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The presence of an intact distal fibula is reported as a prerequisite when considering total ankle replacement and its lack is usually considered a contraindication. The purpose of the study was to describe the results of a surgical technique to reconstruct the distal fibula (Milanese fibular reconstruction technique) in the setting of a total ankle replacement and insufficient fibula.Retrospective analysis of 15 patients (15 ankles) who underwent rotational fibular reconstruction technique with minimum follow-up of 24 months. Patients were evaluated preoperatively and at the last follow-up with AOFAS Ankle and Hindfoot score, VAS pain scale, SF-12 and range of motion. Standard weightbearing radiographs were used for radiographic assessment.The average of all clinical scores significantly improved (P.001). The average radiographic parameters showed a neutral alignment. No cases of reabsorption of the new lateral malleolus were observed even in cases with complications that accounted for 2 superficial wound infection and 2 deep infections.The Milanese fibular reconstruction technique can successfully reestablish a lateral strut and in the setting of an ankle prosthesis in patients with an insufficient fibula.

Background The fracture obliquity of supination-external rotation injury of the fibula is often amenable to lag screw insertion. The purpose of the study was to determine whether biomechanical differences exist between lag screws inserted from an anterior to posterior direction and from a posterior to anterior direction and the thickness of the anterior and posterior fibular cortices were correlated with biomechanical testing. Methods Ten cadaver fibulae were harvested and submitted to material testing following 3.5-mm cortical screw insertion from either an anterior to posterior direction or a posterior to anterior direction. Screw torsional insertion strength and axial pullout strength were measured. Computed tomography images of 40 consecutive patients undergoing preoperative planning for fractures excluding the fibula were examined to define fibular cortical thickness and correlate anatomic findings with the biomechanical testing. Results The axial pullout strength of lag screws inserted from posterior to anterior was significantly greater than that of lag screws inserted from anterior to posterior (p < 0.05). Screw insertion torque measurements demonstrated a similar trend although the data did not reach statistical significance (p = 0.056). The anterior cortex of the distal fibula exhibited a radiographically greater thickness than that of the posterior cortex at the same level (p < 0.001). Conclusions For oblique fractures of the distal fibula, posterior to anterior lag screw insertion exhibited improved biomechanical properties when compared with a similar screw inserted from anterior to posterior. These results correlated with the thicker cortical bone present along the anterior fibula.

Isolated distal fibula fractures represent the majority of ankle fractures. These fractures are often the result of a low-energy trauma with external rotation and supination mechanism. Diagnosis is based on clinical signs and radiographic exam. Stress X-rays have a role in detecting associated mortise instability. Management depends on fracture type, displacement and associated ankle instability. For simple, minimally displaced fractures without ankle instability, conservative treatment leads to excellent results. Conservative treatment must also be considered in overaged unhealthy patients, even in unstable fractures. Surgical treatment is indicated when fracture or ankle instability are present, with several techniques described. Outcome is excellent in most cases. Complications regarding wound healing are frequent, especially with plate fixation, whereas other complications are uncommon.

Background Ankle fractures pose a unique challenge to the treating orthopedic surgeon. Intramedullary (IM) distal fibula fixation is a relatively newer entity offering a viable option to minimize wound complications while providing similar outcomes. Our study utilizes an IM nail featuring proximal fixation via IM talons ensuring maintenance of fracture reduction this is the largest case series utilizing this novel device assessing time to weight-bearing (WB) and fracture union in addition to the safety and reproducibility of percutaneous reduction. Methods A retrospective case series was conducted on 51 ankle fractures treated with a single IM device for lateral malleolar fixation. Postoperative radiographs were assessed, qualifying reductions as good, fair, or poor based on a reduction classification. Patient charts were reviewed for fracture characteristics, reduction method, fracture union, time to WB, and complications. Results Mean follow-up time was 32.2 weeks; 47 fracture reductions (92%) were classified as good, and 4 (8%) were fair. All but 1 fracture (98%) went onto union. Average time to union was 10.3 weeks. Average time to WB with and without a walking boot was 6.8 and 11.2 weeks, respectively. Two patients experienced painful hardware. One patient had a superficial wound infection; Conclusion When evaluating this novel IM device, fracture union and time to union were found to be acceptable, with minimal wound or other complications. Percutaneous reduction permitted good fracture reduction quality. Consistent time to WB for a variety of fractures was reliably demonstrated following operative fixation with this device, including those in the elderly population. Levels of Evidence: Level IV: Clinical case series

Stabile Frakturen des oberen Sprunggelenks (OSG) konnen mit gutem Erfolg funktionell-konservativ behandelt werden, bei instabilen Frakturen fuhrt dagegen die operative Therapie eindeutig zu besseren Ergebnissen. Wie sich die Stabilitat des OSG nach Frakturen am besten bestimmen lasst, wird nach wie vor kontrovers diskutiert. Ein zunehmendes Verstandnis der Verletzungsmechanismen sowie der Biomechanik des OSG hat dazu gefuhrt, dass heute die Unterteilung in stabile und instabile Frakturen mit hoher Spezifitat moglich ist. Im vorliegenden Beitrag werden die haufig angewendeten Methoden zur Bestimmung der Stabilitat des OSG nach isolierten Frakturen des lateralen Malleolus diskutiert. Dazu gehoren die „Stresstests“ sowie die Anwendung von Rontgenaufnahmen im Stehen („weight-bearing radiographs“). Bei Einhaltung der beschriebenen Kriterien konnen uber 90 % aller isolierten, nichtdislozierten Frakturen der distalen Fibula erfolgreich funktionell-konservativ behandelt werden.

