Contemporary guidelines advocate for initial debridement and single-stage definitive fixation with immediate soft tissue reconstruction for open fractures. This study aims to evaluate the effectiveness of single-stage stabilization and immediate definitive soft tissue coverage in open ankle fractures compared to closed fractures.

We compared all isolated open ankle fractures (OF) treated between January 2017 and June 2019 to a control group of operatively managed closed ankle fractures (CF). The OF group included patients with extensive soft tissue injury loss with periosteal stripping and bone exposure (Gustilo and Anderson IIIB) requiring split skin graft, rotational flap or free flap. Clinical outcomes assessed included infection rates, amputation, revision hardware surgery, surgical reduction, non-union rates, and functional outcomes (assessed using the MOXFQ and EQ-5D-5L questionnaires). Health provider matrices were utilized to evaluate cost-benefit parameters, such as length of stay (LOS). Statistical analysis was performed with a significance level set at P < 0.05.

A total of 27 OF and 35 CF cases with AO classification 44 A-C fractures were analyzed following standard treatment protocols. No amputations were reported, but deep/superficial infections occurred in 3 patients in the OF group compared to 2 in the CF group. There was a three-folds increase in mal-union (P = .11), rates of additional surgeries and discharge times in the OF group. (P < 0.05). However, return to functional weight bearing between OF (mean 10.6 weeks) and CF (mean 7.2 weeks) was similar (P = 0.06), and there were no significant differences in EQ-5D-5L and MOXFQ scores at the end of orthopaedic treatment p = 0.5 and 0.16 respectively. The mean hospital LOS was significantly longer for OF (15.6 days) compared to CF (5.4 days) (P < 0.05).

Definitive stabilization and immediate soft tissue reconstruction in the management of open ankle fractures result in high rates of limb salvage and achieve functional outcomes similar to those seen in matched closed ankle fractures upon completion of orthopedic treatment. Although the patient journey is extended, soft tissue and infective complications do not significantly differ. This calls for further investigation to establish the long-term cost-benefit implications of this approach.

Ankle fractures, ranking as one of the very common osteoporotic fractures, pose a substantial socioeconomic burden. We aimed to investigate the incidence of elderly ankle fractures, refracture risks, and mortality rates in South Korea.

Utilizing the Korean National Health Insurance Service (NHIS) registry from January 2006 to December 2022, individuals over 50 years with ankle fractures were identified. Osteoporotic ankle fractures were defined using admission diagnoses, procedural codes, and cast-related codes. Incidence rates, refracture rates, and one-year mortality rates were analyzed with standardization adjusted for gender and age distribution.

From 2006 to 2022, annual ankle fracture incidence rose from 193.90 to 278.83 per 100,000 person-years. Women exhibited 1.93 times higher incidence than men, with a notable increase in women. Most common in ages 60 to 69, ankle fracture rates increased until 2019 and after 2020 but decreased between 2019 and 2020. The one-year ankle refracture rates and osteoporotic refracture rates increased from 3.55% and 4.56% in 2007 to 9.32% and 10.37% in 2021, respectively. The one-year mortality rate after ankle fractures decreased from 2.10% in 2007 to 1.49% in 2021.

This study offers insights into the epidemiology of osteoporotic ankle fractures in South Korea, revealing increasing incidence, gender differences, age-related patterns, and trends in refracture and mortality rates over the study period. This study examines the incidence, refracture risk, and mortality of osteoporotic ankle fractures in South Korea using a nationwide dataset (2006-2022). The incidence of ankle fractures increased significantly, especially in women, and refracture rates also rose, highlighting an unmet need for better osteoporosis management.

Ankle fractures are one of the common fractures that account for hospitalization. Ankle fractures were often thought of inconsequential as limited data on their long-term consequences. After accounting for age, sex, and time, ankle fractures were associated with increased risk of subsequent fracture and mortality.

Ankle fractures are common but it is uncertain whether they are indicative of poor bone health. There are limited data about subsequent fracture and mortality risk following ankle fractures.

To determine if there is increased subsequent fracture and mortality risk after ankle fractures.

