partial weight bearing (20 kg) in a cast or special boot for 6 weeks postoperatively. The syndesmotic screw is then removed in most cases and weight-bearing is rapidly increased., Results: The presence of a dislocation at the time of injury represents a negative prognostic factor in malleolar fractures. Higher rates of posttraumatic arthritis are also observed with trimalleolar fracures, especially fractures of the posterior tibial rim, cartilage damage, and syndesmotic disruption. Irrespective of the fracture classsification, good to excellent results can be obtained in 75-89% of cases with anatomic reconstruction of the ankle mortise and the articular surfaces. Proper reduction of the distal fibula into the tibial incisura is of utmost importance in cases of frank syndesmotic diastasis.

Ankle fractures are the most frequent factures of weight-bearing joints in children while fractures of the hindfoot and midfoot are rare. Metatarsal fractures make up the greatest portion of foot fractures in children and mostly heal uneventfully. Generally, the fracture severity increases with increasing age and the fracture patterns in adolescents resemble those in adults but transitional fractures of the distal tibial epiphysis in adolescents between 12 and 14 years of age are an exception. A subtle clinical and radiographic examination is necessary to detect the injury pattern and to discriminate fractures from accessory bones, juvenile avascular necrosis and apophyses. Computed tomography scanning is most useful to precisely evaluate the degree of injury, especially articular involvement and to allow precise planning of the operative approach. Except for the calcaneus and the metatarsals the bones of the foot and ankle do not display a significant potential for spontaneous correction during growth; therefore, open reduction and internal fixation is indicated in all displaced fractures if closed reduction does not yield a satisfying result in order to avoid relevant post-traumatic deformities.

Injuries to the lateral ankle ligaments are the most common sports injuries. Determination of their severity and exclusion of relevant accompanying injuries requires a subtle clinical and a focussed radiological assessment. Treatment is non-operative and functional in the majority of cases. Consequent application of orthoses limiting supination and proprioceptive training are essential to avoid chronic instability. With recurrent ankle sprains one has to distinguish between functional and mechanical instability. The latter can be treated successfully with anatomic reconstruction and ligamentoplasty in more than 80 % of cases. Extraanatomic tenodeses should be reserved for cases of combined ankle and subtalar instability. Isolated injuries to the medial collateral ligaments are rare. Therefore, osseous injuries or underlying deformities have to be excluded. Isolated deltoid ligament ruptures may be treated non-operatively. Unstable injuries to the distal tibiofibular syndesmosis resulting in a manifest or latent diastasis are treated with open reduction and fixation with two tibiofibular set screws. Anatomic reduction of the distal fibula into the tibial groove is of utmost prognostic relevance and therefore should be reliably proved with either intraoperative 3D fluoroscopy or postoperative CT scanning. For chronic syndesmotic instability an anatomic ligamentoplasty using half the peroneus longus tendon is recommended., (© Georg Thieme Verlag KG Stuttgart · New York.)

Ankle fractures are the most frequent injuries of a load-bearing joint. Their treatment belongs to the daily routine in trauma surgery. However, despite an increased understanding of the mechanism of injury and relatively straightforward fixation techniques, the medium- to long-term results are often less than satisfactory. The following article therefore explicitly focusses on unsolved problems and controversies in the treatment of ankle fractures in the light of the current literature. These include the therapeutic and prognostic relevance of frequently used classification systems, criteria for the indication for surgery, frequent hazards in internal fixation, the question of whether and how to fix the posterior malleolus, and the detection and treatment of syndesmotic instability. Furthermore, trauma surgeons face the increasing incidence of ankle fractures in the elderly. The presence of osteoporosis, diabetes mellitus and neuropathic osteoarthropathy represents a special challenge.

Injuries to the distal tibiofibular syndesmosis are frequent in collision sports. Most of these injuries are not associated with latent or frank diastasis between the distal tibia and fibula and are treated as high ankle sprains, with an extended protocol of physical therapy. Relevant instability of the syndesmosis results from rupture of two or more ligaments leading to a diastasis of more than 2 mm and requiring surgical fixation. Most of these syndesmosis ruptures are associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the fibula and fixation with one or two tibiofibular syndesmosis screws. Proper reduction and positioning of the screws are more predictive of a good clinical result than the material, size, and number of cortices purchased. Chronic injuries without instability are treated by arthroscopic or open debridement and arthrolysis. Chronic syndesmotic instability can be treated with a three-strand peroneus longus ligamentoplasty in the absence of symptomatic arthritis or bony defects.

