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Objective: This systematic review aimed to analyse the effect of early weight bearing versus late weight bearing on rehabilitation outcomes after ankle fractures, which primarily include ankle function scores, time to return to work/daily life and complication rates. Methods: The China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, China Science and Technology Journal, Web of Science, PubMed, Embase and Cochrane Library databases were searched. The focus was on identifying randomised controlled trials centred on early weight‐bearing interventions for post‐operative ankle fracture rehabilitation. All databases were searched for eligible studies published within the period from database inception to 20 June 2023. The eligible studies were screened according to the inclusion criteria. Study quality was evaluated using the methodology recommended by the Cochrane Handbook for the Systematic Evaluation of Interventions. Two authors independently performed the literature search and data extraction. Eligible studies were subjected to meta‐analyses using Review Manager 5.3. Based on the time points at which post‐operative ankle function was reported in the studies included in this paper, we decided to perform a meta‐analysis of ankle function scores at 6 weeks post‐operatively, 12 weeks post‐operatively, 24–26 weeks post‐operatively and 1 year post‐operatively. Results: A total of 11 papers, comprising 862 patients, were included. Meta‐analysis indicated that patients receiving early weight‐bearing interventions, which referred to weight‐bearing for 6 weeks post‐operatively, experienced enhancements in ankle function scores (Olerud–Molander score, AOFAS score or Baird–Jackson score) at various post‐operative milestones: 6 weeks (SMD = 0.69, 95% CI: 0.49–0.88 and p < 0.01), 12 weeks (SMD = 0.57, 95% CI: 0.22–0.92 and p < 0.01) and the 24–26 weeks range (SMD = 0.52, 95% CI: 0.20–0.85 and p < 0.01). The results of subgroup analyses revealed that the effects of early weight‐bearing interventions were influenced by ankle range‐of‐motion exercises. Additionally, early weight bearing allows patients to return to daily life and work earlier, which was evaluated by time when they resumed their preinjury activities (MD = −2.74, 95% CI: −3.46 to −2.02 and p < 0.01), with no distinct elevation in the incidence of complications (RR = 1.49, 95% CI: 0.85–2.61 and p > 0.05). Conclusion: The results showed that early weight bearing is effective in improving ankle function among post‐operative ankle fracture patients and allows patients to return to daily life earlier. Significantly, the safety profile of early weight bearing remains favourable, with no higher risk of complications than late weight bearing. [ABSTRACT FROM AUTHOR]

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Objectives: In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model. Methods: From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration. Results: SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer–Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification. Conclusion: Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture. [ABSTRACT FROM AUTHOR]

Objective: To investigate the clinical effect of the anteromedial cannulated screw approach in the treatment of Hawkins II/III talus fractures in children. Methods: A retrospective study was conducted on 20 children with talar fractures admitted to Renmin Hospital from September 2018 to February 2022. The fracture healing and functional recovery of the affected limb were strictly followed up after the operation. There were 14 males and 6 females. The average age was 9 years (range 6–12 years). According to the Hawkins classification, there were 12 cases of talar neck fracture type II and 8 cases of type III. All patients were fixed with cannulated compression screws via an anteromedial approach. According to the American Orthopedic Foot and Ankle Society ankle and hindfoot function scoring system, limb function was evaluated before and after the operation. A visual analog scale was used to evaluate the degree of postoperative pain. Results: All 20 children were followed up for 12 months to 30 months, with an average of 15 months. We found that there was no significant difference in the excellent and good rate (76.9%) and necrosis rate (30.8%) between male children and female children (71.4%) and necrosis rate (28.6%) (P > 0.05). The excellent and good rates (92.9%) of children younger than 9 years old at the time of injury were higher than those of children older than 9 years old (33.3%), and the