Introduction: The WHO defines giant cell tumor as a benign locally aggressive neoplasm with metastasizing capacity and aggressive behavior. Very rarely, these tumors are seen fungating, mostly when neglected. But when they do, the treatment option commonly conferred is amputation of the limb which is disabling and traumatizing. Case Report: We report three cases of fungating limb masses (proximal tibia, distal fibula, and distal radius) diagnosed with giant cell tumor histologically, undergoing limb saving surgeries with various reconstruction techniques to endorse a good quality of life and functioning limb. Conclusion: Our study is one of the earliest to report medium-term follow-up after such limb salvage procedure. We recommend that salvage procedures should be considered in giant cell tumors even in the presence of fungation if there is no neurovascular encasement. Keywords: Giant cell tumor, fungation, limb salvage surgery, endoprosthesis, mesh reconstruction.

Premature physeal closure (PPC) may lead to clinically significant progressive angular deformity or leg length discrepancy. Many variables seem to play a role in determining which injuries result in PPC. A 8- year-old boy sustained a non-displaced physeal fracture of distal tibia and fibula. He showed no signs of PPC at 7 months post-injury. Seven years later, his ankle became painful. He had developed PPC of distal fibula causing angular ankle deformity, which was treated successfully by corrective osteotomy. To our knowledge, this is the first reported case of a non-displaced fracture of the distal fibula leading to PPC several years after the initial injury, which in our understanding was impossible to predict.

Background Reconstruction modalities described after distal fibula resection varies from no reconstruction to size matched allograft or reconstruction with ipsilateral proximal fibula. Every procedure has their own limitation. We used Prolene mesh to reconstruct lateral restraint (Meshplasty) after distal fibulectomy. Question Is a minimal reconstruction using prolene mesh (meshplasty) adequate to restore ankle stability and function post distal fibula resection? Method This retrospective analysis was performed in patients who underwent distal fibulectomy at the tertiary cancer hospital in India, between 01/01/2006 and 31/12/2016. Distal fibulectomy was performed through standard lateral approach. A prolene mesh was anchored to distal tibia and talus using screws or Ethibond sutures. Rehabilitation protocol included below knee cast for 6 weeks followed by gradual full weight bearing mobilization and ankle range of motion. Total 9 patients with mean age of 25 years (range: 13–43) got operated for distal fibulectomy during this period. Mean resection length was 13.3 cm (range: 9–20). Results Seven patients were available for final assessment at a median follow-up duration of 78 months (range: 34–161 months). Two patients developed local recurrence. Two patients developed distant recurrence both died of disease. One patient of GCT developed local recurrence in soft tissue at 30months, which was excised. Another patient of OGS developed local recurrence after 8 months along with distant recurrence. One patient of PNET developed distant recurrence at 3 months. One patient had a valgus deformity at 55 months follow up without any restriction of activity while the others had a stable ankle without any deformity. The mean MSTS score was 28 (24–29). Conclusion “Meshplasty” after distal fibulectomy is an easy, reproducible, time and cost effective reconstruction modality with minimal complications. It adequately restores ankle function while providing results comparable to other procedures. Level of evidence IV.

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.Bereits geringe residuale Fehlstellungen nach Osteosynthese von Sprunggelenkfrakturen gehen mit einer verschlechterten Prognose einher. Häufige Ursachen für nicht anatomische Repositionen sind Fibulaverkürzungen bei Trümmerfrakturen oder schlechter Knochenqualität, Fehlstellungen und Malrotationen der distalen Fibula in der Tibiainzisur bei instabilen Syndesmosenverletzungen sowie nicht adressierte knöcherne Ausrisse der vorderen oder hinteren Syndesmose. Nach operativer Versorgung von Frakturen mit notwendiger Syndesmosenstabilisierung, komplexer Frakturmorphologie sowie bei jedem Verdacht auf eine ungenügende Reposition im postoperativen Röntgenbild sollte eine CT-Kontrolle unter Einbeziehung der unverletzten Seite erfolgen. Die Korrektur relevanter Fehlstellungen sollte so früh wie möglich erfolgen, um die Rehabilitation zu beschleunigen und Dauerschäden durch die Druckumverteilung bzw. Instabilität in einem lasttragenden Gelenk zu vermeiden.

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.

Distal Fibula Giant cell tumour (GCT) is a rare condition. The described methods of treatment for distal fibula GCT include excision of tumour and ankle arthrodesis, replacement of distal fibula with ipsilateral proximal fibula and autograft or allograft reconstruction. This case report describes treatment of distal fibula grade 3 GCT with involvement of syndesmosis with tumour excision, proximal fibular slide and reconstruction of ankle joint. With this technique the ankle joint movements are preserved and stability is maintained.

Proximal tibial fractures are very rare. Our case is about a six-year-old girl presented with proximal tibial triplane fracture associated with proximal and distal fibula and distal tibial fractures, as a result of a fall of a cement wall on her right knee. A radiograph and computerized tomography (CT) scan were reported as Salter-Harris type III fracture. She was treated by an open reduction and internal fixation by a screw and Kirschner wires. She was followed up for 12 months and showed an excellent knee outcome and her knee range of motion was 10-130o. Anatomical reduction and stable fixation are necessary to prevent future pain, deformity and arthritis. The case demonstrates the efficacy of using an open reduction and internal fixation by a screw and Kirschner wires in treating children with triplane proximal tibial fracture. This type of fracture is not frequently seen and a right diagnosis leads to better management, which could prevent future complications

Background: The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis. Methods: Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software. Results: On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond. Conclusion: Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most. Clinical Relevance: This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.

Introduction Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years. Materials and methods Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy. Results During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail. Conclusions Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.

