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This study was designed to evaluate the biomechanical properties of a hook plate (HP) vs an antiglide (AG) plate for supination-adduction (SAD)-ankle fractures. Identical polyurethane tibial models were obtained and vertical fractures were created. The fractures were stabilized with 1 of the following: one-third tubular plate in an AG fashion with 2 screws proximal to the fracture; an AG plate with an additional screw perpendicular to the vertical shear fragment (MAG), or an HP. Ten models were randomly assigned to each of the 3 groups. The constructs were tested in offset-axial loading and were evaluated for construct stiffness and load-to-failure. The MAG construct yielded better stiffness compared with the AG plate (P < .05) and the HP (P < .05). The plate stiffness of the HP construct compared with the AG was not significant (P = .350). In regards to load-to-failure, the difference between MAG and AG was 638 N, and MAG and HP was 530 N (both P < .05). The HP had a load-to-failure that was, on average, 108 N more than the AG but was not significant (P = .063). A one-third tubular plate in the MAG fashion provided a stable, strong construct for fixation of vertical shear medial malleolus fractures.

Ankle fractures are common and may be treated nonoperatively or by reduction and internal fixation. Both treatments may lead to nonanatomic healing, called malunions. Malunions lead to joint instability and pathologic load transfer. Arthritic joint destruction may be the consequence. Corrective osteotomies for malunited malleolar fractures have to restore anatomic conditions. Osteotomies of the medial malleolus, lateral malleolus, posterior malleolus (Volkmann's triangle), and the posteromedial corner or combinations thereof described. Corrective osteotomies for malleolar malunions show good results in the majority of mid- and long-term studies. Secondary arthrodesis is needed in about 10% to 15% of patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Ankle fracture nonunion is a rare occurrence following closed or operative intervention. When it does occur, patients can experience debilitating symptoms that limit daily function. Malleolar nonunion can be caused by patient factors, such as smoking, malnutrition, or vascular insufficiency. Surgeon factors, such as insufficient or inappropriate operative fixation, also play a role. Several adjuncts, such as bone grafting, bone morphogenic protein, and bone stimulation, are useful in treating nonunions. Through a multimodal approach, malleolar nonunions are reliably treated with operative fixation leading to good patient outcomes with minimal complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Because MRI may overdiagnose or overestimate the extent of OCLs in an acute trauma setting the aim of this study was to determine the incidence of OCLs after ORIF of displaced ankle fractures using MRI at medium-term follow-up, and to analyse if the severity of fracture or the clinical outcome correlates with the incidence of OCLs., Patients and Methods: Following institutional review board approval a total of 100 patients (mean age, 41.3 years; range, 17.9-64.3 years) with a displaced ankle fracture who had undergone ORIF according to the AO principles were included in this study. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was used to quantify the clinical outcome and MR images were evaluated for OCLs of the talus and distal tibia after a mean of 34.5 months (range, 17.5-54.1 months)., Results: OCLs were found in 40.4% of the patients. Logistic regression revealed a significant correlation between the severity of fracture and the incidence of OCLs. Patients with a trimalleolar fracture (p=0.04) or an ankle fracture dislocation (p=0.003) had a significantly higher risk for developing an OCL compared to those with a type B fracture. Logistic regression also demonstrated a significant correlation between the clinical outcome (AOFAS score) and the incidence of OCLs (p=0.01). The risk for developing an OCL increases up to 5.6% when the AOFAS score decreases by one point., Conclusion: OCLs were frequently found in association with acute ankle fractures at medium-term follow-up, and the severity of fracture was associated with an increased number of OCLs. Considering the disadvantages of MRI including the high cost and limited availability, the results of this study may help to explain why anatomic surgical realignment of displaced ankle fractures may still be associated with poor clinical outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Weight bearing after lower extremity fractures still remains a highly controversial issue. Even in ankle fractures, the most common lower extremity injury no standard aftercare protocol has been established. Average non weight bearing times range from 0 to 7 weeks, with standardised, radiological healing controls at fixed time intervals. Recent literature calls for patient-adapted aftercare protocols based on individual fracture and load scenarios. We show the clinical feasibility and first results of a new, insole embedded gait analysis tool for continuous monitoring of gait, load and activity. Ten patients were monitored with a new, independent gait analysis insole for up to 3 months postoperatively. Strict 20 kg partial weight bearing was ordered for 6 weeks. Overall activity, load spectrum, ground reaction forces, clinical scoring and general health data were recorded and correlated. Statistical analysis with power analysis, t-test and Spearman correlation was performed. Only one patient completely adhered to the set weight bearing limit. Average time in minutes over the limit was 374 min. Based on the parameters load, activity, gait time over 20 kg weight bearing and maximum ground reaction force high and low performers were defined after 3 weeks. Significant difference in time to painless full weight bearing between high and low performers was shown. Correlation analysis revealed a significant correlation between weight bearing and clinical scoring as well as pain (American Orthopaedic Foot and Ankle Society (AOFAS) Score rs=0.74; Olerud-Molander Score rs=0.93; VAS pain rs=-0.95). Early, continuous gait analysis is able to define aftercare performers with significant differences in time to full painless weight bearing where clinical or radiographic controls could not. Patient compliance to standardised weight bearing limits and protocols is low. Highly individual rehabilitation patterns were seen in all patients. Aftercare protocols should be adjusted to real-time patient conditions, rather than fixed intervals and limits. With a real-time measuring device high performers could be identified and influenced towards optimal healing conditions early, while low performers are recognised and missing healing influences could be corrected according to patient condition., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Posterior malleolar fractures are relatively common and usually result from rotational ankle injuries. Although treatment of associated lateral and medial structures is well established, several controversies exist in the management of posterior malleolus fractures. We performed a systematic review of the current published data with regard to the diagnosis, management, and prognosis of posterior malleolus fractures. A total of 33 studies (8 biomechanical and 25 clinical) with >950 patients were reviewed. The outcome of ankle fractures with posterior malleolar involvement was poor; however, the evidence was not enough to prove that the size of the posterior malleolus affects the outcome. Significant heterogeneity was noted in the cutoff size of the posterior malleolar fragment in determining management. The outcome was related to other factors, such as fracture displacement, congruency of the articular surface, and residual tibiotalar subluxation. Indirect evidence showed that large fracture fragments were associated with fracture dislocations and ankle instability and, thus, might require surgical fixation. We have concluded that the evidence to prove that the size of the posterior malleolar affects the outcome of ankle fractures is not enough, and the decision to treat these fractures should be determined by other factors, as stated previously., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