incidence of avascular necrosis of the talus was lower. The differences between the two groups were statistically significant (P < 0.05). The average prognosis score of children who underwent surgery within 5 days after injury was 89.2 ± 6.4, which was significantly higher than that of children who underwent surgery after 5 days (72.9 ± 13.1), and the difference was statistically significant (P < 0.05). There was no significant difference between patients who underwent surgery within 5 days after injury (15.4%) and those who underwent surgery after 5 days (51.7%) (P > 0.05). The excellent and good rates of talar neck fracture type II and talar neck fracture type III were 90.1% and 55.6%, respectively. Conclusion: The anteromedial approach combined with cannulated compression screws for the treatment of Hawkins II/III talus fractures in children not only has a clear surgical field, but the fracture can also be reduced and fixed under direct vision using this technique. It does not affect the stability of the ankle joint and is conducive to the recovery of ankle function. It can be used as a surgical scheme for the treatment of talar fractures in children. [ABSTRACT FROM AUTHOR]

Background: This study explores the latest epidemiological characteristics of posterior malleolus fracture and compares the epidemiological differences of posterior malleolus fracture in different periods, regions, and adult age groups. Methods: Clinical information of inpatients with posterior malleolus fracture in Shanghai Tongji Hospital and Karamay Central Hospital from January 2014 to February 2022 was reviewed and collected. The imaging data of patients were acquired using the Picture Archiving and Communication Systems. A statistical analysis was performed as to gender, current age, year of admission, injury mechanism, fracture type, and posterior malleolus fracture classification. Moreover, a comparative analysis was conducted on the injury mechanisms and morphological differences of posterior malleolus fracture at different periods, regions, and age groups. Results: A total of 472 patients (210 patients from Shanghai Tongji Hospital and 262 patients from Karamay Central Hospital) with posterior malleolus fracture and an average age of 48.7 ± 15.6 were included in this study. The peak of posterior malleolus fracture occurs in the age group of 50–59. The injury mechanisms mainly involve low-energy fall and sprain (411 cases, 87.1%), followed by traffic accidents (52 cases, 11.0%), and fall injury from height (9 cases, 1.9%). With aging, the number of fall and sprain cases increases and reaches the peak at the age of 50–59, followed by progressive decline. Traffic accidents presents a relatively flat small peak in the age group of 40–59. The number of cases according to different fracture types shows the following ascending order: trimalleolar fracture-supination external rotation (335 cases, 71.0%) > bimalleolar fracture (60 cases, 12.7%) > trimalleolar fracture-pronation extorsion (43 cases, 9.1%) > posterior malleolus + tibial shaft fracture (19 cases, 4.0%) > simple posterior malleolus fracture (15 cases, 3.2%). The numbers of cases corresponding to the Haraguchi I Type, II Type, and III Type of posterior malleolus fractures were 369 (78.2%), 49 (10.4%), and 54 (11.4%), respectively. The Tongji IIA Type represented the highest number of cases (249 cases, 52.8%), followed by the IIB Type (120 cases, 25.4%), I Type (54 cases, 11.4%), IIIB Type (36 cases, 7.6%), and IIIA type (13 cases, 2.8%). The trimalleolar fracture-supination external rotation, Haraguchi I Type and Tongji IIA Type of posterior malleolus fractures all presented an obvious peak of incidence in the age group of 50–59. However, no obvious statistical difference was observed in the injury mechanism, Haraguchi classification, and Tongji classification of posterior malleolus fractures among different years and regions in recent years (P > 0.05). Conclusions: The injury mechanism of posterior malleolus fracture mainly involves low-energy fall and sprain cases. The trimalleolar fracture-supination external rotation, Haraguchi I type and Tongji IIA type of posterior malleolus fracture are predilection fracture types, and all present an obvious incidence peak in the age group of 50–59. Elderly patients have high risks of falling and their bones are more fragile, conditions which are potential risk factors of posterior malleolus fracture. Early positive control has important significance. This study provides references for relevant basic and clinical studies of posterior malleolus fracture. [ABSTRACT FROM AUTHOR]