(1) Background: Restoration of ankle biomechanics after distal fibula (DF) resection in bone sarcomas can be performed with different techniques. We report the functional and oncological outcomes of a case series, (2) Methods: Ten patients (5 females and 5 males) with a mean age of 27 years (range 10–71) were retrospectively evaluated. Following the resection, different techniques were used to reconstruct the ankle: tibiotalar arthrodesis, residual lateral malleolus fixed to the tibia, non-vascularized or rotational vascularized fibula transposition and intercalary allograft. All complications were recorded, and the functional outcomes were evaluated, (3) Results: The mean follow-up time was 54 months (range, 13–116). Six patients were free of disease while four patients died of disease. All patients had a stable ankle and bone union, which was achieved after a mean of 9.4 months (range 3–20). The mean MSTS Score was 26.7 (range 21–30). Chronic ankle pain and peroneal external nerve palsy were observed. Patients underwent additional surgeries for deep infection and for equinus ankle deformity. No local recurrence was observed. Metastasis occurred in four patients after a mean of 14.7 months (range 2–34), (4) Conclusions: After DF resection, the restoration of ankle biomechanics gives acceptable functional results, but a larger series of patients with long-time follow-up are required to confirm the durability of the reconstruction.

Introduction In isolated Weber B fractures (type B fibular fractures), ruling out instability is critical for safe conservative treatment. In fractures without evident medial injury, additional diagnostics like MRI scan or gravity stress test should be done to differentiate between a stable and unstable fracture. The aim of the current study is to gain more insight in current practice and treatment of type B fractures by Dutch trauma- and orthopaedic surgeons. Materials & methods In December 2017 and January 2018, 559 trauma surgeons were invited by email to join an online survey. This survey consisted of questions regarding diagnostics and treatment of isolated distal fibula fractures. Also, respondents were asked to state their preferred treatment of eight separate cases. Results In total, 161 surgeons participated, covering 68 different hospitals in the Netherlands. Of them, 32.0% treat more than 30 ankle fractures a year. Based on regular mortise radiographs, 13.6% of the respondents chose surgical treatment in case of a medial clear space (MCS) > 4 mm, 33.8% in case of a MCS > 6 mm and 45.5% in case of a MCS > 4 mm in addition to the MCS ≥ superior clear space + 1 mm. Moreover, 18.2% make use of additional diagnostics (43.9% repeat mortise view after a week, 16.6% weight bearing radiograph, 8.6% gravity stress view, 7.9% exorotation radiograph, 6.5% MRI scan, 0.7% ultrasound, 16.8% other) and 8% establishes their decision not based on the mortise radiograph. Fibular dislocation of ≥ 2 mm was used as an indication for surgical treatment by 69%. Of them, 56% decides to treat surgically in these cases, even with proven medial stability. Conclusion Many surgeons treat type B fibular fractures with a MCS > 4 mm at mortise view surgically, even without proven medial injury. Rarely, additional diagnostics as MRI or gravity stress test are performed in cases with a MCS 4–6 mm. Consequently many stable ankle fractures are treated operatively unnecessarily.

We report the case of a 13-year-old girl with multiple recurrences of an aneurysmal bone cyst of the distal fibula successfully treated with denosumab and curettage. Aneurysmal bone cysts are locally aggressive lesions with high rates of recurrence. The novel use of denosumab with curettage in a long bone showed a favorable outcome with no adverse events or signs of recurrence three years after treatment.

CASE A 47-year-old woman with adamantinoma of the entire left tibia and distal fibula underwent resection and reconstruction using a total tibia allograft-prosthetic composite with rotating hinged knee replacement and ankle fusion. She is ambulating without tumor recurrence with 2-year follow-up. CONCLUSION This case report offers a unique reconstruction option for extensive tibia bone primary malignancy. To our knowledge, this is the longest survival for total tibia allograft prosthetic composite reconstruction.

INTRODUCTION Tibio-talo-calcaneal (TTC) fusion is a successful surgery for Charcot neuropathy affecting the hindfoot. A case series of Charcot neuropathy is presented with almost complete loss affecting hindfoot treated with tibio-talo-calcaneal nail. MATERIAL AND METHODS Seven patients with Charcot neuropathy of the hindfoot having varying degrees of talus loss underwent tibio-talo-calcaneal nailing between January 2014 and Feb 2016 at a tertiary care hospital by a single surgeon. All the patients were type 3a as per Brodsky classification. Patients with active infection, fractures and avascular necrosis of talus was excluded from the study. The final outcome was measured using the AOFAS and FADI scores at the end of 2 years. RESULTS The mean duration of diabetes was 8.16 ± 3.12 years. Two patients (28.6%) had total and 5 (71.4%) patients had subtotal talus loss. Anterior approach was used in four, and lateral approach was used in three cases respectively. The talus was reconstructed by using the iliac crest or the graft from the distal fibula wherever appropriate. The average surgical duration was 93.28 ± 4.84 min. One patient had deep infection, 2 years after the surgery which was treated by implant removal and antibiotics. No patients had non-union. The pre-operative AOFAS scores improved from 32.2 ± 2.58 to 73.4 ± 3.36 at 2-year follow-up (p < 0.0001). Similarly, the pre-operative FADI scores were 31.74 ± 1.98 which improved to 65.94 ± 3.68 at the end of 2 years (p < 0.0001). CONCLUSION Retrograde tibio-talo-calcaneal nail is a good option for limb salvage in patients with severe talus loss with good functional outcome. LEVEL OF EVIDENCE Therapeutic IV.

