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Background The diagnosis of clinically important instability following isolated supination-external rotation (SER) distal fibular fractures is a challenge. The purpose of this study was to investigate the accuracy of clinical findings including medial tenderness, swelling, and ecchymosis, combined with the gravity stress test and magnetic resonance imaging (MRI), in the assessment of ankle mortise stability in association with isolated SER-type lateral malleolar fractures. The external rotation (ER) stress test was used as the reference with which the methods of assessment were compared. Methods Thirty-seven patients were enrolled prospectively. Using the ER stress test as a reference, we evaluated the sensitivity, specificity, likelihood ratio (LR), and post-test probability of instability when using clinical examination, the gravity stress test, and MRI for diagnosing ankle mortise instability after an isolated SER lateral malleolar fracture. Results The positive LR for clinical findings ranged from 1.45 to 2.54, and the negative LR ranged from 0.25 to 0.70, shifting the pre-test probability to a rarely important degree. In contrast, the positive LR for the gravity stress test was 5.71 with a 95% confidence interval (CI) of 1.52 to 21.48, a moderate shift from the pre-test probability, and the negative LR was 0.33 (95% CI = 0.16 to 0.66), indicating a small shift. In cases with a deep deltoid ligament disruption identified on MRI, the positive LR was 3.05 (95% CI = 1.03 to 9.02) and the negative LR was 0.53 (95% CI = 0.31 to 0.91), demonstrating a small but sometimes important shift. Conclusions The gravity stress test is a reliable method for diagnosing ankle mortise instability in patients with an isolated SER lateral malleolar fracture. Nevertheless, this test alone would not qualify as a replacement for the ER stress test. However, when the gravity stress test result is consistent with the clinical or MRI findings, its diagnostic value is almost equivalent to that of the ER stress test. Level of evidence Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background Lateral ankle ligament injury is among the most common orthopedic injuries. The objective of this study is to present the preliminary prospective results of treatment using the "Inside-Out" variant of the fully arthroscopic Brostrom–Gould technique. Methods Twenty six patients were included: 20 male and 6 female, aged 19–60 years, mean 41 years. All patients had positive "anterior drawer" and "talar tilt" tests. When necessary, cartilage injuries were treated with microfracture and arthroscopic resection for anterior impingement; three patients had hindfoot varus, on whom Dwyer osteotomy was performed; one patient had peroneal tendinopathy and was treated with tendoscopic debridement and another one had partial injury of the deltoid ligament, which was treated by direct repair. Two arthroscopic surgery portals were used; the anteromedial and anterolateral. After careful inspection of the joint, the anterior surface of the fibula was cleaned to resect the remains of the anterior talo-fibular ligament. An anchor with two sutures was placed on the anterior aspect of the fibula, 1cm from the distal apex of the malleolus. The sutures were passed through the remnant of the anterior talo-fibular ligament as well as the extensor retinaculum using special curved needles. Duncan knots were used to tie the ligament and the inferior extensor retinaculum while the ankle was kept in a neutral position. Patients were kept immobilized non-weight bearing for 2 weeks and were then allowed to start weight bearing in a removable protective boot for 4 weeks. The patients were able to return to sporting activities 6 months after surgery. Results After a mean follow-up of 27 months (range 21–36 months), patients were functionally evaluated using the American Orthopedics Foot and Ankle Society (AOFAS) ankle score. The mean preoperative value was 58 points, while the mean postoperative value increased to 90 points. One patient had paresthesia in the superficial fibular nerve area, which resolved spontaneously. Conclusion Despite the limited cohort and the relatively short follow-up period, the use of the "inside-out" arthroscopic technique may be considered as a valid option for the treatment of chronic ankle instability.