Objective: To explore the latest clinical characteristics and development trends of posterior malleolus fracture. Methods: Clinical information of inpatients with posterior malleolus fracture in Shanghai Tongji Hospital and Karamay Central Hospital from January 2014 to December 2022 were reviewed and collected. The imaging data of patients were acquired using the Picture Archiving and Communication Systems. A statistical analysis was performed as to gender, current age, year of admission, injury mechanism, fracture type, and posterior malleolus fracture classification. Moreover, a comparative analysis was conducted on the injury mechanisms and morphological differences of posterior malleolus fracture at different periods, regions, and age groups. Results: A total of 472 patients (210 patients from Shanghai Tongji Hospital and 262 patients from Karamay Central Hospital) with posterior malleolus fracture with a mean age of (48.7±15.6) years were included in this study. The peak of posterior malleolus fracture occurs in the age group of 50-59 years. The injury mechanisms mainly involve low-energy fall and sprain (411 cases, 87.1%), followed by traffic accidents (52 cases, 11.0%), and fall injury from height (9 cases, 1.9%). The number of cases according to different fracture types showed the following descending order: trimalleolar fracture-supination extorsion (335 cases, 71.0%), bimalleolar fracture (60 cases, 12.7%), trimalleolar fracture-pronation extorsion (43 cases, 9.1%), posterior malleolus+tibial shaft fracture (19 cases, 4.0%), simple posterior malleolus fracture (15 cases, 3.2%). The numbers of cases corresponding to the Haraguchi Ⅰ, Ⅱ and Ⅲ type of posterior malleolus fractures was 369 (78.2%), 49 (10.4%), and 54 (11.4%), respectively. The Tongji ⅡA type represented the highest number of cases (249 cases, 52.8%), followed by the ⅡB type (120 cases, 25.4%), Ⅰ type (54 cases, 11.4%), ⅢB type (36 cases, 7.6%), and ⅢA type (13 cases, 2.8%). However, no obvious statistical difference was observed in the injury mechanism, Haraguchi classification, and Tongji classification of posterior malleolus fractures among different years and regions from the year of 2014 to 2022 (all P >0.05). Conclusions: The injury mechanism of posterior malleolus fracture mainly involves low-energy fall and sprain cases. The trimalleolar fracture-supination extorsion, Haraguchi Ⅰ type and Tongji ⅡA type of posterior malleolus fracture are predilection fracture types, and all present an obvious incidence peak in the age group of 50-59 years. There has been no significant change in the development trend of clinical characteristics of posterior malleolus fractures in recent years.

Objective. The aim of this study was to investigate the respective correlation between the height (H) of a posterior malleolar fracture (PMF) and the involved area (S) of an articular surface and the presence of "die-punch." Methods. Patients with closed posterior malleolar fractures admitted to our hospital from January 2015 to December 2017 were selected, with complete X-ray and 3D reconstruction CT imaging data. The gender, age, injured side, and surgical fixation methods of the patients were recorded. A preoperative ankle CT scan was performed, and the images were viewed through the PACS (Picture Archiving and Communication Systems). Simultaneously, the involved joint surface area (S) by the posterior malleolar fracture was measured, as well as the proportion of the fracture area to the total ankle joint area. On the sagittal reconstruction CT images, the height (H) of the posterior malleolar fracture was measured to compare the correlation between the height of the fracture and the area of the fracture, as well as the area ratio. Besides, according to the presence or absence of "die-punch," patients were divided into two groups: A and B. And each group was further divided into three subgroups according to age (16-39 years old, 40-59 years old, and ≥60 years old). The statistical differences in the height of fracture between the subgroups were compared. Results. A total of 48 patients, aged 16-82 years, with an average age of 48.9 years, were included in this study, including 13 males and 35 females. There were 20 cases of left ankle injury and 28 cases of right ankle injury. The average height of the posterior malleolar fractures was 18.19 mm, the average area of the fracture was 202.28 mm2, and the average ratio of the fracture area to the total articular surface area was 17.84%. Besides, die-punch was seen in 27 cases and not in 21 cases. The average height of fractures was 21.33 ± 5.38 mm in group A1, 14.38 ± 9.01 mm in group B1, 18.30 ± 7.95 mm in group A2, 14.48 ± 5.37 mm in group B2, 26.26 ± 6.73 mm in group A3, and 12.77 ± 3.07 mm in group B3. Conclusion. The height (H) of the posterior malleolar fractures is positively correlated with the fracture area (S) and the fracture area ratio (FAR). The posterior malleolar fractures with "die-punch" tend to have a greater average height than that without "die-punch." In clinical work, orthopedic surgeons should not only pay attention to the size of the posterior malleolus fracture but also value its height, which hopefully could provide insight into the treatment and prognosis of PMF patients. [ABSTRACT FROM AUTHOR]