The indications and clinical necessity for routine hardware removal after treating ankle or distal tibia fracture with open reduction and internal fixation are disputed even when hardware-related pain is insignificant. Thus, we determined the clinical effects of routine hardware removal irrespective of the degree of hardware-related pain, especially in the perspective of patients' daily activities. This study was conducted on 80 consecutive cases (78 patients) treated by surgery and hardware removal after bony union. There were 56 ankle and 24 distal tibia fractures. The hardware-related pain, ankle joint stiffness, discomfort on ambulation, and patient satisfaction were evaluated before and at least 6 months after hardware removal. Pain score before hardware removal was 3.4 (range 0 to 6) and decreased to 1.3 (range 0 to 6) after removal. 58 (72.5%) patients experienced improved ankle stiffness and 65 (81.3%) less discomfort while walking on uneven ground and 63 (80.8%) patients were satisfied with hardware removal. These results suggest that routine hardware removal after ankle or distal tibia fracture could ameliorate hardware-related pain and improves daily activities and patient satisfaction even when the hardware-related pain is minimal.

Previous biomechanical studies have advocated the use of locking plates for isolated distal fibula fractures in osteoporotic bone. Complex rotational ankle injuries involve an increased number of fractures, which can result in instability, potentially requiring the same fixed angle properties afforded by locking plates. However, the mechanical indication for locking plate technology has not been tested in this fracture model. The purpose of the present study was to compare the biomechanical properties of locking and conventional plate fixation for distal fibula fractures in trimalleolar ankle injuries. Fourteen (7 matched pairs) fresh-frozen cadaver leg specimens were used. The bone mineral density of each was obtained using dual x-ray absorptiometry scans. The fracture model simulated an OTA 44-B3.3 fracture. The syndesmosis was not disrupted. Each fracture was fixated in the same fashion, except for the distal fibula plate construct: locking (n = 7) and one-third tubular (n = 7). The specimens underwent axial and torsional cyclic loading, followed by torsional loading to failure. No statistically significant differences were found between the locking and conventional plate constructs during both fatigue and torque to failure testing (p > .05). Our specimen bone mineral density averages did not represent poor bone quality. The clinical implication of the present study is that distal fibular locking plates do not provide a mechanical advantage for trimalleolar ankle injuries in individuals with normal bone density and in the absence of fracture comminution., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients., Materials and Methods: From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively., Results: 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM., Conclusions: The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.

Posterior antiglide plating is widely used to treat lateral malleolar fractures caused by supination-external rotation injuries. Despite its widespread use, this technique can be associated with postoperative peroneal tendinopathy. The purpose of the present observational review was to report the incidence of peroneal tendinopathy after the use of posterior antiglide plating to treat lateral malleolar fractures caused by a supination-external rotation injury. A total of 70 patients were followed up for a minimum of 12 (mean 55, range 12 to 109) months. Bony union was obtained in all cases after a mean of 57 (range 37 to 81) days. The median number of screw holes in the plate was 4.9 (range 4 to 7), and the median number of screws used to fixate the fibula was 6.58 (range 5 to 10). The mean American Orthopaedic Foot and Ankle Society hindfoot-ankle score at the final follow-up examination was 90.8 (range 55 to 100). Clinically, 3 (4.29%) of the 70 patients had lateral or posterolateral ankle pain indicative of peroneal tendinopathy after the index surgery, without any objective evidence. Of the 70 patients, 41 (58.57%) underwent surgical removal of the fibular hardware, 2 (4.87%) because of lateral ankle discomfort. At removal, inspection of the peroneal tendon sheath and/or tendons showed no gross evidence of tendinopathy in any of the patients. We concluded that the incidence of clinically evident peroneal tendon symptoms associated with posterior antiglide plating is low (4.3%), and direct operative inspection revealed no gross evidence of tendinopathy., (Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

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.

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

Background: Tibial plafond fractures are a uncommon injury, and the outcomes described in literature are generally poor. The purposes were to determine the effect of the tibial plafond fractures on general health-related quality of life, and to examine the factors that influence these outcomes., Methods: Retrospective study of 43 patients with average age of 45.6 (range 18-69) years who were also invited for a clinical and radiological reassessment. The primary outcome measure was quality of life assessed by the Short Form-36 questionnaire. Visual analogue scale for pain, and motion of both ankle and subtalar joints were also assessed. Radiological evaluation was performed to assess bone healing, fracture reduction quality, and tibial alignment., Results: The mean follow-up at last visit was 8.1 (range, 4-12) years. Patients who had suffered plafond fracture had significantly poorer quality of life compared with age- and gender-matched general population of our country regardless of the treatment method used. Multivariate analyses showed that the age had influence on the emotional outcomes, educational level and fracture pattern on physical outcomes, and marital status, fracture reduction quality, and ankle motion on both physical and mental component summaries., Conclusion: Tibial plafond fractures have a significant negative impact on general health-related quality of life regardless of the operative treatment used which reflects injury severity. In addition, psychosocial characteristics of patients may influence the outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The most important determinant in the treatment of malleolar fractures is stability. Stable fractures have an intact deep deltoid ligament and do not displace with functional treatment. If the deep deltoid/medial malleolar complex is disrupted, the talus is at risk of displacement. Weber (2010) showed that weightbearing radiographs predicted stability in patients with undisplaced ankle fractures. We developed clinical criteria for potential instability and applied them to a prospective series of patients. The criteria included a medial clear space of <4 mm; medial tenderness, bruising or swelling; a fibular fracture above the syndesmosis; a bimalleolar or trimalleolar fracture; an open fracture; and a high-energy fracture mechanism. A prospectively documented series of 43 patients chose functional brace treatment of the potentially unstable fractures. Weightbearing radiographs were performed with the patient wearing the brace before treatment and free of the brace at clinical union (6 to 9 weeks for all patients). The patients were encouraged to bear full weight and actively exercise their ankles in the brace. All fractures healed without displacement. The risk of displacement was 0% (95% confidence interval 0% to 9.5%). The results of the present preliminary series give support for the use of weightbearing radiographs to guide treatment of undisplaced ankle fractures., (Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In cases of severe vascular trauma, traditional means for assessing viability using Doppler and angiography can have limited application. Indocyanine green angiography (ICGA) allows for a rapid qualitative assessment of tissue perfusion that serves as an important adjunct to these traditional methods, which can also be particularly helpful in guiding therapy., Methods/results: We present a case of complicated ankle fracture with severe vascular compromise, which illustrates the role of ICGA as an assessment tool to guide therapy and decision-making in cases of acute limb threat. ICGA using SPY system (Novadaq, Bonita Springs, FL) was performed as part of our initial assessment to evaluate the extent of malperfusion and potential for revascularization. Preprocedural imaging with ICGA showed very limited uptake in the foot. Treatment was also performed with traditional angiography and infusion of intra-arterial nitroglycerin into the posterior tibial artery. Postprocedure imaging with ICGA was performed a day later and showed marked difference in the perfusion profile, with rapid uptake into the forefoot and toes, which corresponded with the patient's clinical improvement. The patient went on to have complete limb salvage., Conclusions: The addition of ICGA for assessment of tissue perfusion in cases of complex vascular trauma has several implications: it guides surgical therapy for excision of devitalized tissue and aids in decision-making for major considerations such as revascularization efforts or amputation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: Sarcopenia might be associated with bone fragility in elderly individuals. This study aimed to investigate the prevalence of sarcopenia and its association with fragility fracture sites in elderly Chinese patients., Methods: Patients (322 men and 435 women) aged 65-94 years and with a history of fragility fractures in the ankle, wrist, vertebrae or hip, and healthy men (n = 1263) and women (n = 1057) aged 65-92 years without a history of fractures were enrolled. Whole-body dual energy X-ray absorptiometry was used to analyze skeletal muscle mass index (SMI), fat mass and bone mineral density. Sarcopenia was defined as SMI less than two standard deviations below the mean of a young reference group., Results: Sarcopenia occurrence varied with fracture location. Sarcopenia was more common in females with vertebral and hip fractures and in men with hip and ankle fractures than in the non-fracture group). Sarcopenia was significantly more prevalent in men with wrist, hip and ankle fractures than in women. SMI was correlated with BMD in different fracture groups. Logistic regression analyses revealed that lower SMI was associated with an increased risk of hip fracture both in men and women and ankle fracture in men., Discussion: Sarcopenia may be an independent risk factor for hip and ankle fractures in men, and for hip fractures in women.