A prospective population-based cohort of 143,070 women and 123,818 men in the 45 and Up Study (NSW, Australia) had baseline questionnaire responses that were linked to Emergency Department Data Collection (EDDC), the Admitted Patient Data Collection (APDC), and the NSW Registry of Births Deaths & Marriages death registrations from 2006 to 2017. Secure data access was provided through the Sax Institute's Secure Unified Research Environment (SURE). Sex-specific excess risks of subsequent fracture and mortality following ankle fractures were quantified using relative survival analysis.

During 1,490,651 person-years, women and men experienced 1379 and 579 ankle fractures and 78 deaths and 76 deaths, respectively. Ankle fractures were associated with a 5-year 5% (95% CI 3-8%) excess risk of subsequent fracture in both women and men, compared to subjects' risk of an incident fracture in the study. There was a 5-year cumulative excess mortality of 10% (95% CI 6-13%) following ankle fractures in men but no excess mortality in women compared to the overall cohort. Participants with ankle fractures who died were older (P < 0.001), more likely to have had a second fracture (P < 0.001), have had a prior fracture (P < 0.001), and have more comorbidities (P < 0.001).

In the 45 and Up cohort, there was a modest but significant increased risk of fracture following ankle fracture seen in both women and men. In men, but not women, ankle fractures were associated with 10% excess mortality. Ankle fractures should be considered for secondary fracture prevention in those who are older and have more comorbidities.

IntroductionBiomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.MethodsBimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.ResultsData revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.ConclusionsThe present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.Level of Evidence:III, Retrospective observational cohort study.

To identify what constitutes a satisfactory outcome following ankle fracture from the perspectives of people with ankle fracture, clinicians and health service managers.

Semi-structured interviews were conducted with adults with lived experience of ankle fracture, clinicians experienced in ankle fracture treatment and managers of hospitals providing care for people with ankle fracture.

Patients (n = 12), clinicians (n = 12) and managers (n = 8) were interviewed. We identified two themes. A satisfactory outcome at six to 12 months following ankle fracture is: (1) a collaborative construct determined by patients and clinicians; and (2) influenced by the patient's experience of care. The first theme was elaborated through three subthemes which explained how patients and clinicians collaborate to determine a satisfactory outcome: (1) establishing indicators; (2) consideration of contextual factors; and (3) revision throughout the patient recovery journey. Managers considered re-referrals and patient feedback reflecting patient outcome and experience of care.

A satisfactory outcome is determined collaboratively by patients and clinicians and monitored by organisational indicators. During this process patients preference outcomes of activity/participation and clinicians preference outcomes of body structure/function. Clinicians play an important role in determining a satisfactory outcome through consideration of patient preferences and providing a positive experience of care.

An effective and appropriate method to support the ankle joint optimally is particularly important during the healing phase of ankle fractures. The purpose of this review was to assess the functional outcomes, ankle-related quality of life, and associated complications of cast immobilization versus removable braces for the treatment of adult ankle fractures.

Studies comparing cast immobilization and removable braces after ankle fracture were included by systematic searches of PubMed/MEDLINE, Web of Science, Scopus, and EMBASE databases according to PRISMA (Preferred Reporting Items for Systematic Evaluation and Meta-Analysis Statements) guidelines. Primary outcome measures included early to mid-late Olerud Molander Ankle Score (OMAS). Secondary outcomes were ankle dorsiflexion and plantarflexion, swelling, pain, time to return to work, calf muscle atrophy, and complications. Subgroup analysis was performed. Risk of bias was assessed in both randomized controlled trials and cohort studies.

Eleven studies including 1485 patients met the eligibility criteria. The fracture types of the study included Weber A/B/C and Lauge-Hansen supination external rotation (SER), supination-adduction (SA), pronation-external rotation (PER) and pronation-abduction (PA). The results of the meta-analysis showed that removable braces had better early (mean difference (MD) -2.14; 95% confidence interval (CI) -4.26, 0.00) and mid-term functional outcomes (MD -5.81; 95% CI -10.35, -1.27) after ankle fracture compared with cast immobilization. In addition, removable braces caused significantly more wound breakdown (Odds ratio (OR) 0.39; 95% CI 0.17, 0.90) and wound infections (OR 0.32; 95% CI 0.17, 0.58) than cast immobilization.