As a rare and exceptional injury with significant syndesmotic disruption, the outcome of Logsplitter injury remains poor and unfavorable. In this study, we retrospectively investigated the relationship between the intraoperative reduction quality and the prognosis such as the posttraumatic osteoarthritis to help surgeons achieve better functional outcomes for this high-energy transsyndesmotic ankle fracture dislocation. From January 2015 to February 2019, 31 patients (average 37.6 ± 9.4 years with 19 male and 12 female) diagnosed with the Logsplitter injury were treated by ORIF procedure and enrolled in our study. Particularly, nine vital radiographic parameters including medial clear space, talocrural angle, superior clear space, tibiofibular clear space, tibiofibular overlap, talar tilt, coin sign, tibial medial malleolus angle, and fibular lateral malleolus angle were measured from a postoperative film (AP and mortise view). Next, we compared the clinical outcome by using range of ankle motion, AOFAS scores, Burwell-Charnley score system, and Kellergen-Lawrence criteria from the patients who obtained the intraoperative anatomical reduction with those who failed. Our results showed that AOFAS score with all the patients was 79.33 ± 5.82 at the final follow-up. 14 (45.1%) of 31 patients were observed with radiographic posttraumatic arthritis of the ankle joint with an average Kellgren-Lawrence score of 1.75 ± 1.6 at final follow-up. Most importantly, our results proved that there were significant differences between the patients eligible for anatomical reduction quality with those who failed with regard to OA rate (33.3% vs. 85.7%, P = 0.003) and AOFAS scores (75.33 ± 6.53 vs. 66.89 ± 4.28 , P = 0.037) at the final follow-up. Furthermore, the functional outcome after the operation showed an increased range of motion of the ankle joint of the patients obtained anatomical reduction compared with those who failed (P < 0.05). In this study, the significant discrepancy with regard to the functional outcomes was observed between the acceptable and unacceptable radiographic parameters, indicating that the quality of intraoperative reduction is scientifically significant and thus can be utilized as the major factor to predict the clinical outcomes for Logsplitter injuries. Moreover, this reduction algorithm arising from our study can also be applied to other ankle fractures and dislocation involving syndesmotic complex. [ABSTRACT FROM AUTHOR]

Purpose: Syndesmosis injury is common in external-rotation type ankle fractures (ERAF). Trans-syndesmosis screw fixation, the gold-standard treatment, is currently controversial for its complications and biomechanical disadvantages. The purpose of this study was to introduce a new method of anatomically repairing the anterior-inferior tibiofibular ligament (AITFL) and augmentation with anchor rope system to treat the syndesmotic instability in ERAF with posterior malleolus involvement and to compare its clinical outcomes with that of trans-syndesmosis screw fixation.Methods: 53 ERAFs with posterior malleolus involvement received surgery, and the syndesmosis was still unstable after fracture fixation. They were randomised into screw fixation group and AITFL anatomical repair with augmentation group. Reduction quality, syndesmosis diastasis recurrence, pain (VAS score), time back to work, Olerud-Molander ankle score and range of motion (ROM) of ankle were investigated.Results: Olerud-Molander score in AITFL repair group and screw group was 90.4 and 85.8 at 12-month follow-up (P>0.05). Plantar flexion was 31.2° and 34.3° in repair and screw groups (P=0.04). Mal-reduction happened in 5 cases (19.2%) in screw group while 2 cases (7.4%) in repair group. Postoperative syndesmosis re-diastasis occurred in 3 cases in screw group while zero in repair group (P>0.05). Pain score was similar between the two groups (P>0.05). Overall complication rate and back to work time were 26.9% and 3.7% (P=0.04), 7.15 months and 5.26 months (P=0.02) in screw group and repair group, respectively.Conclusions: For syndesmotic instability in ERAF with posterior malleolus involvement, the method of AITFL anatomical repair and augmentation with anchor rope system had an equivalent functional outcome and reduction, earlier rehabilitation and less complication compared with screw fixation. It can be selected as an alternative. [ABSTRACT FROM AUTHOR]