Pain has been identified as the dominant factor in patient outcomes. The purpose of this study was to evaluate the degree of pain reported in a large series of acute ankle fractures and to determine what factors are associated with higher pain scores. We prospectively evaluated 457 consecutive patients with acute Weber B supination external rotation ankle fractures upon presentation for pain in 9 areas of the ankle. There were 231 females and 226 males, average age 46.2 (18-96) with 133 bi/tri-malleolar and 324 lateral malleolar fractures. There were 101 SE2, 73 stress (+) SE4, and 150 ligamentous SE4 injuries. The highest pain score (VAS 0-10) for the medial and lateral regions was chosen for analysis. Other factors included in the multivariate analysis were: age, ethnicity, DM, alcohol presence, and days from injury to presentation on the level of pain reported using a linear regression model and set statistical significance at 0.05. In univariate analysis, the type of injury (medial malleolus or deltoid ligament) nor instability differed with respect to medial pain. However, patients presenting with instability had more lateral pain (5.6±3) than those with stable injuries (2.6±3) (p<001). Additionally, those with bony medial injury had more lateral pain (7±2.7) than those with isolated lateral malleolar fractures (4.0±3.4) (p<0.001). Most importantly, in the multivariate analysis, the only factor that was significant for both medial and lateral pain (separate regressions) was ethnicity, with blacks having more pain given the same injury than whites (p<0.001). Latinos trended towards having more lateral pain than whites (p=0.15), but not more medial pain (p=0.3). For lateral pain, in addition to ethnicity, presence of a displaced mortise (p<0.0001), having a medial bony injury (p<0.0001), and the days from injury (p=0.008) were significant. Pain decreased with time from injury. In this evaluation of over 450 patients with Weber B, SE pattern ankle fractures we confirmed previous work in the upper extremity indicating an important difference in the reported pain by ethnicity. In particular, black patients have more pain than white or latino patients given the same injury., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Unlabelled: In a cross-sectional analysis in postmenopausal women, prior ankle fractures were associated with lower areal bone mineral density (BMD) and trabecular bone alterations compared to no fracture history. Compared to women with forearm fractures, microstructure alterations were of lower magnitude. These data suggest that ankle fractures are another manifestation of bone fragility., Introduction: Whether ankle fractures represent fragility fractures associated with low areal bone mineral density (aBMD) and volumetric bone mineral density (vBMD) and/or bone microstructure alterations remains unclear, in contrast to the well-recognised association between forearm fractures and osteoporosis. The objective of this study was to investigate aBMD, vBMD and bone microstructure in postmenopausal women with prior ankle fracture in adulthood, compared with women without prior fracture or with women with prior forearm fractures, considered as typically of osteoporotic origin., Methods: In a cross-sectional analysis in the Geneva Retirees Cohort study, 63 women with ankle fracture and 59 with forearm fracture were compared to 433 women without fracture (mean age, 65 ± 1 years). aBMD was measured by dual-energy X-ray absorptiometry; distal radius and tibia vBMD and bone microstructure were measured by high-resolution peripheral quantitative computed tomography., Results: Compared with women without fracture, those with ankle fractures had lower aBMD, radius vBMD (-7.9%), trabecular density (-10.7%), number (-7.3%) and thickness (-4.6%) and higher trabecular spacing (+14.5%) (P < 0.05 for all). Tibia trabecular variables were also altered. For 1 standard deviation decrease in total hip aBMD or radius trabecular density, odds ratios for ankle fractures were 2.2 and 1.6, respectively, vs 2.2 and 2.7 for forearm fracture, respectively (P ≤ 0.001 for all). Compared to women with forearm fractures, those with ankle fractures had similar spine and hip aBMD, but microstructure alterations of lower magnitude., Conclusion: Women with ankle fractures have lower aBMD and vBMD and trabecular bone alterations, suggesting that ankle fractures are another manifestation of bone fragility.