Background: Transfer of the flexor hallucis longus (FHL) tendon is a therapeutic option to replace a dysfunctional Achilles tendon in cases of rerupture with large defects, loss of the Achilles tendon after postoperative infection or severe tendinosis., Materials and Methods: Between January 1994 and December 2005, 35 patients (5 female and 30 male, average age 47 years) were treated with 36 FHL transfers and 25 patients with 26 FHL transfers could be re-evaluated at a mean follow-up time of 79 months (range 20-133 months) after surgery., Results: Of the 25 patients, 18 (72%) subjectively rated the result as excellent, 5 (20%) as good, and 1 patient (4%) each as fair and poor. According to the criteria of Trillat and Mournier-Kuhn, 18 patients (72%) were rated excellent, 4 (16%) good and 3 (12%) fair. The AOFAS ankle/hindfoot score at follow-up averaged 91 (range 13-100), the AOFAS forefoot score averaged 95 (range 24-100)., Conclusions: FHL transfer to the Achilles tendon provides favorable results in cases of complicated cases with defects, infections or severe tendinosis after Achilles tendon rupture.

Ankle fractures belong to the most frequent injuries to the human skeleton. Correct treatment requires knowledge of the trauma mechanism and thorough analysis of the injured bony and ligamentous components. Isolated, non-displaced fractures of the medial or lateral malleolus are subject to non-operative, functional treatment with favorable long-term results provided that instability of the ankle mortise has been definitely ruled out. Fracture-dislocations have to be reduced as an emergency under sufficient analgesia to avoid severe soft-tissue complications. The most important prognostic factors after operative treatment are exact reconstruction of the articular surfaces and correct position of the distal fibula within the tibial incision after a mechanically relevant syndesmosis rupture. Besides malalignment, negative prognostic factors include delayed reduction, injury of several ankle components and hereditary or acquired neuropathy.

The use of external fixation methods has become increasingly popular throughout the past decade in the treatment of tibial pilon fractures to prevent the dreaded soft tissue complications after high velocity injuries. A variety of methods has been proposed, including ankle-spanning half-pin frames; circular (Ilizarov) frames with tensioned wires; or hybrid frames, either as the sole treatment or, more frequently, in conjunction with limited internal screw fixation. External fixation also has a role in staged protocols as a primary tool for reduction and preliminary fixation until soft tissue consolidation makes internal fixation feasible. Although good to excellent results are reported in a high percentage of cases in most studies and infection rates have dropped to less than 10%, even for high velocity injuries with considerable soft tissue compromise, no single form of treatment seems to be suitable for all types of pilon fractures. Major concerns after external fixation are the development of pin track infections, malunions or nonunions, and the danger of imperfect reduction of the articular surface. Staged protocols that are based on the severity of the fracture and soft tissue injury are likely to play a major role in the future treatment of pilon fractures. In the treatment of acute malleolar fractures, ankle-spanning external fixation is reserved for fractures with considerable soft tissue compromise, open fractures, or compartment syndrome as a temporary transfixation until internal fixation becomes feasible.

Aim: Postoperative treatment following osteosynthesis of ankle fractures in a flexible arthrodesis boot (Variostabil) aims at fast restoration of the function of the injured extremity while allowing early full weight bearing. This treatment regimen was validated in a clinical and experimental study., Methods: (1) In the clinical study part, 56 patients with internally fixed ankle fractures received after treatment with the arthrodesis boot for 6 weeks. (2) In the experimental study part, the intravascular pressure was recorded in a foot vein of 8 healthy volunteers during knee bends., Results: (1) No implant failure or secondary dislocation was seen due to the after treatment. All patients rated subjective comfort and mobility as excellent. 90.5 % had a good to excellent functional result with the Philips Score. (2) Wearing the arthrodesis boot effected significantly faster venous outflow (25.8 +/- 15.2 vs. 11.3 +/- 6.0 mmHg/sec, p < 0.05) and higher pressure amplitude (53.6 +/- 12.0 vs. 26.5 +/- 9.6 mmHg) during knee bends, compared to a below-the-knee plaster cast., Conclusions: The flexible arthrodesis boot offers safe protection of ankle fractures combined with superior functional performance (undisturbed gait, training of the ankle joint, high patient comfort and mobility, accelerated venous outflow) as compared to cast immobilization.