Background: Reverse flow sural neurocutaneous flap has been utilized more frequently during the past decade to cover vital structures around the foot and ankle area. The potential advantages are the relatively constant blood supply, ease of elevation and preservation of major vascular trunks in the leg. The potential disadvantages remain venous congestion, donor site morbidity and lack of sensation. Methods: This descriptive case series was conducted at Queen Mary Hospital, Hong Kong, from 1997 to 2003. Ten patients having undergone reverse flow sural neurocutaneous flap were identified through medical records. There were six females (60%) and four males (40%), with an average age of 59.8 years. The defects occurred as a result of trauma in five patients (50%), diabetic ulcers in four (40%) and decubitus ulcer in one (10%) paraplegic patient. The defect site included non weight bearing heel in four (40%), tendo Achilles in two (20%), distal tibia in two (20%), lateral malleolus in one (10%) and medial aspect of the midfoot in one patient (10%). The maximum flap size harvested was 14 x 6 cm. Preoperative doppler evaluation was performed in all patients to identify perforators and modified plaster of paris boot was used in the post operative period. A detailed questionnaire was developed addressing variables of interest. Results: There was no flap failure. Venous congestion was encountered in one case. The donor site was relatively unsightly but acceptable to all patients. The loss of sensation in the sural nerve distribution was transient in all patients. Conclusion: Reverse sural artery flap remains to be the workhorse flap to resurface the soft tissue defects of the foot and ankle. Anastomosis of the sural nerve to the digital plantar nerve can potentially solve the issue of lack of sensation in the flap especially when used for weight bearing heel. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of modified posteromedial approach combined raft technique in the treatment of posterior Pilon fractures with collapsed articular surface. Methods: A retrospective analysis was conducted on the clinical data of 51 patients with posterior Pilon fractures combined with collapsed articular surface treated in West China Hospital between January 2014 and June 2017. There were 30 males and 21 females with an average age of 49 years (range, 19-66 years).Subjective assessment of the results was performed according to the pain visual analog scale (VAS).The general function recovery was assessed with American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scale at the latest follow-up. The fracture reduction quality was determined according to Burwell-Charnley imaging standard by the anteroposterior(AP)/mortise X-ray view and three-dimensional CT of the ankle on the 3rd day after operation. The t -test was used to compare the normal distribution parameters. Results: Primary healing of incision and bone were obtained in all patients without loosening, breakage or infection of internal fixation in (3.7±0.7) months (range, 3-6 months). According to the Burwell-Charnley's standards, 50 cases achieved anatomical reduction, 1 case achieved fair reduction. According to AOFAS scales, the results were excellent in 41 cases, good in 9, and fair in 1; the excellent rate was 98.0%. According to the AOFAS scores, the average score was 93.6±2.2. The preoperative VAS score was 7.5±1.1, and the postoperative score was 0.3±0.7, in which the difference was statistically significant ( t= 31.231, P= 0.000). At the last follow-up, the angle of injured side were 13.3°±3.4° in dorsal extension, 33.5°±4.7° in plantar flexion, and 46.9°±6.1° in the range, while angel of uninjured side were 19.8°±2.3°, 36.0°±5.7° and 55.6°±2.7°, respectively; there were significant differences in the up-mentioned indexes between the both sides ( t= 78.932, 121.231, 113.432, all P< 0.05). Conclusion: Excellent short-term effectiveness can be achieved through the modified medial approach in patients with posterior Pilon fractures, which can be used to restore the ankle joint surface under direct vision; and with the raft technique, a small plate is used to fix small fragments firmly with less soft tissue complications.