17 patients with ankle syndesmosic injury were treated with a 4.5mm single cortical screw fixation (passage of screw 4 cortices) and 15 patients were treated with single-level elastic fixation material. All patients were evaluated according to the AOFAS ankle and posterior foot scale at the third, sixth and twelfth months after the fixation. The ankle range of movement was recorded together with the healthy side. The Student's t test was used for statistical comparisons. No statistical significant difference was observed between the AOFAS scores (p>0.05). The range of dorsiflexion and plantar flexion motion of the elastic fixation group at the 6th and 12th months were significantly better compared to the screw fixation group (p<0.01). Elastic fixation is as functional as screw fixation in the treatment of ankle syndesmosis injuries. The unnecessary need of a second surgical intervention for removal of the fixation material is another advantageous aspect of this method of fixation., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Literature evaluating surgical outcomes after ankle fixation in an active patient population is limited. This study determined occupational outcomes and return to running following ankle fracture fixation in a military cohort., Methods: All service members undergoing ankle fracture fixation at a single military hospital from August 2007 to August 2012 were reviewed. Univariate analysis determined the association between patient demographic information, type of fracture fixation, and the development of posttraumatic ankle arthritis and functional outcomes, including medical separation, return to running, and reoperation. Seventy-two primary ankle fracture fixation procedures were performed on patients with mean age of 29.1 years. The majority of patients were male (88%), were 25 years of age or older (61%), were of junior rank (57%), underwent unimalleolar fracture fixation (78%), and did not require syndesmotic fixation (54%). The average follow-up was 35.9 months., Results: The mean time to radiographic union was 8.6 weeks. Twelve service members (17%) were medically separated from the military due to refractory pain following ankle fracture fixation with a minimum of 2-year occupational follow-up. Among military service members undergoing ankle fracture fixation, 64% returned to running. Service members with higher occupational demands had a statistical trend to return to running (odds ratio [OR] 2.49; 95% CI, 0.93-6.68). Junior enlisted rank was a risk factor for medical separation (OR 11.00; 95% CI, 1.34-90.57). Radiographic evidence of posttraumatic ankle osteoarthritis occurred in 8 (11%) service members., Conclusions: At mean 3-year follow-up, 83% of service members undergoing ankle fracture fixation remained on active duty or successfully completed their military service, while nearly two-thirds returned to occupationally required daily running., Level of Evidence: Level IV, retrospective case series., (© The Author(s) 2015.)

The incidence of ankle fractures is increasing rapidly due to the ageing demographic. In older patients with compromised distal circulation, conservative treatment of fractures may be indicated. High rates of malunion and complications due to skin fragility motivate the design of novel casting systems, but biomechanical stability requirements are poorly defined. This article presents the first quantitative study of ankle cast stability and hypothesises that a newly proposed close contact cast (CCC) system provides similar biomechanical stability to standard casts (SC). Two adult mannequin legs transected at the malleoli, one incorporating an inflatable model of tissue swelling, were stabilised with casts applied by an experienced surgeon. They were cyclically loaded in torsion, measuring applied rotation angle and resulting torque. CCC stiffness was equal to or greater than that of SC in two measures of ankle cast resistance to torsion. The effect of swelling reduction at the ankle site was significantly greater on CCC than on SC. The data support the hypothesis that CCC provides similar biomechanical stability to SC and therefore also the clinical use of CCC. They suggest that more frequent re-application of CCC is likely required to maintain stability following resolution of swelling at the injury site.

Background: The optimal post-operative care regimen after surgically fixed Lauge Hansen supination exorotation injuries remains to be established. This study compares whether unprotected weight bearing as tolerated is superior to protected weight bearing and unprotected non-weight bearing in terms of functional outcome and safety., Methods/design: The WOW! Study is a prospective multicenter clinical trial. Patients between 18 and 65 years of age with a Lauge Hansen supination exorotation type 2, 3 or 4 ankle fractures requiring surgical treatment are eligible for inclusion. An expert panel validates the classification and inclusion eligibility. After surgery, patients are randomized to either the 1) unprotected non-weight-bearing, 2) protected weight-bearing, or 3) unprotected weight-bearing group. The primary outcome measure is ankle-specific disability measured by the Olerud-Molander ankle score. Secondary outcomes are 1) quality of life (e.g., return to work and resumption of sport), 2) complications, 3) range of motion, 4) calf wasting, and 5) maximum pressure load after 3 months and 1 year., Discussion: This trial is designed to compare the effectiveness and safety of unprotected weight bearing with two commonly used post-operative treatment regimens after internal fixation of specified, intrinsically stable but displaced ankle fractures. An expert panel has been established to evaluate every potential subject, which ensures that every patient is strictly screened according to the inclusion and exclusion criteria and that there is a clear indication for surgical fixation., Trial Registration: The WOW! Study is registered in the Dutch Trial Register ( NTR3727 ). Date of registration: 28-11-2012.

Background: The study by Lauge-Hansen published in the Archives of Surgery in 1950 still stands as the seminal work for our understanding of the pathomechanics of ankle fractures. The purpose of the present study was to recreate Lauge-Hansen's experiments for the supination-external rotation (SER) fracture mechanism and to determine whether the predicted sequence of osseous and soft-tissue injury is reproducible on the basis of his originally described methodology., Methods: Ten fresh-frozen cadaver specimens amputated above the knee were utilized. The foot was axially loaded in a position of neutral dorsiflexion and supination. External rotation was applied manually in accordance with Lauge-Hansen's description until osseous and/or soft-tissue injury occurred. Fluoroscopic images were made and anatomic dissection was performed., Results: Although several specimens exhibited findings consistent with certain stages of the SER injury pattern, no specimen demonstrated the complete sequence of predicted osseous and soft-tissue injury., Conclusions: Loading cadaver specimens with an SER mechanism utilizing a methodology similar to that in the original experiments by Lauge-Hansen does not reliably produce the sequence of osseous and soft-tissue injury predicted by Lauge-Hansen., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Previous studies have demonstrated the efficacy of popliteal block anesthesia in decreasing post - operative narcotic administration, nausea, and length of stay in patients undergoing foot and ankle surgeries. The purpose of this study was to compare the amount of narcotic medication administered, the need for anti-emetic medication, PACU length of stay, and discharge status in patients treated surgically for ankle fractures who received popliteal blocks with those who received general anesthesia alone., Methods: All patients being treated with open reduction and internal fixation for ankle fractures were randomized to receive either general anesthesia (GETA) or popliteal block. Postoperatively, data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collection on the amount of anti-emetic and pain medication in the PACU., Results: Fifty-one patients agreed to participate in the study. There was no significant difference between the two groups with regards to the need for anti-emetic medication, the amount of pain medication received in the PACU, or amount of time spent in the PACU. Patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia., Discussion: While previous studies have demonstrated the efficacy of popliteal block in decreasing anti-emetic and pain medication administration in the PACU, we found no difference in the amount of medication administered. We found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia.