Compared with cast immobilization, removable braces had better functional outcomes in the early and mid-term periods after ankle fractures and were less likely to result in deep vein thrombosis (DVT). Overall, the removable brace is a comfortable ankle fracture option that might improve functional outcomes.

To assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures.

A retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18 - 65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥ 2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American Orthopedic Foot and Ankle Society ankle hindfoot score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test.

During the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, diabetes, or smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American Orthopedic Foot and Ankle Society ankle hindfoot score revealed no significant difference between dislocation and no-dislocation patients.

Dislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.

Background Surgical fixation of posterior malleolar fractures (PMFs) has traditionally been guided by fragment size. Recent studies have proposed fragment morphology as a more effective determinant for optimal fixation. To determine the optimal strategy for PMFs, we conducted a radiographic review of our patients. Methods Between January 2016 and December 2019, all adult patients with ankle fractures who underwent surgical fixation at our institution were reviewed (n=648). The exclusion criteria included pilon fractures, tumors, or infections causing neuromuscular dysfunction, insufficient follow-up, bilateral involvement, and prior injuries. After applying these criteria, 110 eligible patients remained for the study. They were further categorized on the basis of treatment type (non-fixation, screw, and plating) and fracture classification system (Haraguchi, Lauge-Hansen, and Weber classifications). The fracture fragment involvement was further classified as large (>25% of the articular surface) or small (<25%). The outcomes were evaluated via the modified Kellgren-Lawrence grade and the final malleolar step-off to assess osteoarthritis severity and fixation stability. Results Compared to non-fixation treatment, surgical intervention was associated with better outcomes in the Haraguchi type 1, supination-external rotation (SER), and pronation-external rotation (PER) groups. Additionally, surgical fixation using plates resulted in a lower step-off rate compared to screws. Notably, patients with small-fragment fractures who underwent surgical fixation exhibited outcomes comparable to or more favorable than those with larger fragments. These findings suggest that fracture morphology with size may have greater prognostic significance than fragment size alone. Conclusion This study on PMFs highlights that fracture morphology, rather than fragment size alone, should guide surgical decision-making for PMFs. Different PMF patterns call for personalized surgical strategies. Compared with screw fixation and non-fixation treatment, plate fixation yields superior outcomes, particularly in terms of joint space narrowing and stability. This study advocates for a morphology-based approach to managing PMFs, prioritizing plate fixation to achieve better results.

 Previous studies have shown large variation in the incidence of ankle fractures. Nationwide data covering longer periods is necessary to gain knowledge of the current trends. The aim of this study was to describe the trends in incidence, treatment, and mortality of ankle fracture during a 20-year period.

 Ankle fractures in patients ≥ 18 years old were identified in the Danish National Patient Register using the validated diagnosis and surgical procedure codes for ankle fractures. Incidence rates per 100,000 and incidence rate ratio (IRR) are reported with 95% confidence intervals (CI).

 We identified 155,740 ankle fractures. The overall mean incidence rate during the period 1997-2018 was 164 (CI 163-165) per 100,000 person-years, being 154 (CI 152-155) for men and 203 (CI 202-205) for women. The incidence rate increased from 155 (CI 131-179) during 1997-2006 to 173 (CI 147-199) during 2007-2018, corresponding to an IRR of 1.12 (CI 1.10-1.12). This increase was primarily driven by an increase in women, with an IRR of 1.21 (CI 1.20-1.23) and for patients above 50 years, with an IRR of 1.22 (CI 1.08-1.10). The proportion of patients surgically treated increased from 21% in 1997-2006 to 25% in 2007-2018. The 1-year mortality risk was higher for patients above 65 years with an ankle fracture compared with the general population of the same age, with an IRR of 1.47 (CI 1.42-1.53).

 The incidence of ankle fracture increased from 1997 to 2018, primarily due to an increased incidence in women and in the elderly population. The proportion of surgically treated patients increased from 21% to 26%. Excess mortality after ankle fracture in patients above 65 years was observed.