Category: Ankle; Trauma Introduction/Purpose: The aim of our study is to compare two types of plates, one third tubular plate and LCP distal fibula plate, evaluating the clinical outcome and the skin complications associated with their use. Methods: We collected the data of 122 consecutive unimalleolar or bimalleolar fractures treated by internal fixation for a closed, displaced distal closed fibular fracture. Exclusion criteria were: 1) open ankle fractures,2) trimalleolar fractures, 3) previous ankle fractures 4) severe venous insufficiency, 5) ankleosteoarthritis previous to surgery, 6) associated ankle dislocation. After this selection, 93 patients were included in our study and assigned in two groups, based on using of different implant: in group A48 patients were treated with one-third tubular and in group B 45 patients were treated with LCP distalfibula plate. There were no significant differences in the baseline characteristics. Patients received the same surgical procedure and the same post-operative care, then they were radiologically evaluated at1-3-12 months and clinical examination was made at 24 (range 15-36) months using AOFAS clinical rating system. All data were evaluated using chi-square test. Results: At the final 24-month follow-up a comparison between the two groups showed no statistical significant differences in reduction accuracy and bone union ratio at radiological examination. The wound complications rate of the overall study group was 7.6%. There were no statistical differences in the rate of wound complications between the two groups. There were no differences between both group in percentage of hardware removal at follow-up (overall 5.4%). In the group A occurred 1 deep infection, 2 superficial infection, no wound dehiscence; in group B occured 1 deep infection, 1 superficial infection and 2 wound dehiscence. There were no statistical differences in the rate of wound complications between the two groups (p=0.70; Fisher exact test). Conclusion: Our study has shown no difference in radiographic bone union rate, no significant differences in terms of clinical outcomes, in time of bone reduction and wound complication rate between the LCP distalfibula plate and conventional one-third tubular plate. RCT or metanalasys are in this case useful to improve scientific evidence and give more information for the correct surgical treatment of ankle fractures.

Category: Trauma; Ankle Introduction/Purpose: Intramedullary fixation of the distal fibula in unstable ankle fractures provides an alternative treatment strategy to traditional techniques and may reduce the complication profile. While often reserved for soft-tissue protection or elderly patients, the indications for this technique continue to expand. The purpose of this study was to evaluate the radiographic outcomes of ankle fractures treated with intramedullary fixation of the distal fibula with screw or flexible fixation of the syndesmosis. Methods: A retrospective case-series was performed of patients >18 years old with unstable ankle fractures treated at a single institution. Patients were treated with intramedullary fixation of the distal fibula and screw or suture-button fixation of the syndesmosis if indicated. Radiographic parameters measured included the medial clear space, tibiofibular overlap, tibiofibular clear space, talocrural angle, and fracture displacement. Fracture pattern, comorbidities, and postoperative complications were also assessed. Results: Fourteen patients (6 males, 8 females) with torsional ankle fractures (71% SER-IV patterns) were included in the study with a mean follow-up period of 5 months. Five patients had suture-button fixation and one patient had trans-syndesmotic screw fixation of the syndesmosis. All patients had improvement in radiographic parameters following surgical stabilization. Medial clear space decreased from a mean of 5.6 +- 3.1mm to 2.8 +- 0.79mm (pConclusion: This case-series demonstrates the successful use of intramedullary fixation of distal fibula fractures in unstable ankle injuries with good radiographic and clinical outcomes. The use of an intramedullary device does not preclude trans-syndesmotic screw or suture-button fixation of concomitant syndesmotic injuries. Orthopedic surgeons can consider this treatment strategy as an alternative to traditional techniques.

Distal tibiofibular syndesmosis is a complex anatomical structure that is essential for the stability and function of the ankle. Ankle fractures are a common source of chronic syndesmosis instability with associated functional impairments and early development of osteoarthritis. Case presentation: we described a case of a 28-year-old patient who presented with symptomatic ankle subluxation and chronic syndesmosis instability. Eight months earlier, the patient sustained a minimally displaced ankle fracture that had been treated conservatively elsewhere. The surgical approach included the anatomical realignment of the distal fibula with a lengthening derotational osteotomy and tibiofibular syndesmosis reconstruction using an autologous semitendinosus tendon graft. One year after surgery, the ankle function was restored, and the patient was asymptomatic. Conclusion: The instability of ankle fractures should be carefully evaluated during the treatment decision-making. Surgical treatment of syndesmosis instability should be performed even in chronic cases to restore function. The reconstruction of syndesmosis with semitendinous tendon graft associated with fibular length and realignment improves the ankle stability and function.

Background: In the setting of apparently isolated distal fibula fractures, the gravity stress view (GSV) is a validated method to determine mortise stability. There is currently no published data evaluating whether dynamic muscle activation can reduce an unstable mortise. If patients with instability can overcome gravity, resultant images could yield false-negative results. The goal of this investigation was to determine if patient effort can influence medial clear space (MCS) measurements in proven unstable bimalleolar-equivalent ankle fractures. Methods: Patients presenting with Weber B fibula fractures were assessed for mortise stability using the GSV. If the GSV demonstrated instability based on MCS widening >4 mm, 3 additional views were performed: GSV with an assistant maintaining the ankle in a neutral position; GSV with the patient actively dorsiflexing to neutral; and GSV with the patient actively dorsiflexing and supinating the foot. Twenty-four consecutive patients met inclusion criteria, with a mean age of 48.7 (range, 22-85) years. Fifteen patients (62.5%) were female and 9 (37.5%) were male. The laterality was evenly divided. Results: The mean MCS was 5.8 ± 2.0 6.0 ± 2.6, and 6.2 ± 2.7 mm for the manual assist, active dorsiflexion, and active supination radiograph measurement groups, respectively ( P = .434). Only 5 of 24 subjects had any measurable decrease in their MCS with active supination, with a maximum change of 1.2 mm. The remainder of the patients had an increase in MCS ranging from 0.1 to 4.0 mm. Conclusion: There was no significant difference between measurement states indicating that muscle activation is unlikely to yield a false-negative result on GSV. Mortise instability, secondary to deep deltoid injury in the presence of gravity stress, is unlikely to be actively overcome by dynamic stabilizers, supporting the validity and specificity of the GSV. Level of Evidence: Level III, prospective study.