Background: Extremity fractures such as wrist and ankle fractures are a common and costly healthcare problem. The management of these fractures depends on fracture type and loss of congruity of the joint, resulting in cast immobilization or operative treatment. Loss of congruity or displacement leading to uneven joint loading, osteoarthritis and an increased probability of a poor functional outcome should be identified within the first 2 weeks post-trauma, based upon radiographs to determine optimal treatment. After this period, routine radiographs are scheduled for monitoring the bone-healing process. Current protocols describe imaging at 1, 2, 6 and 12 weeks post-trauma. However, it is questionable whether routine radiography following the initial follow-up ( 2-weeks post-trauma) is cost effective. The aim of this study is to determine whether a modification of the radiographic follow-up protocol can be conducted with no worse outcome and less cost than the current standard of care for patients with a wrist or ankle fracture., Methods/design: In a multicenter randomized controlled trial, 697 patients aged 18 years or older will be included: 385 wrist fracture- and 312 ankle fracture patients. Patients will be randomized into two groups: Group 1 receives usual care, consisting of radiographs 1, 2, 6 and 12 weeks post-trauma; Group 2 receives radiographs beyond the initial follow-up only when clinically indicated. The primary outcome is the overall extremity-specific function. For wrist fractures, this includes the Disabilities of the Arm, Shoulder and Hand Score; for the ankle fractures, this includes the Olerud and Molander ankle score. Secondary outcomes include: healthcare cost, the specific function measured with the Patient Rated Wrist and Hand Evaluation for wrist fractures and American Academy of Orthopaedic Surgeons foot and ankle questionnaire for ankle fractures, pain-intensity, health-related quality of life, self-perceived recovery, and complications. Both groups will be monitored at 1, 2, and 6 weeks and 3, 6, and 12 months., Discussion: This study will provide data on (cost) effectiveness of routine radiography in the follow-up of wrist and ankle fractures, and could pave the way for a change in (inter)national protocols., Trial Registration: Netherlands Trial Register NTR4610 , registration date 22 June 2014.

This study examines stress radiograph use in SER IV ankle fracture fixation; the efficacy of external rotation (ERST) and lateral hook (LHST) stress tests with incidence of subsequent fixation failure secondary to syndesmotic diastasis. 154 skeletally mature patients were admitted to our unit with ankle fractures in 12 months. 42 non-SER fractures and 32 SER fractures treated without ORIF were excluded, as were 14 which featured a syndesmotic screw in the primary ORIF. The remaining 66 SER IV fixations were included in the final sample (17 men, 49 women; median age 49 years). No stress test was performed in 51.5% of cases without a single subsequent failure in these fixations. ERST was the more commonly performed test (incidence 30.3%); negative predictive value (NPV) 0.95. Incidence of LHST was 18.2%; NPV 0.83. Both tests were performed in 6.1% of cases; NPV 0.75. The incidence of failure secondary to syndesmotic diastasis was 6.1% (4/66). Notably, there were no failures in the cases where no stress test was performed. Use of either or both external rotation and lateral hook stress tests resulted in failures to detect syndesmotic diastasis with consequent failure of fixation. This study suggests that syndesmotic injuries are not missed due to an absence of a stress test but that stress tests are not sufficiently sensitive or correctly interpreted. Clinical judgement in cases where syndesmotic injury is not present appears accurate. If syndesmotic injury is clinically suspected, apply caution and insert a syndesmotic screw rather than relying on stress test results., (Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.)

Background: Syndesmosis fixation of Lauge-Hansen SER IV, Weber B ankle fractures is controversial. This study compared a matched pair of SER IV patients with stress proven syndesmotic injuries with the same number without stress proven syndesmotic injury in terms of functional, pain, and radiologic result., Methods: The study was based on a RCT-study comparing syndesmotic transfixation to no fixation in SER IV (Weber B)-type ankle fractures. Twenty-four patients with a syndesmosis injury found on the intraoperative 7.5 Nm standardized external rotation test were compared to 24 patients with a stable syndesmosis. The pairs were matched by fracture morphology, sex, and age. The primary outcome measure was ankle function as assessed by the Olerud-Molander score. Weight-bearing plain radiographs and 3T MRI of the injured ankle were used to assess ankle joint congruity and osteoarthritis, according to Kellgren-Lawrence classification and cartilage defects., Results: The Olerud-Molander score was 86 in syndesmosis injury patients and 90 in patients with normal syndesmosis (P = .28). The incidence of ankle joint osteoarthritis on plain radiographs was not significantly different between the groups (Grade I 5% vs 21%; Grade II 86% vs 75%; Grade III 9% vs 4%; P = .34). MRI scans showed TC joint cartilage defects in 54% of the patients: 12 (56%) in the syndesmosis injury group vs 13 (54%) in the group without syndesmosis injury (P > .9)., Conclusion: After 4 to 6 years of follow-up, clinical and radiologic outcome were not different in patients with syndesmosis injury compared to patients with stable syndesmosis in SER IV (Weber B)-type ankle fractures., Level of Evidence: Prognostic Level II, comparative study., (© The Author(s) 2014.)