The medial malleolus is involved in up to 50 % of ankle fractures. When surgery is required, a thorough understanding of bone mass distribution within the distal tibia is crucial for selecting and positioning screws to ensure stable fixation. Despite its clinical significance, data on the bone mass distribution in the distal tibia remains limited.

A total of 892 anonymized computed tomography data sets were analyzed to assess bone mass distribution in the distal tibia. Patients were categorized based on age, sex and stratified into those with normal (Hounsfield units (HU) ≥ 122) and reduced (HU < 122) bone density. Utilizing color-coded thermal maps, bone density and bone mass distribution in the distal tibia was visualized. Subsequently, simulation of potential screw trajectories for medial malleolar fracture treatment were conducted and bone density along those trajectories measured.

Patients exhibiting reduced bone density (n = 442) were significantly older (69 (IQR 60-78)) than those with regular bone density (n = 450) aged (62 (IQR 47-72)) and more often female (p < 0.0001). The highest bone density was located within the proximal one centimeter from the distal tibial articular surface. Another region of dense bone was found at the transition from the distal tibia to the medial malleolus. Bone density was lowest at the distal tibial shaft region beginning at around 30 mm (in females) and 33 mm (in males) from the tip of the medial malleolus.

Our data highlights the areas with the highest bone density in the distal tibia. When fixing medial malleolar fractures with unicortical partially threaded screws, this data suggests that screws with a length between 36 and 41 mm should be used at the anterior colliculus and intercollicular. However, regardless of our findings, fracture morphology must be considered, and the AO principles of fracture fixation should be adhered to.

III.

The three-dimensional evaluation of patients in the gait laboratory is a diagnostic method that is gaining ground in various orthopedic pathologies and, in the case of ankle fractures, can more accurately detail the degree of joint limitation.

To present the importance of laboratory gait studies in the postoperative period of ankle fractures associated with syndesmosis ligament injuries, increasing the arsenal for assessing whether the surgical approach and outcome were satisfactory.

Case series of 13 patients who underwent surgical treatment for ankle fractures associated with syndesmosis injuries, evaluated postoperatively in the gait clinic using the BTS GAITLAB hardware program. Kinetic and kinematic data using a three-dimensional movement system were collected and analyzed.

Alterations were found in the Temporal and Spatial Parameters and in the Statistical Angles of the lower limb joints, comparing the operated limb with the non-operated limb.

The results of the study suggest that, despite subtle variations between the limbs assessed, the program was able to identify these differences in a significant way, demonstrating that gait assessments bring great benefits in understanding biomechanical limitations, and make more effective and individualized rehabilitation protocols possible. Level of evidence IV, Case series.

Isolated distal fibula fractures (DFF) are usually treated with open reduction and internal fixation (ORIF) and non-weight-bearing protocols. The study assessed the outcomes of immediate weight-bearing on DFF healing and stability after lateral locking plating.

For this study, 49 patients affected by isolated DFF were enrolled. They underwent ORIF with a lateral polyaxial locking plate and were allowed immediate weight-bearing with crutches postoperatively. Clinical and radiographic evaluations were performed at 2, 6, and 12 weeks using the AOFAS (American Orthopedic Foot and Ankle Society) score and X-rays evaluations..

Immediate weight-bearing yielded positive outcomes, with a significant increase of the AOFAS score during the clinical re-evaluations. All patients tolerated early and progressive full weight-bearing without complications. Radiographic findings at 12 weeks showed complete bone healing in all cases.

The immediate weight-bearing protocol combined with lateral locking plating resulted in favorable clinical outcomes, accelerated recovery, and successful bone healing for stable DFF cases.

The aim was to assess psychometric properties of Manchester Oxford Foot Questionnaire (MOXFQ), the Self-reported Foot and Ankle Score (SEFAS), the Olerud Molander Ankle Score (OMAS), and the Forgotten Joint Score (FJS) in adults with ankle fractures.