Purpose: To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice. Methods: This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded. Results: All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases). Conclusion: In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials. Key words: Ankle fractures; Supination-external rotation; Deltoid ligament; Fracture fixation, external

The present prospective study examined the utility of the intraoperative tap test/technique for distal tibiofibular syndesmosis in the diagnosis of deltoid ligament rupture and compared the outcomes of transsyndesmotic fixation to deltoid ligament repair with suture anchor. This diagnostic technique was performed in 59 ankle fractures with suspected deltoid ligament injury. The width of the medial clear space of 59 cases was evaluated to assess the sensitivity and specificity. Those with deltoid ligament rupture were randomly assigned to 2 groups and treated with deltoid ligament repair with a suture anchor or with syndesmosis screw fixation. All the patients were assessed with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, short-form 36-item questionnaire (SF-36), and visual analog scale (VAS). The tap test was positive in 53 cases. However, surgical exploration demonstrated that 51 cases (86.4%) had a combined deltoid ligament injury and fracture. The sensitivity and specificity of the tap test was 100.0% and 75.0%, respectively. Finally, 26 cases (96.3%) in the syndesmosis screw group and 22 (91.7%) in the deltoid repair group were followed up. No statistically significant differences were found in the AOFAS ankle-hindfoot scale score, SF-36 score, or VAS score between the 2 groups. The malreduction rate in the syndesmosis screw group was 34.6% and that in the deltoid repair group was 9.09%. The tap test is an intraoperative diagnostic method to use to evaluate for deltoid ligament injury. Deltoid ligament repair with a suture anchor had good functional and radiologic outcomes comparable to those with syndesmotic screw fixation but has a lower malreduction rate. We did not encounter the issue of internal fixation failure or implant removal.

The purpose of this study was to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus and appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex.This study included 590 subjects (0-15 years), who underwent ankle AP, lateral and mortise radiographs. Presence of the medial malleolus and incisura fibularis were recorded. Tibiofibular overlap, tibiofibular clear space, medial clear space, talar tilt, talocrural angle, relative fibular width and fibular position were measured.All radiographic measurements showed good to excellent intraobserver and interobserver reliability (ICCs, 0.603 to 0.949). The timing of ossification of medial malleolus and appearance of tibial incisura between boys and girls were not different. Tibiofibular clear space on mortise views, and medial clear space on AP and mortise view significantly decreased by age. Tibiofibular overlap on AP and mortise views, relative fibular width on AP view significantly increased by age. Talocrural angle, tibiofibular overlap on AP view, tibiofibular clear space on AP and mortise views, medial clear space on AP and mortise views and fibular position were significantly larger in boys than in girls. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on AP view of both sides was50% in 97.1%, 93.1%, and 97.2% of patients, respectively. The difference in tibiofibular overlap, tibiofibular clear space and medial clear space on mortise view of both sides was50% in 98.0%, 96.5%, and 100% of patients, respectively.For skeletally immature patients, the criteria for absolute radiographic values used in adults to assess distal tibiofibular syndesmosis or deltoid ligament injury cannot be applied, but comparison of both sides of ankle joint could help physicians to predict the need for additional evaluations.

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

Evaluation and management of ankle fractures has progressed in parallel to an evolving understanding of ankle stability. While stability of the mortise had historically been attributed to the lateral malleolus, Lauge-Hansen’s contributions followed by multiple other investigations increased the emphasis on the significance of medial-sided injury in destabilizing the mortise. As the importance of the deltoid ligament has been elucidated, the means of assessing ligamentous incompetence and the prognostic significance of an unstable mortise continue to be defined. Level of Evidence: Level V, expert opinion.

Background: In patients with ankle and foot pain, it is crucial to detect the lesion responsible for the pain for deter-mining adequate treatment. MRI in combination with other radiologic images is currently regarded as the most appropriate diagnostic imaging of benign bone and soft tissue lesions in chronic ankle pain.Aim of Work: To evaluate the role of ultrasound and magnetic resonance imaging in diagnosis of the etiology of chronic ankle pain.Material and Methods: This study included ninety patients with chronic ankle pain. All patients were subjected to clinical evaluation, ultrasound examination and MRI.Results: Both ultrasound and MRI revealed nearly the same results in evaluation of tendon abnormalities. Ultra-sonography couldn't detect injuries of the posterior talo-fibular ligament as well as posterior tibio-fibular ligament while MRI could clearly detect them. Regarding other ligaments (anterior talo-fibular, anterior lower tibio-fibular and deltoid ligaments), MRI was slightly superior to ultrasound in evaluation of injuries of these ligaments. Ultrasonography could detect some cases of postero-medial impingement syndromes (caused by deltoid ligament injury), however it couldn't detect cases of posterior or anterior impingement (usually caused by bony abnormalities), these cases were better assessed by MRI examination. Cases of osteochondritis dessicans and bony tumors could be assessed by MRI examination however; ultrasonography was negative in detecting these lesions.Conclusion: Ultrasound and MRI showed similar results in evaluation of tendon and ligament injuries as well as entrapment neuropathy, MRI was superior to ultrasound in evaluation of impingement syndromes and osseous pathologies.