Background. There has been historical debate as to whether the distal tibiofibular syndesmosis can be overtightened during operative fixation. We used finite-element analysis to determine if overtightening of syndesmotic screws can cause widening of the lateral gutter clear space in the ankle joint. Methods. A 3D finite-element model was constructed and analyzed using geometries from a computed tomography scan of a cadaveric lower leg. Starting 2 cm from the plafond, screw fixation was simulated at 5-mm increments to a distance of 5 cm from the plafond. The fibula was compressed 2 mm toward the tibia at each interval, and the change in distance between the lateral talus and distal fibula was measured. Results. Medial deflection of the fibula resulted in widening of the lateral clear space, which was proportional to the amount of deflection. The effect increased as screws were placed closer to the plafond, with 1.5 mm of widening at 2 cm (0.76 mm/mm) versus 0.7 mm at 5 cm (0.34 mm/mm). Conclusion. Our finite-element model demonstrated that overtightening of the distal tibiofibular syndesmosis with medial fibular displacement can cause widening of the lateral clear space. Clinical relevance. The results suggest that screws placed farther from the plafond widen the lateral clear space to a lesser degree, which may be advantageous during surgical fixation to prevent clear space widening and increased tibiotalar contact forces. Levels of Evidence: Level I

Osteoporotic fractures of the distal fibula in elderly patients is a challenge to manage. Non-operative management has a poor outcome so operative management is preferred. There are a variety of options for operative management such as locked plate systems, anti-glide plate construct, dual plating constructs, fibula nail, plate with tibial pro-fibular screws, and injectable bone cement (polymethylmethacrylate (PMMA), calcium phosphate). However, no clear guidelines exist for the operative management of osteoporotic distal fibula fractures. The surgeon should detect osteoporotic fractures early to make the best use of resources and avoid complications such as implant failure.

Stress fractures of the ankle and hindfoot are common injuries in athletes. Most of these fractures can be treated nonoperatively, but certain factors including fracture location, vascular supply, lower leg alignment, and return to play considerations may require surgical intervention. Stress fractures of the ankle and hindfoot can also be classified as low risk and high risk in regard to propensity to heal with conservative treatment. Generally, low-risk fractures include the distal tibia, distal fibula, talus, and calcaneus. High-risk fractures include the medial malleolus and navicular. The treating health-care provider should have a low index for suspicion for stress fracture and be able to identify risk factors in regard to bone health, structural alignment, and training/competing issues in order to achieve a quick recovery and minimize the chance for recurrence of injury.

The patient was a 26-year-old man who fell while riding a motorcycle and friction led to defects in the lateral malleolus and soft tissue of the ankle. Although the wound surface healed with scarring and skin grafting, the patient had symptoms of ankle joint instability 4 months after the injury. Using a second metatarsal composite tissue flap with a dorsalis pedis artery pedicle, we repaired the soft tissue defect of the ankle and reconstructed the lateral malleolus. The head of the metatarsal bone was used to reconstruct the lateral malleolus and the flap was used to cover the wound surface. The distal fibula and metatarsus were completely healed 36 months postoperatively. The ankle had maintained stability at this time, with equal limb length and only a mild limitation of dorsal flexion in the ankle joint. The patient could walk, jog, and walk up and down stairs without limitations. There was no pain or limitation in activity at the donor site. Our findings suggest that the second metatarsal composite tissue flap with a dorsalis pedis artery pedicle is an effective option in reconstruction of the adult distal fibula.

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures. Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures. Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus. Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively. Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057

Background: Giant cell tumor (GCT) is a destructive bone tumor. The predilection of the GCT is mostly on the epiphysial of long bones. GCT of the distal fibula is a very rare case that becomes challenging in surgical management. The chosen surgical management is crucial and still under debate.Case Report: A 38-years-old male complaint of a painful lump in the lateral side of his left ankle for three months. Plain radiographs demonstrate a lytic lesion involving distal fibula, appropriate with 2nd-grade Campanacci. MRI showed a mass centered on the distal fibula with intermediate to high T2 signal, low T1 signal, and homogenous contrast enhancement. The patient underwent a wide excision and reconstruction of the distal fibula with a fibular head graft from the ipsilateral side. After fifteen months of evaluation, the result was excellent. The patient can full-wight-bearing with a full range of ankle joint movement, return to daily activities without pain, and no signs of recurrence. Functional status measured by the MSTS and CAIT showed good results, with total scores was 28 and 27.Discussion: Ten centimeters distal fibula is a crucial component to form stability of the ankle. Reconstruction of the distal fibula after wide excision requires the bone graft and is considered to maintain ankle stability. It can be achieved using autograft from fibula or iliac crest.Conclusion: Reconstruction of distal fibula GCT with proximal fibular autograft showed a great result. This method is a viable option as it provides good pain relief and functional improvement.

Musculoskeletal tumours of the lower limbs especially malignant tumours are not common. The fibula is the site of primary bone tumours as reported in 2.4% of lower limb tumours with the proximal third being more frequently involved than the distal segment. Osteosarcoma is the most common primary malignant bone tumour of nonhaematopoietic origin, with distal fibular involvement in 0.47% of patients. The advances in imaging techniques and neo-adjuvant chemotherapy have now made it possible to accurately define the extent of tumour and plan limb salvage with tumour resection. The purpose of this case report is to highlight the successful outcome of limb salvage procedure with a five year follow up in an 11-year old boy with distal fibular osteosarcoma. Limb salvage surgery with distal fibulectomy and retention of the foot are a good alternative to radical amputation.