Traumatic ankle fractures are common injuries. Following injury, patients ask their doctor 'when can I drive doctor?' The ability to safely drive depends on several variables including reaction time, force, range of movement and pain. Return of the braking force is essential for return to driving and to our knowledge has not been addressed previously in the literature. The aim of this study is to pilot a sample of patients with ankle fractures for the return of their normal power and visual reaction time following injury using a simulator (DTS: Drive Test Station). Normal parameters were defined by the patient's contra-lateral non-injured limb. After confirming fracture union, 12 drivers with an isolated right ankle fracture were recruited 7.8 days after coming out of plaster (0-21 days). DTS was used to examine patients' ability to apply a braking force of 35 kg, representing the amount of force required to do an emergency stop at 70 mph. Visual reaction time was tested to assess patients' cognitive function. Results showed the average maximum brake pedal force to be 34.4 kg (range: 32-35 kg). Paired sample t-test for the total visual reaction time and visual pathway reaction time showed the p-value>0.05 indicating no statistical difference between the injured limb and non-injured control side at the time of the examination. In conclusion, the DTS can be used to simulate an emergency stop to assess the motor power and cognitive function (visual reaction time) in case of right ankle fractures as this can give the patient an idea regarding their ability to apply brake force and the return of their visual reaction time. It is a practical assessment tool that could be used in fracture clinic setting. We still reserve our ability to advise patients to return to driving as this could bear significant medicolegal responsibility., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: The majority of ankle fractures seen in clinic are stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable ankle fractures are advised that they need a cast. In this study we counseled patients regarding the different options for conservative management of their stable ankle fracture. We then encouraged them to make an informed decision on which method of treatment they would like to pursue., Materials and Methods: We analyzed eight years of a single consultant's fracture clinic. 163 patients were offered a choice of: a weight bearing below knee cast; a functional ankle brace; or a regime of rest, ice, compression bandage and elevation ("RICE" regime). All patients were advised to mobilize on the injured ankle as their pain allowed., Results: 163 patients were suitable for all 3 treatment options. 82% (133/163) chose an ankle brace, 15% (25/163) opted for a RICE regime and 3% (5/163) chose a below knee cast. Of these only one returned to clinic complaining of increased pain, however after further discussion the patient opted to continue with his RICE regime as planned., Discussion: A conservative approach to these injuries is now common practice; however there is a wide variation in what type of conservative management is given. Recent studies suggest orthopedic surgeons are still treating the majority of these injuries with a weight-bearing cast despite risks of stiffness, skin damage and thromboembolism. This study showed when the patient is given opportunity to make an informed choice the vast majority opt not to have a cast. The study suggests management of these injuries should be decided via a two-way conversation between patient and practitioner., Conclusions: Using a shared decision making approach to these injuries is a useful method of providing patients with the most suitable treatment for their personal treatment goals., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

According to the literature data incomplete restoration of the muscular strength is observed after malleolar fractures that made us evaluate the contractile capacity of the tibial muscles after treatment of 59 adult patients with these fractures using Ilizarov method. Additionally, late follow-up of 5 cases were examined in complex. Practically, full restoration of the anatomical sizes, electrogenesis and contractile property of the tibial muscles is possible in the interval from 5 to 8 years after treatment that can be explained by fine reduction and reliable fixation of the bone fragments during treatment and increase of neuro-motor apparatus sensitivity to the specific impacts while muscles' work in the conditions of habitual motor activity.

The radiolucent plate has many advantageous properties in the treatment of complex ankle fractures, particularly trimalleolar fractures. Surgeons may sometimes have difficulty observing the posterior malleolus after synthesis of lateral malleolus with a traditional plate because common materials of conventional plates are not radiolucent. In this study, the authors highlight the importance of the radiolucent property in the treatment of ankle fractures and describe their preliminary experience with a carbon fibre-reinforced polyetheretherketone distal fibula plate, with good results at 4 months' follow-up and no signs of tissue inflammatory reaction., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: This prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space., Methods: Sixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment., Results: Thirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively)., Conclusions: On the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Study Design: Systematic review and meta-analysis of longitudinal studies., Objectives: To quantify the prognosis of physical function following ankle fracture., Background: Information about the course of recovery of physical function after ankle fracture is essential for patient care and health care policy. The existing data have not previously been included in a meta-analysis., Methods: Studies were identified using searches of electronic databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, PEDro, AMED, SPORTDiscus) and gray literature to September 2012. Studies of people with traumatic ankle fracture were included. Two reviewers independently screened references for inclusion, then extracted data and evaluated risk of bias. The outcome of interest was physical function (physical activity and activity limitation). Outcomes were converted to a common 100-point scale, on which higher scores indicated better outcomes. Meta-regression was conducted using generalized estimating equations., Results: Thirty-one studies (37 articles) were included. Adults with ankle fracture, present with significant activity limitation in the short term (mean at 1 month, 31.9; 95% confidence interval [CI]: 18.8, 45.1), recovered markedly but incompletely in the short to medium term (mean at 6 months, 78.3; 95% CI: 70.1, 85.1), and showed little further improvement in the long term (mean at 24 months, 86.6; 95% CI: 78.2, 95.0). Studies with older participants and predominantly male participants tended to report worse functional outcomes., Conclusion: Adults typically experience a rapid initial recovery of physical function after ankle fracture (approximately 80% function at 6 months), but, on average, recovery remains incomplete 24 months after injury. PROSPERO registration number: 42012002979., Level of Evidence: Prognosis, level 2a.