Background Osteochondral lesions of the talus (OLT) are recognized as being commonly associated with trauma. However, the etiology of OLT remains unclear. In the case of a posteromedial lesion of OLT (medial OLT), the deep layer of the deltoid ligament is located close to the medial OLT, and this relationship between a medial lesion and deltoid ligament could be a risk factor for medial OLT. The purpose of this study is to investigate the unique anatomic feature of the deep deltoid attachment to the talus in patients with medial OLT compared with patients with non-medial OLT. Methods Forty ankles with medial OLT and 40 ankles without medial OLT were retrospectively reviewed in this study. On the coronal images of MRI, the attachment of deltoid ligament was measured. The continuity of the osteochondral fragment and its bed was evaluated on MRI and arthroscopic findings. Results Coronal MRI images showed that the attachment of the deep deltoid ligament to the medial OLT was broader and located more proximally than in non-medial OLT. The continuity of fibers from the insertion site of deltoid ligament to the talus to the osteochondral fragment was observed (76.7%). In the arthroscopic findings, the osteochondral fragment was obviously connected to the talus at the medial site in 85.2% of feet. Conclusions The location of the deep deltoid ligament attachment to the medial OLT was more proximal and there was the possibility of these anatomic feature might contribute to the pathogenesis of medial OLT.

Background The diagnosis of instability in the apparent, isolated distal fibula fracture can be challenging and often necessitates stress radiography. Danis & Weber classified lateral malleolar fractures based on the level of the fracture in relation to the syndesmosis. While Weber B fractures occur at the level of the syndesmosis, some such injuries present with a long, oblique pattern extending well above the syndesmosis. Given the well-established literature demonstrating that fractures above the syndesmosis correlate with a higher level of concomitant syndesmotic and deltoid ligament injury, we hypothesize that increased fracture obliquity, length and height of Weber B fibula fractures similarly correlates with increased mortise instability. Methods All patients with isolated Weber B fibula fractures who underwent gravity stress radiography met inclusion criteria. Fracture height was measured on mortise radiographs as: (1) the distance from the distal tip of the fibula to fracture apex, (2) the distance to the fracture apex as measured on a line drawn perpendicular to a line parallel to the plafond, (3) an angle subtended by a line drawn parallel to the plafond and a line drawn to the fracture apex and (4) a ratio of the absolute length as compared to fibular width. Results 51 patients were included in the study. The group of 39 patients with stable ankles had a mean medial clear space of 3.12 ± 0.65 mm (range, 1.5 mm to 4.0 mm). The group of 12 patients with unstable ankles had a mean medial clear space of 6.29 ± 3.11 mm (range, 4.1 mm to 14.0 mm). These groups showed no significant difference in fracture angle (p = 0.93), fracture height from plafond (p = 0.49), fracture height from tip of fibula (p = 0.42), and as a ratio of absolute length to fibular width (p = 0.85). Conclusion Increased fracture obliquity, length and height of Weber B fibula fractures did not correlate with a higher incidence of mortise instability. Despite the lack of positive correlation, future studies should continue to investigate and identify radiographic parameters of distal fibula fractures that are most predictive of instability.

Category: Ankle; Trauma Introduction/Purpose: Diagnosis and treatment of ankle medial ligament lesions in malleolar fractures has always been a matter of controversy. Even when deltoid involvement is clear, the direct repair of this structure is not a consensus. Recently, deltoid reparation through an arthroscopic technique was described aiming to potentialize better clinical results and minimize complications. We intend to demonstrate safety and functional results of operated ankle fractures that had an arthroscopic deltoid repair. Methods: This is a retrospective study in patients diagnosed with ankle fractures associated with acute deltoid injuries submitted to malleolar fixation and deltoid arthroscopic repair between June 2016 and January 2020. All patients were evaluated for pain and function according to the Visual Analogue Scale (VAS) and the American Orthopaedic Foot & Ankle Society Score (AOFAS) at a minimum of 6 months in follow-up. Results: Between January 2016 and January 2020, 20 ankles with fractures or dislocations were operated and the deltoid ligament rupture was repaired arthroscopically. A mean follow-up of 14.45 months (6-48) was observed, and patients presented an average AOFAS of 93.5 (SD 7.25) and a VAS of 0.75 (SD 1.05). Three minor complications were noticed and no signs of medial chronic instability, loss of reduction or osteoarthritis were observed. Conclusion: The repair of the deltoid complex and the low morbidity of the arthroscopic technique used may improve the clinical outcomes of these patients. Additional studies, with a prospective and comparative methodology are required to sustain this proposal.