Patients received all four questionnaires 6, 12, 14, 24, 52, and 104 weeks following an ankle fracture. According to COSMIN guidelines, statistical tests were performed to assess floor- and ceiling effects, structural validity, construct validity and reliability. Cognitive interview was performed with 9 patients.

MOXFQ showed best model fit in Confirmatory Factor Analysis. When testing construct validity, all hypotheses were accepted except for OMAS and FJS. All questionnaires had an almost perfect test-retest reliability (Interclass Correlation Coefficient 0.81 to 0.91) and Cronbach's alpha ranged from 0.76 to 0.95. MOXFQ was the best rated questionnaire.

All questionnaires performed well and we recommend MOXFQ for future use in ankle fracture studies.

Level IV.

The traditional classification for lateral malleolus fracture has its limitations. In this study, we introduced a three-dimensional (3D) fracture mapping technique using computed tomography (CT) data to assess fracture line distributions and their impact on patient outcomes, offering a refined classification approach.

Retrospectively, we analysed 97 patients who underwent lateral malleolus fracture surgeries (2014-2019), using CT Digital Imaging and Communications in Medicine data to create 3D models and fracture maps. This methodology refined the Danis-Weber classification and enabled the assessment of fracture severity and syndesmotic stability through clinical scoring.

Danis-Weber type B fractures were predominant (83.5%), showing a distinct pattern. Subtypes were identified based on the bone fragments that are clinically associated with increased injury severity but did not significantly affect syndesmotic stability or prognostic scores.

The 3D fracture map provides a detailed view of fracture characteristics, enabling precise classification. In type B fractures, bone fragments indicating higher trauma do not predict clinical outcomes, thereby supporting personalised surgical planning.

Background Ankle fractures are one of the most common presentations in orthopaedic surgery and represent the third most frequent musculoskeletal injury in the elderly population. Syndesmotic injuries can be associated with ankle fractures, and surgical intervention is critical in these injuries to restore stability and prevent long-term disability. Traditionally, syndesmotic screw fixation has been the standard treatment for acute traumatic syndesmotic injuries, but controversies regarding this fixation method remain. Over recent years, the TightRope system (Arthrex, Florida, US) has gained popularity as a dynamic alternative, offering the advantage of restoring anatomical function while maintaining reduction. The optimal surgical fixation method for managing syndesmotic injuries remains a topic of ongoing debate within orthopaedic practice. Therefore, this study aims to compare the clinical outcomes of these two fixation methods to provide further guidance on their use in managing acute traumatic syndesmotic injuries. Methods A retrospective cohort study was performed for all patients with ankle syndesmotic injuries who underwent surgical fixation using either TightRope devices or syndesmotic screws at Buckinghamshire Healthcare NHS Trust between June 2020 and June 2023, identified through the BlueSpier electronic record system (Bluespier, Droitwich, United Kingdom). Data on demographics and surgical details were extracted from electronic medical records while radiographic images were systematically reviewed to confirm eligibility for inclusion. Clinic letters were also reviewed for complications and reasons for metalwork removal. Results A total of 217 patients met the eligibility criteria for this study, with 132 (61%) females and 85 (39%) males, aged between 13 and 93 years (mean age: 49 years). Of the cohort, 28 (13%) underwent syndesmotic fixation with TightRope devices while 189 (87%) were treated with syndesmotic screws. Metalwork removal was required in 11% of TightRope cases (3 patients) and 28% of syndesmotic screw cases (52 patients). The most common reason for metalwork removal in our study cohort was for broken or loosened screw(s), followed by discomfort and patient preferences. The metalwork removal rates in our study cohort are consistent with those reported in the current literature. Conclusion In conclusion, our study found that the use of TightRope devices is associated with lower removal rates in comparison to syndesmotic screws. This finding is consistent with those reported in the current literature. The most common documented reason for metalwork removal in our study cohort was due to screw breakage or loosening. Although emerging evidence suggests that routine removal of syndesmotic screws may not be necessary, given the lack of consensus regarding the routine removal of syndesmotic screws, decisions for metalwork removal should be tailored by clinical judgement and individual patient needs. Despite its limitations, this study contributes valuable insights into the outcomes and metalwork removal rates associated with syndesmotic fixation methods in the management of acute ankle fractures with syndesmotic injuries.