Background: Fractures of the fifth metatarsal base are a relatively common injury. Whether treated surgically or nonsurgically, injury rehabilitation typically involves immobilization in a rigid sandal or short controlled ankle movement (CAM) walker boot., Objective: To determine the peak pressure, contact pressure, and impulse at the base of the fifth metatarsal in 3 common footwear devices during common gait activities., Design: This was a retrospective comparative study., Setting: Research was conducted in a sports performance laboratory at a university., Participants: Twenty subjects without a recent history of foot injuries volunteered to participate., Methods: Each subject performed 3 common gait activities (walking, heel walking, and pivoting) in 3 footwear devices (short CAM walker boot, postoperative sandal, running shoe). Pressure data were sampled (100 Hz) using individually sized plantar pressure insoles and software (Tekscan). Walking trials were collected at 1.0 m/s ± 5% (FusionSport Timing Gates)., Outcome Measurements: Peak pressure, contact pressure, and impulse at the fifth metatarsal base region were determined for all trials for all subjects. Mixed-effect regression models were used to compare pairwise differences in outcome variables between footwear devices., Results: The CAM walker boot resulted in significantly lower peak pressure at the fifth metatarsal during walking and heel-walking relative to the postoperative sandal (P < .01) and during heel-walking (P < .01) relative to the standard athletic shoe. The CAM walker boot significantly reduced contact pressures at the fifth metatarsal during walking and heel-walking relative to the postoperative sandal (P < .01), and during heel-walking relative to the standard athletic shoe (P < .001)., Conclusions: Our results suggest that the short CAM walker boot more effectively offloads the fifth metatarsal during common gait activities than a postoperative sandal or a standard athletic shoe. A short CAM walker boot may be a beneficial rehabilitative tool for patients undergoing rehabilitation after treatment of Jones fractures and other base of fifth metatarsal fractures., (Copyright © 2014 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Introduction: Open ankle dislocation fractures are one of the most severe injuries of the ankle. Development of posttraumatic arthrosis is well known. However, there are just a few case reports describing evidence of posttraumatic osteonecrosis (PON) of distal tibia. The pathophysiological mechanism remains unclear and the question of morphologic or personal risk factors cannot be answered. The goal of this study was to evaluate the morphologic characteristics of open dislocated ankle fractures in correlation with the development of PON to facilitate early identification of patients with higher risk of posttraumatic osteonecrosis., Material and Methods: In this study data from 28 patients with open dislocation fractures of the ankle between 1975 and 2006 found at our databases were evaluated retrospectively. For each patient we documented personal data, mechanism of injury, type of lateral malleolar fracture, severity of open fracture, degree of tibiotalar dislocation, presence of medial malleolar fracture, presence of deltoid ligament rupture, time until joint reduction and kind of surgical treatment. We also documented clinical complications and number of surgeries. Presence of PON was examined by radiographs, magnetic resonance imaging (MRI) or histological analysis., Results: Within 12 out of 28 patients with open ankle dislocation fractures a PON of the distal tibia could be found. Nine out of 15 patients with high-energy trauma and 12 out of 19 patients with type C fibular fracture developed PON. 73% of male patients and 88% of the patients with type III soft tissue damage according to Gustillo developed PON. However, if patients suffered from type C fibular fracture, total talus dislocation and grade III soft tissue damage ("necrotic triad") PON was developed in 100% of cases. Other patient's characteristics like late joint reduction, postoperative infection or bimalleolar fracture showed no higher proportion of patients with PON., Conclusion: In this study we were able to identify clinical manifestations and risk factors for the development of PON of the distal tibia. All indentified risk factors were associated with heavy fracture mechanisms leading most likely to a serious devascularisation of at least parts of the distal tibial epiphysis. With regard to presented results early identification of patients with higher risk of PON might be possible and maybe additional treatment options can be initialised to protect patients from this process., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site., Setting: Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO., Methods: After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation., Results: Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12-208 weeks). There were no screw removals for painful hardware and no cases of non-union., Conclusions: Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Study Design: Systematic review and meta-analysis., Objectives: To compare early ankle movement versus ankle immobilization after surgery for ankle fracture on clinical and patient-reported outcomes., Background: A significant proportion of patients undergoing surgery for ankle fracture experience postoperative complications and delayed return to function. The risks and benefits of movement of the ankle in the first 6 weeks after surgery are not known, and clinical practice varies widely., Methods: We searched bibliographic databases and reference lists to identify eligible trials. Two independent reviewers conducted data extraction and risk-of-bias assessments., Results: Fourteen trials (705 participants) were included in the review, 11 of which were included in the meta-analysis. The quality of the trials was universally poor. The pooled effect of early ankle movement on function at 9 to 12 weeks after surgery compared to immobilization was inconclusive (standardized mean difference, 0.46; 95% confidence interval: -0.02, 0.93; P = .06; I(2) = 72%), and no differences were observed between groups at 1 year. The odds of venous thromboembolism were significantly lower with early ankle movement compared to immobilization (Peto odds ratio = 0.12; 95% confidence interval: 0.02, 0.71; P = .02; I(2) = 0%). Deep surgical site infection (Peto odds ratio = 7.08; 95% confidence interval: 1.39, 35.99; P = .02; I(2) = 0%), superficial surgical site infection, fixation failure, and reoperation to remove metalwork were more common after early ankle movement compared to immobilization., Conclusion: The quality of evidence is poor. The effects of early movement after ankle surgery on short-term functional outcomes are unclear, but there is no observable difference in the longer term. There is a small reduction in risk of postoperative thromboembolism with early ankle movement. Current evidence suggests that deep and superficial surgical site infections, fixation failure, and the need to remove metalwork are more common after early ankle movement. Level of Evidence Therapy, level 1a-.

Background: In an intra-articular calcaneal fracture, the sustentaculum tali is generally thought to remain tightly bound to the talus by the interosseous talocalcaneal ligaments, spring ligament, and deltoid ligament, providing a "constant" fragment that remains anatomically aligned. The extensile lateral approach is commonly used for reduction based on this assumption, but because it provides only limited access to the medial aspect of the calcaneus, indirect fracture reduction is required to restore an anatomic relationship of these fragments to the sustentacular fragment. The purpose of this study was to determine the prevalence and displacement of sustentacular fractures in patients with an intra-articular calcaneal fracture, and thus determine whether the sustentacular fragment can be accurately considered as constant and can be consistently relied on to maintain anatomic alignment., Methods: All patients with an intra-articular calcaneal fracture who presented to two level-I trauma centers from 2006 to 2012 were included in the study if computed tomography scanning was performed. The presence or absence of a sustentacular fracture was documented, along with the displacement and the comminution of any such fracture and the subluxation or dislocation of the sustentaculum tali., Results: Sustentacular fractures were present in ninety-four (44.3%) of the 212 patients who met the inclusion criteria. Seventy-two (76.6%) of the sustentacular fractures were nondisplaced, eleven (11.7%) were displaced, and ten (10.6%) were comminuted. The articulation between the sustentaculum tali and the talus was anatomically aligned in 166 (78.3%) of the calcaneal fractures, subluxated in forty-three (20.3%), and dislocated in two (0.9%)., Conclusions: This study provides a detailed description of the frequency of sustentacular fractures, the displacement of such fractures, and articular subluxation or dislocation associated with intra-articular calcaneal fractures. Fixation by means of a lateral approach may be compromised when the sustentaculum tali is fractured or subluxated. A medial approach or combined medial and lateral approaches may be considered in such circumstances. Special attention should be paid to the integrity and alignment of the sustentacular fragment prior to surgical fixation., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: Surgical treatment of distal tibial fractures demands a stable fracture fixation while minimizing the irritation to the soft tissues by approach and implant. Biomechanical studies have demonstrated superior performance for angular-stable locked nails over standard locked nails in distal tibial fractures. The experimental Retrograde Tibial Nail (RTN) is a minimally invasive local intramedullary osteosynthesis, which has been under design by our group. We conducted a biomechanical comparison in composite tibiae of the Retrograde Tibial Nail against the Expert Tibial Nail (Synthes®). Our hypothesis was that the RTN would provide equivalent biomechanical stability with respect to extra-axial compression, torsion and load to failure testing, in an extra-articular distal tibia fracture model., Methods: Biomechanical composite bone testing was conducted in 14 biomechanical composite tibiae in an AO 43 A3 fracture model. In both groups, triple angle stable interlocking was performed in the distal fragment., Results: Results show a statistically non-significant higher stability of the ETN during the axial loading tests. Torsional stability testing resulted in a statistically superior performance for the RTN (p = 0.018). Destructive extra-axial compression resulted in failure of six ETN constructs, while all RTN specimens survived the maximal load., Conclusions: The experimental Retrograde Tibial Nail provides the key features for the treatment of distal tibial fractures. It combines a minimally invasive local intramedullary osteosynthesis with the ability to securely fix the fracture by multiple angle stable locking options.