Goal of this study was to investigate whether a gravity stress radiograph is beneficial in determining instability in Supination-External rotation (SER)-type ankle fractures without a medial fracture. 39 Patients with a SER-type ankle fracture without a medial or posterior fracture and medial clear space (MCS)

Background To assist with visualization, orthopaedic surgeons often apply ankle distraction during arthroscopic procedures. The study aimed to investigate whether ankle distraction suppresses fibular motion in cadaveric specimens with an unstable syndesmotic injury. Methods Fourteen fresh-frozen above knee specimens underwent arthroscopic assessment with 1) intact ligaments, 2) after sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, and the posterior inferior tibiofibular ligament, and 3) after sectioning of the deep and superficial deltoid ligament. In all scenarios, the lateral hook test, anterior-posterior hook test, and posterior-anterior hook test were applied. Each test was performed with and without ankle distraction. Coronal plane anterior and posterior tibiofibular diastasis as well as sagittal plane tibiofibular translation due to the applied load were arthroscopically measured. Findings Tibiofibular diastasis in the coronal plane, as measured at both the anterior and posterior third of the incisura, was found to be significantly less when ankle distraction was applied, as compared to arthroscopic evaluation in the absence of distraction. In contrast, measurement of sagittal plane tibiofibular translation was not affected by ankle distraction. Interpretation Since arthroscopic findings of syndesmotic instability are subtle the differential values of the syndesmotic measurements taken on and off distraction are clinically relevant. To optimally assess syndesmotic instability one should evaluate the syndesmosis without distraction or focus on fibular motion in the sagittal plane when distraction is required.

Deltoid ligament repair can be challenging, and implementation of an arthroscopic method can be useful in terms of minimizing morbidity associated with open dissection, as long as the repair is effective and durable. In this brief report, we describe a method of arthroscopic deltoid ligament repair that we have found to be useful.

Background:There is no consensus on the optimal treatment or preferred method of operation for the management of acute deltoid ligament injuries during an ankle fracture fixation. This study aimed to analyze the outcomes of repairing the deltoid ligament during the fixation of an ankle fracture compared to conservative management.Methods:We retrospectively evaluated 78 consecutive cases of a ruptured deltoid ligament with an associated ankle fracture between 2001 and 2016. All of the ankle fractures were treated with a plate and screw fixation. Patients in the conservative treatment for ruptured deltoid ligament underwent management from 2001 to 2008 (37 fractures, group 1), while the operative treatment for ruptured deltoid ligament was included from 2009 to 2016 (41 fractures, group 2). The outcome measures included radiographic findings, the American Orthopaedic Foot & Ankle Society ankle-hindfoot scores, visual analog scale scores, and the Foot Function Index. All patients were followed for an average of 17 months.Results:Radiologic findings in both groups were comparable, but the final follow-up of the medial clear space (MCS) was significantly smaller in the group 2 ( P < .01). Clinical outcomes were similar between the two groups ( P > .05). Comparing those who underwent syndesmotic fixation between both groups, group 2 showed a significantly smaller final follow-up MCS, and all clinical outcomes were better in group 2 ( P < .05). Linear regression analysis showed that the final follow-up MCS had a significant influence on clinical outcomes ( P < .05).Conclusion:Although the clinical outcomes were not significantly different between the 2 groups, we obtained a more favorable final follow-up MCS in the deltoid repair group. Particularly when accompanied by a syndesmotic injury, the final follow-up MCS and the clinical outcomes were better in the deltoid repair group. In the case of high-grade unstable fractures of the ankle with syndesmotic instability, a direct repair of the deltoid ligament was adequate for restoring medial stability.Level of Evidence:Level III, retrospective comparative case series.