Introduction: Ankle fractures are the most common type of fractures treated in orthopaedics with isolated malleolar fractures, accounting for two-thirds of fractures. The most common injury mechanism is supination external rotation, which accounts for the majority of all ankle fracture patterns. Supination external rotation stage II is the classic short oblique fracture of the distal fibula without a medial side injury, which responds well to non-operative treatment as it is a stable fracture. The purpose of this study is to compare efficacy of elasticated support bandage versus plaster cast in the patient with isolated lateral malleolus fracture (Lauge-Hansen supination- eversion external stage II.) Method: A prospective comparative study was carried out in the Department of Orthopaedics in Bir Hospital from February 2007 to January 2009. Patients with ankle fracture were initially treated by below knee posterior slab for seven days to allow the swelling to subside and on seventh day follow-up they were grouped in two groups. Group A were patients with below knee cast and Group B were elasticated support bandage. Both groups were followed-up in the 5 th week for cast or elasticated bandage removal and were evaluated after a week, thereafter, every monthly for 3 months and finally at 6 month. Result: Of the 48 cases enrolled, the mean age of the patients was 38.85 years. The common mode of injury was fall from height followed by road traffic accident. The modified subjective ankle score of Olerud and Molander (1984) was found more in group B in comparison to group A in all follow ups. In initial three successive follow ups at 6 week, 12 week and at 3 month subjective score was found statistically significant ( p> 0.05) however, it was not significant at 6 month follow up. The range of motion was significantly improved in group B in all follow ups but the difference between the two groups at 6 weeks and 10 weeks follow ups was statistically significant. Immobilized group required less analgesic but the difference was not significant statistically. Conclusion: Both below knee cast and elasticated support bandage treatment methods are safe, satisfactory and equally effective with a better early result in elasticated support bandage. Supination External Rotation stage II type fracture can be treated conservatively, if there is no medial tenderness. Journal of Society of Surgeons of Nepal Vol. 17, No. 2, 2014, Page: 7-11

Introduction. Distal fibula fractures are common orthopaedic injuries that often require open reduction internal fixation (ORIF) to anatomically reduce the fracture and minimize the risk of posttraumatic arthritis. In certain clinical situations, stouter fixation may be advantageous to decrease the risk of fixation failure. In this study, the authors report on 12 patients who underwent distal fibula ORIF with 2 one-third tubular plates. Materials and Methods. Twelve consecutive patients who underwent distal fibula ORIF with 2 one-third tubular plates were retrospectively reviewed. Clinical and radiographic outcomes were reviewed, and functional outcomes were obtained using the Foot and Ankle Outcome Score (FAOS). Institutional review board approval was obtained. Results. All 12 fractures healed clinically and radiographically. One patient was lost to follow-up after healing of the fracture. One patient had removal of fibular hardware at 15 months after surgery. Ten patients had no hardware related pain and good ankle function. FAOS scores were obtained at a mean of 25.6 months after surgery and were as follows: pain (87.6, SD = 9.5), activities of daily living (90.4, SD = 14.5), symptoms (93.3, SD = 9.5), sports (89.5, SD = 18.1), and quality of life (57.4, SD = 21.3). Conclusions. Double plating of distal fibula fractures is a viable technique for problem fractures that potentially provides a readily accessible, low-cost alternative to other means of enhancing fixation. Levels of Evidence: Level IV

The aim of this study was to present outcomes of operative treatment of the posterior malleolus fractures of type four of the Bartonicek/Rammelt classification. In 19 patients, direct reduction and fixation of the posterior malleolus was performed from the posterolateral or posteromedial approaches. The accuracy of reduction was assessed with the use of postoperative CT scans. The mean size of the avulsed articular surface carried by posterior malleolus amounted to 36%. Reduction of the posterior malleolus fracture was assessed as anatomical in 14 cases and as satisfactory in five cases. Position of the distal fibula was assessed as anatomical in 15 cases. The mean AOFAS score was 89.4 points. All nine patients with anatomical reduction of all lesions achieved the mean AOFAS score of 93.1 points, five patients with malposition of posterior malleolus 89.1 points and five patients with malposition of the fibula in the fibular notch 87.8 points. A total of six patients developed osteoarthritic changes of grades one and two according to the Kellgren and Lawrence classification. Outcomes of the study demonstrated good mid-term results in type four fractures of the posterior malleolus treated by direct reduction from posterior approaches. Postoperative CT examination allowed evaluation of the accuracy of reduction of all fractures and reduction of the distal fibula into the fibular notch. Based on postoperative CT examination, it will be possible to assess the effect of reduction of individual lesions on the functional results.

Category: Trauma Introduction/Purpose: The current gold-standard for unstable distal fibula fractures is plate and screw fixation; however, intramedullary distal fibular fixation is becoming more commonplace. Although surgeons may consider this technique only for patients requiring extra soft tissue protection, recent studies are showing that it is a safe and effective technique for maintaining adequate reduction and promoting proper fracture healing in a wide-variety of ankle fractures. As newer techniques and equipment are developed, it is important to continue with analyzation of patient outcomes. Our study evaluates a intramedullary device that contains a unique proximal locking mechanism that deploys fins against the inner cortex to help maintain fracture length and control rotation. To our knowledge, no other study in the literature has evaluated this technique for distal fibula fractures. Methods: A retrospective case-series was conducted on all patients >18-years old with unstable ankle fractures treated with the same intramedullary distal fibular fixation, that contained the unique proximal locking system. Surgeries were performed at a single institution by a single surgeon between September 2015 and June 2018. Patient imaging was carefully assessed for quality of reduction using previously established guidelines classifying reductions as “good”, ”fair”, or “poor”. Patient charts were also assessed for comorbidities, initial fracture classification, postoperative complications, and need for additional surgery. Results: Forty-one patients were included in the study. Twenty-five patients were female and 16 patients were male. Average age was 52. Average follow-up was 10.0 months. Eleven fractures were bimalleolar (27%), eight were isolated distal fibula fractures (20%), eight were bimalleolar-equivalent fractures (20%), nine were trimalleolar fractures (22%), and five were pilon fractures (12%). Seventy-one percent were Weber B and 29% were Weber C. Based on the classification system, 37 fracture reductions (90%) were classified as ”good”, four were “fair” (10%), and no reductions were ”poor”. There were no instances of hardware failure, loss of reduction, or nonunion. One patient had a superficial wound infection, one patient had a deep wound infection, five patients require painful hardware removal, and one patient had a delayed union. Conclusion: This large case-series is the first study, to our knowledge, in the Foot and Ankle literature to evaluate this specific intramedullary distal fibular fixation system that contains a unique-proximal fixation mechanism within the canal itself. This technique was used for a variety of unstable ankle fractures and was shown to be both safe and effective, and will help guide future prospective studies comparing outcomes with the gold-standard plate and screw fixation.