Background: A pronation external rotation (PER) ankle fracture is a relatively uncommon injury. The purpose of this study was to examine the immediate and short-term clinical outcomes of operatively treated PER IV ankle fractures and compare them with a similarly treated cohort of supination external rotation IV (SER IV) fractures., Methods: 22 PER IV and 108 SER IV fractures were identified from a single surgeon's prospectively collected database from 2004 to 2010. All patients were treated with fracture fragment and ligament specific fixation during the same time period by the same surgeon. Postoperative radiographs and bilateral ankle computed tomography (CT) scans were reviewed for articular incongruity, syndesmotic malreduction, and loss of reduction. Clinical outcome measures, including the Foot and Ankle Outcome Score (FAOS) and ankle range of motion (ROM), were collected at latest follow-up visit., Results: There was no difference in the rate of wound complications, fracture nonunion, or loss of reduction between the PER IV and SER IV groups. There was no significant difference in the incidence of postoperative articular incongruity (19% vs 8%, P = .23); however, the PER IV cohort was found to have a significantly higher rate of syndesmotic malreduction (40% vs 18%, P = .04). No clinically or statistically significant differences were detected between the 2 groups in regard to all FAOS domains., Conclusion: In a cohort of operatively treated PER IV fractures, fracture fragment and ligament specific fixation resulted in good short-term outcomes that were comparable to those seen in similarly treated patients with an SER IV fracture pattern. However, a notably greater number of syndesmotic malreductions were noted in the PER IV cohort, and therefore heightened scrutiny is recommended in treating this particular injury pattern., Level of Evidence: Level III, retrospective comparative study.

Purpose: Fibular tip ossicle separation can cause ligament injury leading to chronic lateral ankle instability. A cadaveric study was conducted to preliminarily assess the effects of fibular tip separated ossicle location and size on lateral ankle ligament complex integrity., Methods: X-ray examinations and dissection of the anterior talofibular and calcaneofibular ligaments were conducted in ten radiographically confirmed normal below-knee cadaveric specimens extracted from donated fresh cadavers. Ossicle and bone fragment location and size were recorded, and distal fibula, articular surface, and adjacent ligament effects were determined by a novel 9-region matrix., Results: Ligament risk varied by region. Anterior talofibular ligament width, perpendicular distance to fibular tip, sagittal width of distal fibula, and coronal width of distal fibula at attachment were 7.45 ± 0.22, 11.75 ± 1.03, 20.56 ± 1.54, and 8.68 ± 0.12 mm, respectively. Sagittal distal fibula and calcaneofibular ligament maximum widths at fibular attachment articular surfaces were 16.81 ± 0.96 and 3.50 ± 0.44 mm, respectively. Anterior talofibular to calcaneofibular ligament distance was 2.35 ± 0.14 mm. Separated ossicles >10 mm in regions 1-3 affected anterior talofibular ligaments, calcaneofibular ligaments, and fibular ankle joints; while those in regions 4, 8, and 7 or 9 affected anterior talofibular or calcaneofibular ligaments or were without impact., Conclusions: At the fibular tip, separated ossicles sized >10 mm impact collateral ligaments and articular surfaces, while those 5-10 and <5 mm impact anterior talofibular or calcaneofibular ligaments, potentially impairing the lateral ankle ligament complex. Thus, systematic matric-based assessment of ossicle size and location can potentially improve and standardize ankle fracture care.

Purpose: The objective of the study is to evaluate the degree of balance disorders in patients with surgical treatment of ankle fractures with the use of stabilometric examinations., Methods: The subjects in the study were 21 patients with ankle fractures treated surgically, within one year of the procedure. The control group comprised 20 healthy subjects. The balance was evaluated with the use of force platform in standing posture in both single and double limb stance. The parameters analysed were the transition area of the centre of feet pressure (COP), the length of the COP path and the COP velocity. The range of movement in the ankle joint and the intensification of pain were also measured., Results: In the balance evaluation in double limb stance, there were no statistically significant differences. A significant difference was found in the attempts of single limb-stance. An average value of COP transition area in the study group was 261.2 mm2 in single stance (on the right operated limb) and in the control group--93.2 mm2, so the difference was statistically significant (p = 0.0096). The presence of pain, the presence or the removal of anastomosis had no significant influence on the balance of the subjects under study. Also a significant correlation between the balance of the subjects and their age was found., Conclusions: The balance in single limb stance after an instable ankle fracture within one year of the surgical procedure is significantly poorer in comparison with healthy subjects. Elderly persons have significantly poorer balance control.

Ankle fractures are a common injury across all age groups. Management may be operative or nonoperative, depending on the severity of the injury and the patient's overall health and functional status. Although imaging defines the nature of the fracture, a careful history and physical also helps determine the patient's plan of care. Initial management is focused on adequate alignment and safe immobilization of the injury. Definitive management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues. Rehabilitation after either operative or nonoperative treatment aims at restoring range of motion, strength, proprioception, and function.

Background: A restriction in ankle dorsiflexion is a common complication of ankle fractures. This kind of dysfunction, if severe, can significantly influence gait. A restriction in ankle dorsiflexion (forward movement of the shin relative to the foot) can cause, among others, hyperextension of the knee during the stance phase. The length of leading leg step is shortened and alternant walk downstairs is very difficult. The aim of this study was to examine the correlation between the range of dorsiflexion in the ankle joint and the range of extension (hyperextension) in the knee joint., Material and Methods: The study enrolled 17 patients after ankle joint fractures treated conservatively or surgically. The extension ranges of motion in the ankle and knee joints were assessed by goniometry to compare these values in injured vs. healthy limbs. Non-parametric methods (the Wilcoxon signed-rank test) were used for the analysis., Results: The results showed limitation in ankle dorsiflexion in the fractured limb, which amounted to 4.40 vs. 16.00 in healthy limbs in all patients. This difference was statistically significant (p<0.001). There was also a significantly (p<0.001) greater range of knee hyperextension on the side of injury (5.00 vs. 1.90 in healthy limbs)., Conclusions: 1. Post-traumatic restriction of ankle dorsiflexion can cause knee joint overload. 2. Examinations of knee function during walking should be carried out in patients with trauma-related dysfunctions of the ankle joint in order to prevent secondary musculoskeletal abnormalities.