Objective To evaluate the feasibility of point-of-care ankle ultrasound compared with magnetic resonance imaging (MRI) for diagnosing major ligaments and Achilles tendon injuries in patients with recurrent ankle sprain and chronic instability, and to evaluate inter-observer reliability between an emergency physician and a musculoskeletal radiology fellow. Material and methods A prospective cross-sectional study was conducted in an emergency department. Patients with recurrent ankle sprain and chronic instability were recruited. An emergency physician and a musculoskeletal radiology fellow independently evaluated the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), distal anterior tibiofibular ligament (ATiFL), deltoid ligament, and Achilles tendon using point-of-care ankle ultrasound. Findings were classified normal, partial tear, and complete tear. MRI was used as the reference standard. We calculated diagnostic values for point-of-care ankle ultrasound for both reviewers and compared them using DeLong's test. Intra-class correlation coefficients (ICCs) were calculated for agreement between each reviewer and the reference standard, and between the two reviewers. Results Eighty-five patients were enrolled. Point-of-care ankle ultrasound showed acceptable sensitivity (96.4–100%), specificity (95.0–100%), and accuracy (96.5–100%); these performance markers did not differ significantly between reviewers. Agreement between each reviewer and the reference standard was excellent (emergency physician, ICC = 0.846–1.000; musculoskeletal radiology fellow, ICC = 0.930–1.000), as was inter-observer agreement (ICC = 0.873–1.000). Conclusion Point-of-care ankle ultrasound is as precise as MRI for detecting major ankle ligament and Achilles tendon injuries; it could be used for immediate diagnosis and further pre-operative imaging. Moreover, it may reduce the interval from emergency department admission to admission for surgical intervention, and may save costs.

Irreducible ankle fractures are a relatively rare phenomenon. We present a case of a pronation abduction-type ankle fracture that was irreducible in the emergency room despite sedation. The patient was taken to the operating room, where the posterior tibialis tendon and retinaculum, deltoid ligament, and anteromedial capsule were found to be trapped within the joint. After removal of the tissue, alignment was restored. The patient did well clinically and was advanced to full weightbearing at 6 weeks. This is, to the best of our knowledge, the first report of entrapment of all 4 anatomic structures, preventing closed reduction.

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

Context: Deltoid ligament sprains among collegiate student-athletes have not been extensively investigated. Research regarding the mechanisms, participation-restriction time, and recurrence of deltoid ligament sprains in collegiate student-athletes is lacking. Objective: To describe the epidemiology of deltoid ligament sprains in 25 National Collegiate Athletic Association championship sports. Design: Descriptive epidemiology study. Setting: National Collegiate Athletic Association Injury Surveillance Program. Main Outcome Measure(s): We analyzed deltoid ligament sprains recorded in the Injury Surveillance Program for the 2009–2010 through 2014–2015 academic years. Deltoid ligament sprain injury rates, rate ratios, and injury proportion ratios with 95% confidence intervals (CIs) were reported. Results: During the study period, 380 deltoid ligament sprains were reported, resulting in a combined injury rate of 0.79/10 000 athlete-exposures (AEs; 95% CI = 0.71, 0.87). Most deltoid ligament sprains occurred in practices (54.2%, n = 206). However, the competition injury rate was higher than the practice injury rate (rate ratio = 3.74; 95% CI = 3.06, 4.57). The highest deltoid ligament sprain rates were in women's gymnastics (2.30/10 000 AEs; 95% CI = 1.05, 3.55), men's soccer (1.73/10 000 AEs; 95% CI = 1.14, 2.32), women's soccer (1.61/10 000 AEs; 95% CI = 1.13, 2.09), and men's football (1.40/10 000 AEs; 95% CI = 1.18, 1.62). Nearly half of all deltoid ligament sprains (49.7%, n = 189) were due to player contact, and 39.5% (n = 150) were non–time-loss injuries (ie, participation restricted for less than 24 hours). Only 8.2% (n = 31) of deltoid ligament sprains were recurrent. Conclusions: The highest deltoid ligament sprain rates were in women's gymnastics, men's and women's soccer, and men's football. However, the rate for women's gymnastics was imprecise (ie, the CI was wide), highlighting the need for further surveillance of deltoid ligament sprains in the sport. Most deltoid ligament sprains were due to player contact. Future researchers should assess interventions that may prevent deltoid ligament sprains.