Complete traumatic rupture of the tibialis posterior tendon is absolutely rare. From the scarce case reports in the medical literature a extreme pronation-abduction or pronation-external rotation mechanism according to the Lauge-Hansen classification can be presumed, leading to a malleolar fracture because of forced pronation, external rotation and dorsiflexion of the foot. With primary suture the prognosis is favorable. Traumatic dislocations, mostly with luxatio pedis sub talo, are treated by atraumatic reduction and refixation of the retinaculum. Again, the prognosis is favorable. Incomplete traumatic rupture of the tibialis posterior tendon with development of posttraumatic pes plano valgus, according to case reports and our own experience result from severe pronation-external rotation-soft tissue injuries as well as with pronation-abduction or pronation-external rotation-type ankle fractures. In these cases no macroscopic rupture of the tendon is evident, however occult interstitial micro-ruptures can occur because of excessive stretching, which can be determined histologically. If conservative measures fail, a modified Evans osteotomy to lengthen the lateral foot column is indicated. Degenerative complete and incomplete ruptures of the tibialis posterior tendon are predominantly seen in women more than 42 years old. Staging of this entity can be achieved with clinical tests (muscular force, external rotation), ultrasound, weight-bearing x-rays, CT and MRT. According to the degree of decompensation of tendon function, treatment consists of augmentation, modified Evans procedure or triple arthrodesis of the hind-foot.

Non-unions after fracture dislocation of the ankle joint are extremely rare with predominantly operative treatment. In contrast, after fractures of the tibial plafond (pilon fractures) infections are seen in the literature in 37 % and non-unions are seen in 27 % after open reduction and internal fixation, requiring secondary ankle arthrodesis in about one quarter of all cases. In contrast to aseptic non-union or arthrosis, which can be salvaged with screw arthrodesis, with prevailing infection and severe osteoporosis external fixation (either one- or two-sided) is the treatment of choice. In isolated non-unions of the malleoli, either plate osteosynthesis with 3.5 low-contact dynamic compression plate or tension banding with autologous bone graft interposition, or alternatively sliding graft technique, is performed with good results.

Charcot foot in its original sense is equivalent to stage 4 of hereditary motor and sensory neuropathy (HMSN) which is known as Charcot-Marie-Tooth disease since 1886. This entity, which can be subdivided into 3 groups including subgroups, predominantly begins during childhood and progresses slowly. The first symptom, often unnoticed by the patient for a long period, is weakness of the intrinsic foot muscles with consecutive hammer-toe formation and mobile pes cavus. Progredient atrophy of the peroneal, extensor, tibialis posterior and finally triceps surae muscles leads to fixed pes cavus varus excavatus with severe varus deformity of the hindfoot, secondary varus position of the talus at the ankle level and subsequent arthrosis of the medial compartment. Permanent varus deformity of the ankle almost invariably leads to stress fractures of the malleoli because of repetitive microtrauma (stage 5 of HMSN). Early detection of the disease with nerve conduction studies at clinical suspicion allows tibialis posterior transfer, correctional osteotomy of the hindfoot or arthrodesis of Chopart's or Lisfranc's joint and can postpone or prevent the otherwise inevitable triple arthrodesis which has a less favorable long-term prognosis. At stage 4 (manifest Charcot foot) and stage 5 (neuropathic fracture of the ankle) a reorientating ankle arthrodesis is advocated, with additional subtalar pathology correctional double arthrodesis becomes necessary. In diabetic arthropathy of the ankle (Type IV according to Sanders and Frykberg), which is often referred to as "Charcot Ankle", tibiocalcanear arthrodesis is indicated. In case of supervening infection or extensive necrosis a modified Pirogoff amputation is carried out as a salvage procedure. Doubled periods of non weight-bearing, immobilization and brace protection of the ankle help to reduce the frequently observed implant failure in both forms of osteoarthropathy. In addition to stable implants retrograde calcaneotalotibial transfixation with a Steinmann pin may help to protect the achieved result despite prolonged bone consolidation.