To biomechanically analyze instability in supination external rotation (SER) II/III patterns.Nineteen cadaver legs were tested in a mechanical jig. One, 2, 3, and 4 Nm of external rotation were applied to intact ankles, SER II injuries, and SER III injuries. The talar position relative to the tibia was recorded using 3D motion tracking. Change from the unloaded state in each condition and the torque level was calculated. Results were analyzed using analysis of variance with post hoc paired t tests.SER II showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1 and 2 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER III showed statistically significant differences from the intact state with coronal translation (2, 3, and 4 Nm), sagittal translation (1, 2, and 3 Nm), axial rotation (1, 2, 3, and 4 Nm), and coronal rotation (3 and 4 Nm). SER II and SER III differed significantly from each other with coronal translation (1, 2, and 3 Nm), axial rotation (2, 3, and 4 Nm), and coronal rotation (1, 3, and 4 Nm).Instability in SER injuries has only been described with coronal translation and suggests that deltoid rupture is necessary. Our data demonstrate instability in SER II/III in sagittal translation and axial rotation as well as subtle instability in coronal translation. The clinical impact is unclear, but better understanding of long-term sequelae of this instability is needed.

Introduction. A Bosworth fracture-dislocation is a rare lesion resulting in a fixed dislocation of the distal fibula behind the posterior tibial tubercle. Only few cases have been reported showing an associated consequent fracture, namely, a pilon or a medial malleolus fracture. Case Report. We present a case report of a patient with an unusual combination of a Bosworth injury with a pilon fracture and an open multifragmentary talus fracture and our approach for open reduction and internal fixation. At one year postoperative, the patient developed an invalidating tibiotalar and subtalar arthrosis that eventually required an ankle-hindfoot arthrodesis. A Bosworth injury is an infrequent entity and is even rarer when associated with other fractures. Careful preoperative planning is necessary, as the combination of these fractures is a surgical challenge. Special care must be taken to preserve the neurovascular bundle. Discussion. The present case highlights a Bosworth injury involving a severity that has never been described before and suggests adding an eighth stage to the classification presented by Perry et al.

Instability is a common sequela after repeated ankle sprains. When nonoperative treatment fails, open lateral ligament complex repair and reinforcement with the inferior extensor retinaculum has been the gold standard procedure. The recent advancements in arthroscopic techniques have created comparable biomechanical and functional results to open procedures. The authors’ modification to the standard arthroscopic technique permits ligament approximation to the distal fibula over a larger surface area, using knotless anchors to avoid the need of an accessory portal and limit potential suture knot–related complications. Level of Evidence: Level V, expert opinion.

Defects of the lateral malleolus and distal fibula occur occasionally, mainly because of severe trauma or wide resection of fibular neoplasms. These bony defects should be reconstructed to avoid persistent pain and to prevent an abnormal gait induced by ankle instability. Various methods of repair have been developed, including allografting, autologous iliac crest transplantation, scapular apophysis transplantation, and arthrodesis and prosthetic reconstruction. A reverse transfer of the proximal vascularized fibula is also effective. Its morphologic advantage is apparent, and the surgery is simple and direct, with no need for vascular anastomosis. We treated recurrent fibrous dysplasia in the distal fibula of a young male with wide resection and reconstruction using reverse transfer of the proximal, vascularized fibula. At the 6-year follow-up examination, the patient had an American Orthopaedic Foot and Ankle Society ankle-hindfoot score of 100, without any apparent complications. Additionally, we critically reviewed other methods for reconstructing the lateral malleolus and distal fibula and have concluded that reverse transfer of the proximal vascularized fibula compares favorably and could be the treatment of choice.

Failure to anatomically reduce and stabilize the fractured distal fibula can result in malunion of the fibula and malreduction of the ankle mortise. Fibular malunion results in altered ankle joint biomechanics which often leads to the development of pain, stiffness, and premature joint degeneration. Fortunately, many fibular malunions can be successfully salvaged using osteotomy techniques to restore anatomic fibular length and rotation. Different osteotomy techniques are indicated depending on the location and characteristics of the malunion. In this review, the oblique fibular osteotomy is described for the reconstruction of SER-type fibular fractures. For more proximal fibular malunion, the transverse osteotomy technique with lengthening and structural bone graft is reviewed.Level of Evidence: Level V, expert opinion.

A rare case of symmetrical open bimalleolar fractures with bilateral dislocation of ankles is described. A 30-year-old man sustained indirect trauma working in squatting position with a heavy log of wood falling on his knees with ankles in inversion, and sustained symmetrical open III B bimalleolar fractures with dislocation of bilateral ankles with the distal fibula coming out of the skin. The patient underwent operative management on bilateral ankles and the post-operative course was uneventful. The patient had no complaints at 4 years’ follow-up and had a full, pain-free function. The probable mechanism of the fracture is discussed.