Background: Ankle injuries gain importance because body weight is transmitted through it and location depends upon the stability of this joint. Unstable displaced and open fractures require open reduction internal fixation. Objectives were retrospective study of functional out come and results of surgical treatment of bi-malleolar fractures and to know the complications of open reduction and internal fixation in bi- malleolar fractures. Methods: The results of retrospective study of 125 patients were studied from January 2009 to January 2015. They were classified according to Lauge Hansens classification and treated according to the AO system. Assessment of the outcome was done using the scoring system of Baird and Jackson which is based on subjective, objective and radiological criteria. Results: Mean follow up was 3.5yr in between January 2009-January 2015. Out of 125 patients evaluated, overall good to excellent results were obtained in 95 (76%) patients. The results were fair in 15 (12%) and poor in 15 (12%) patients. There were no intraoperative complications. The post-operative complication we came across is superficial skin infection in 20 (16%) patients. Interpretation and conclusion: Anatomical reduction is essential in all intra articular fractures, more so if a weight bearing joint like ankle is involved open reduction and internal fixation guarantee high standard of reduction besides eliminating chances of loss of reduction. The fibular length has to be maintained for lateral stability of the ankle. Chances of non-union of medial malleolus interposition of the periosteum and deltoid ligament are avoided. Poor clinical results are found to be associated with unsatisfactory surgical reduction.

Objectives. The purpose of this study was the importance of applying Kinesio tape (KT) in relieving the pain in athletes' ankles using Y balance test and star. Methods. 22 male athletes with average age of 22.33±1.37 were discussed with and without Kinesio tape. At first athletes didn’t use kinesiology tape on their deltoid ligament and did the (Y) balance test in 3 directions, then star twirling test (SEBT) in 8 directions that focused on the center of one plexus. These tests were repeated 3 times and all the stages of them were recovered after 24 hours and then the tests done on a pad and on a solid surface. Results. Athletes in both tests on a soft pad experienced a high pressure on their muscles according to the position of their leg in plantar and dorsiflexion state;and they couldn’t finish the test. Conclusion. The test showed that the Kinesio tape on a soft surface (pad) did have any positive effects on the muscles.

Introduction Determining deltoid ligament incompetence in supination external rotation (SER) injuries commonly relies on stress radiography, given several studies demonstrating low predictive value of physical examination. Stress radiography can be difficult to obtain and may result in suboptimal radiographs with equivocal determination of stability. This study revisits the concept of medial ankle tenderness and its association with mortise instability. Methods Patients who presented with an isolated lateral malleolus fracture underwent prospective data collection. VAS scores were recorded with palpation at the lateral malleolar fracture site, anterior deltoid ligament, and posterior deltoid ligament. Three non-weightbearing radiographs of the ankle and a gravity stress view were obtained. Statistical analysis was performed to determine a correlation between tenderness and instability defined as MCS widening > 4 mm on gravity stress x-ray. Results 51 patients met inclusion criteria. Group I (stable) and Group II (unstable) demonstrated no difference in tenderness over the lateral malleolus (p = 0.94) or anterior deltoid (p = 0.12), but patients in Group II reported significantly more tenderness over the posterior deltoid (p = 0.03). Taking the higher pain score from either anterior or posterior deltoid palpation, patients with unstable ankle fractures reported significantly more tenderness with medial palpation (p = 0.02). The relative risk of having an unstable ankle fracture with any tenderness to palpation over either the anterior or posterior deltoid ligament was 1.77 (95% CI 1.03 - 3.06, P = 0.039). When comparing no pain versus the presence of any pain with palpation medially, the sensitivity for any medial tenderness to detect an unstable ankle fracture was 0.76 (specificity 0.59, PPV 0.79, NPV 0.56). Conclusion Patients with any medial tenderness were at significantly higher risk of having an unstable SER ankle fracture in this study, but strict reliance on the presence or absence of medial tenderness without stress radiographs would lead to an unacceptable number of both false positive and false negative determinations of instability. However, our findings suggest that medial tenderness is associated with instability. The 0.79 PPV of any medial tenderness for instability may be useful to cast doubt on equivocal stress radiography and prompt surgeons to repeat stress radiography or shorten the interval for radiographic follow up. Level of evidence Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]).