Ankle fractures are common orthopaedic injuries often requiring open reduction and internal fixation. A variety of positions for plate placement exist for surgical fixation of distal fibula fractures, including direct lateral, posterior, or posterolateral. Direct lateral is more common, despite evidence that posterior and posterolateral placement is mechanically superior. However, concern for peroneal tendon injury from posterior plating remains. Our study investigates clinical and functional outcomes of patients who underwent operative fixation of distal fibula fractures with posterior or posterolateral plating over a 3-year period. Analyses were performed on 59 patients with at least 2 years of follow-up. Questionnaires were used to obtain demographic data, in addition to information regarding the presence of ankle pain, subsequent hardware removal, and Foot and Ankle Outcome Scores (FAOS). In patients with at least 2 years of follow-up (average 39.6 ± 10.6 months), 37.2% reported ongoing ankle pain; 11 patients underwent hardware removal (18.6%), with 8 patients undergoing removal because of hardware-related pain (13.6%). FAOS scores (n = 51) were as follows: pain (79.9 ± 22.3), activities of daily living (84.2 ± 22.6), symptoms (75.7 ± 23.5), sports (69.4 ± 31.6), and quality of life (58.3 ± 30.5). Posterior and posterolateral plating achieved good clinical and high functional outcomes across our study population. The percentage of hardware removal in our study was either equivalent to, or less than, historical controls for any type of fibular fixation, and removal may be helpful for those patients whose postoperative ankle pain is subjectively related to the hardware. Levels of Evidence: Therapeutic, Level IV: Retrospective

Fractures of the distal fibula secondary to rotational ankle injuries are one of the most common injuries requiring surgical intervention. The aim of this study was to describe the anatomy of the distal fibular medullary canal as a means of aiding in surgical management with an intramedullary device. Twenty fresh cadaveric below-knee specimens (group 1, 10 in 2015, group 2, 10 in 2016) were dissected to expose the distal fibular. Fifteen (10 mm each) segments were sectioned with a sagittal saw from the distal tip proximally and measured with a digital caliper. In group I, the widest and narrowest fibular diameter was at the 20-mm interval (mean 15.02 mm) and 90-mm interval (mean 3.51 mm), respectively. From 70 to 120 mm, the mean diameter was less than 4.0 mm. In group 2, the widest and narrowest diameter was at the 20-mm interval (mean 15.05 mm) and 100-mm interval (mean 4.33 mm), respectively. From 70 to 140 mm, the mean diameter was less than 5.0 mm. The combined mean diameter at the 60- to 80-mm intervals were 4.99 ± 1.70, 4.35 ± 1.63, and 4.02 ± 1.35 mm, respectively. Based on our investigation, we propose an intramedullary device diameter of 4.5 to 5.0 mm in diameter with a length of 60 to 80 mm may provide most appropriate bony purchase to achieve acceptable cortical contact for expected osseous compression. Levels of Evidence: Level IV: Cadaveric case series

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group ( P =.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group ( P =.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group ( P =.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [ Orthopedics. 2017; 40(6):e1024–e1029.]

Background: Despite the frequency of distal fibula fractures in elite athletes and the significant potential impact on the athletes’ season and future careers, little data exist characterizing the epidemiology of these injuries or, more importantly, return to competition. Purpose: To (1) evaluate the incidence of acute distal fibula fractures in National Football League (NFL) athletes, including isolated distal fibula and combined ankle fracture patterns; (2) analyze distal fibula fracture rates in NFL athletes by position, type of play, and contact type; (3) determine the rates of distal fibula fracture surgery in NFL athletes; and (4) report the days missed due to distal fibula fractures in NFL athletes. Study Design: Descriptive epidemiology study. Methods: A retrospective review of distal fibula fractures reported to the NFL from 2000 to 2014 was performed using the NFL Injury Surveillance System. All distal fibula fractures were included, along with isolated and combined fracture patterns. Stress fractures and proximal fibula fractures were excluded. Epidemiological data and rates of surgery were determined. Return to sport was calculated and stratified by injury pattern and management. Results: Overall, 237 distal fibula fractures in NFL athletes from 2000 to 2014 were included; 197 (83%) were isolated distal fibula fractures. A mean of 16 distal fibula fractures occurred each year (median, 16 per year). Fractures occurred most frequently on running (38%) and passing (24%) plays, but the frequency was next highest on kickoffs (16%), despite the relative infrequency of kickoffs during the average game compared with other play types. Surgery was reported for more than half of all distal fibula fractures (n = 128, 54%). Overall, patients who underwent surgery missed significantly more days (mean, 123.8 days) than players who did not undergo surgery (mean, 75.3 days) (P < .001). Players with isolated distal fibula fractures had significantly fewer days missed (mean, 93.6 days) compared with those with combined patterns (mean, 132.3 days) (P = .0004). Conclusion: Fibula fractures affect a number of NFL athletes and result in significant time missed from competition. Further research is required to determine the optimal management of fibula fractures in NFL athletes. In this study, time to return to play depended on both the fracture pattern and whether surgery was required and ranged from 72 to 145 days.

Patient positioning is key to successful fixation of distal fibula fractures. When supine, the leg rests in an externally rotated or neutral position. The leg must be rotated internally throughout the operation to enable adequate visualisation of the lateral ankle. Exposure is improved by elevating the ipsilateral hip with a sandbag. However, in patients with a stiff hip or excessive external rotation, this is not enough. In these cases, exposure can be improved further by placing a size 7.5 or greater glove over the foot and securing the glove fingers over the contralateral foot. This provides internal rotation throughout the operation and covers dirty toes.