Background This study was performed to evaluate the value of using ultrasound for stability assessment of isolated lateral malleolar fractures compared to simple X-ray, stress radiography, and arthroscopy. Methods This is a prospective cohort study with 25 consecutive patients who underwent an arthroscopic examination and subsequent surgery for isolated lateral malleolar ankle fractures. Before operation, simple and external rotation stress radiographs were obtained. Ultrasound was performed to assess the medial deltoid ligament prior to operation. Arthroscopic findings were used as reference standards. Sensitivity, specificity, and positive and negative predictability were calculated and compared using receiver operating characteristic (ROC) curve analysis for simple radiography, stress radiography, and ultrasound examination. Results The sensitivity and specificity of ultrasound for tears of the deep deltoid ligament were 94.74% and 66.67%, respectively. But, they were both 100% for complete tears of the ligament. ROC curve analysis showed that the ultrasound examination was significantly more accurate than simple and stress radiography. Conclusions Ultrasound could be used to assess the instability of isolated lateral malleolar fractures. Commonly used stress radiography appears to overrate the need for operative treatment.

Fractures and dislocations of the ankle are among the most common injuries in the musculoskeletal system. Sports-related lower limb fractures and dislocation are particularly problematic for athletes because they often result in significant periods of non-weight rehabilitation. The disability and time away from sports resulting from these injuries warrant close attention to diagnosis and management. Stable ankle fractures are treated nonoperatively with good results in the majority of patients. Meticulous clinical and radiographic evaluation is necessary to determine which ankle fractures will require operative treatment. We present a practical approach to evaluation and management of the most common ankle fracture variants. We also offer an approach to the management of deltoid ligament injuries in association with ankle fractures, and discuss the role of adjunct treatments such as arthroscopic assisted ankle fracture treatment. Fractures of the lateral process of the talus and anterior process calcaneus fractures are often difficult to detect on radiographs and many times misdiagnosed as ankle sprains. These common sports related hindfoot fractures are discussed in detail, and we offer a simple approach for diagnosis and management of these injuries.

Ankle sprains are one of the most common injuries that occur in sports. They range from mild to severe and often include injury to other structures in addition to the ligaments. When the injuries are more severe or treated inadequately, chronic problems can develop ranging from pain to instability to post-traumatic arthritis. The most common sprain to the ankle involves the lateral ligaments, with medial and syndesmosis sprains occurring less frequently. Acute lateral sprains are typically managed nonoperatively with functional treatment, but certain conditions require early surgical intervention. When there is obvious pain and instability, temporary immobilization is warranted, and if persistent, it may indicate a need for more investigation and potentially surgical intervention. Medial sprains to the deltoid ligament can be difficult to elicit instability, and by nature often present in a chronic form that may involve other structures. Syndesmosis injuries are being recognized with increasing frequency and usually result in more lost playing time than other sprains of the ankle. Stabilization of the syndesmosis is not without controversy, particularly when it comes to the best method of evaluation and surgical treatment. Regardless of the specific type of ankle sprain, when there is persistent debilitating instability, surgical correction is essential, followed by a well-designed rehabilitation program. Ultimately, ankle sprains are ubiquitous in sports, and the skillful physician will evaluate the injury carefully and institute the treatment plan that will foster the best recovery and return to play for the athlete, regardless of their level of participation.

Purpose The first descriptions on medial talar tubercle fractures are attributed to Cedell. He described avulsion fractures of the insertion of the posterior talotibial ligament. However the true etiology has not been established. Since little is known about these fractures, they are easily misdiagnosed as simple ankle sprains. Untreated, these fractures may lead to chronic ankle pain. To improve the understanding of the etiology and outcome of these fractures a systematic review was conducted of all cases of isolated fractures of the medial tubercle of the posterior talar process. In addition we present the first series of competitive athletes treated by means of the two-portal hindfoot approach for isolated medial talar tubercle fractures. Methods A systematic search was performed to identify all cases of medial tubercle fractures. Data on trauma mechanism, clinical presentation, imaging and treatment were extracted. In addition we retrospectively report on the results of endoscopically treated patients in our institution over the last fifteen years. Of all patients Numeric Rating Scores (NRS) for Satisfaction, Pain and Function, Foot Ankle Outcome Scores (FAOS), return to sport and complications were reported. Results Eightteen articles were included reporting on 33 patients with an isolated fracture or avulsion of the posteromedial talar process. Most of the fractures occurred during sport activities (58%), followed by motor vehicle accidents (21%) and fall from height (12%). Of the activities during sport, 73% resulted following an ankle sprain. Reasonable to good outcomes are described in cases treated with immobilization, open reduction internal fixation or open excision. Of the nine patients treated in our institution, five were male and the median age was 29. All were participating in sports at a competitive level, with four of them being a professional athlete. In most patients the diagnosis was made more than a year after initial trauma. Ankle sprain was most common trauma mechanism. In some patients it was evident the avulsion was part or the deep portion of the deltoid ligament, however in two cases it was more likely an avulsion of the flexor hallucis longus (FHL) retinaculum. The median follow-up was 69 months (IQR 12.0–94.3). At final follow-up patients had little pain, NRS 1. Median NRS for satisfaction and function were 7 and 8, respectively. All patients did resume sport activities, however only four reached the preinjury level. Of the five patients that did not return to their pre-injury level of activity, two were professional athletes at the end of their career, and retired not due to ankle complaints. One complication was reported. Conclusion Fractures of the medial tubercle are rare and based on the available literature there is not one distinct trauma mechanism. Based on literature no recommendation for treatment can be made. Our results show endoscopic excision of the fragment as a save alternative for open surgical treatment.

Aims To assess the incidence of spring ligament failure in patients who have complete deltoid ruptures. Patients and methods The authors retrospectively analysed ankle fractures in our trauma database from January 2015 to January 2019. 61 patients who sustained ankle fractures with complete deltoid ligament ruptures based on an AP ankle radiographs with increased medial joint space were identified. 25 patients attended clinic for assessment. Of these, 5 were found to have gross planovalgus with pre-existing spring ligament laxity in the uninjured control foot and these were excluded from the analysis. 20 patients were assessed for spring ligament failure /laxity. For each patient, the uninjured foot was used as the control. Results The TMT instability score and the lateral translation score showed statistically significant increases in the injured compared to the uninjured foot. The ratio of increase in both TMT instability and lateral translation scores (strain) in the injured versus the uninjured foot was assessed. A strong correlation (+0.62 pearson correlation coefficient) was found between the two ratios. Conclusion All 20 patients showed increased spring ligament laxity and 19 patients showed increased TMT instability. Our results show that with complete deltoid rupture, there is likely greater disruption of the medial ligamentous structures of the foot than previously recognised. The degree of increase in the spring ligament strain also correlates with the degree of strain at the plantar TMT joint ligaments, and thus first ray instability. This finding has significant implications for the long-term assessment and management of ankle fractures involving complete deltoid disruption. Early intervention with orthotics in this cohort may prevent progressive destabilisation of the midfoot and the first ray. This evolving understanding may lead to the prospect of earlier surgical intervention to reconstitute the integrity of the spring ligament and protect the foot progressing to stage 2 AAFD.

Introduction: Acute syndesmotic sprain is rarely associated with instability in the absence of fracture. The surgical treatment of these injuries is usually performed as an open procedure with direct visualization of the anatomical reduction of the joint. However, direct visualization of the reduction can be achieved by arthroscopy with minor incisions avoiding damage to the soft tissues. The aim of this study is to present the short-term outcomes of a series of patients with acute unstable syndesmotic injuries who were surgically treated through an arthroscopic reduction and percutaneous fixation with a suture button. Methods: We report a series of 8 patients with a mean age of 25,62 years with acute instability of the syndesmosis without fracture who were treated through arthroscopic reduction of the syndesmosis followed by percutaneous fixation using a suture button, between October 2014 and May 2018. Medical records, the visual analogue scale (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, pre and postoperative radiological results (stress radiographs, computed tomography and magnetic resonance imaging) and complications were retrospectively reviewed. Results: After a mean follow-up of 13,4 months, the mean VAS was 0 and the mean AOFAS was 100. All patients were able to return to their preinjury activities and were completely satisfied with the treatment outcomes. Two patients had an associated deltoid ligament rupture and were treated by open repair at the same time. Two complications were observed. One patient developed an aseptic cyst over the distal knot, and one evolved with complex regional pain syndrome. The last one required a reoperation to remove the anterior button. Conclusion: Arthroscopic treatment represents an effective approach for acute syndesmotic instability. In the short-term, it provides satisfactory clinical and functional results, allowing patients to return to their previous activities. It is reliable regarding anatomic reduction of the syndesmotic joint and percutaneous fixation with a suture button without aggression toward the soft tissue of the ankle.

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.