Implant removal after open reduction and internal fixation (ORIF) of ankle fractures is common. Mini-fragment implants have gained popularity for their smaller size, with studies showing similar load to failure to small-fragment implants. We hypothesized mini-fragment implant use for ORIF of the distal fibula is associated with a lower implant removal rate and without an increase in implant failure.

In this retrospective review study at two level-one trauma centers, adult patients (>18 years) with a lateral malleolar or bimalleolar fracture were included. Chart review was performed to determine if patients received ORIF of the distal fibula with mini-fragment implants or small-fragment implants. The primary outcome was elective implant removal of the fibular plate. Secondary outcomes included complications requiring reoperation.

Five-hundred and five patients were included with a mean age of 50.6 ± 17.8 years old with a mean follow-up of was 75.7 ± 61.0 weeks. Sixty patients (11.9 %) received mini-fragment fixation. The rate of elective distal fibula implant removal for the mini-fragment group was 8.3 % (5 of 60) compared to 10.8 % (48 of 445) in the small-fragment group (p = .66). The complication rate was 6.7 % (4 of 60) for the mini fragment group versus 6.5 % (29 of 445) for the small fragment group (p = 1.00). Logistic regression demonstrated that each additional week of follow-up increased the implant removal rate with the observed odd ratio (OR) of 1.007 (95 % CI 1.002-1.012).

Elective implant removal rates and complications requiring reoperation were similar between mini-fragment and small-fragment fixation of distal fibula fractures. The hypothetical benefit of low-profile mini-fragment implants should be balanced with the higher implant cost.

Bone fractures are a global public health issue and a major source of significant illness and financial hardship. However, to date, there is limited research on patella, tibia or fibula, or ankle fractures (FPTFA) disease burden.

Using the framework of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we conducted temporal trends of disease burden, effects of sex and socio-demographic index (SDI) on age standardized prevalence rate (ASPR) and age-period-cohort model. Machine learning models were built to predict the ASPR of FPTFA in 2035.

In 1990 and 2019, the top three of all fractures with the highest ASPR was FPTFA. Globally, in 2019, there were 13529.45 million (95%UI: 11811.02, 15642.25), 9198.67 million (95%UI: 8518.9, 10009.91) and 77.54 million (95%UI: 34.09, 149.9) prevalent cases of fracture attributable to fall, transport injury and mechanical external force, respectively. The number of fracture prevalence and years lived with disability (YLDs), and ASPR were higher in males than in females. From 1990 to 2019, most of GBD regions showed a downward trend in average annual percent change (AAPC) of ASPR attributable to transport injuries, High-income Asia Pacific had the highest decline (AAPC= -1.81%, 95%CI: -1.89% to -1.74%). However, an upward trend in East Asia was observed (AAPC = 1.60%, 95%CI: 1.48-1.73%). With increasing SDI, the ASPR for FPTFA attributed to the fall and mechanical external force slowly increased and then turned downward, especially in high-income and high-SDI countries. The longitudinal age curve suggested that the attributed rate was increased for the three sites of lower limb fractures. The best predictive models for FPTFA caused by falls, transport injuries and mechanical external force were autoregressive integrated moving average model (ARIMA) (0,2,1), ARIMA (2,0,1) and ARIMA (0,2,2), with R2 of 0.96, 0.78 and 0.94, respectively. By 2035, ASPR for the fall-related FPTFA will continue to rise rapidly, whereas the ASPR of the transport injury-related FPTFA will gradually decrease.

FPTFA attributed to the falls is the dominant type and the burden and trends of the fall-related FPTFA are substantial. Fall prevention and access to treatment are crucial for reducing FPTFA burden.

This study will evaluate the therapeutic effect of pin distractor assisted reduction of fibular fracture on ankle fracture. A retrospective analysis was performed on 98 patients diagnosed as ankle fracture or pilon fracture. These patients were all combined with fibular fracture. Retrospective analysis included 48 patients in the experimental group (distractor assisted reduction) and 48 patients in the control group (without pin distractor). The statistical indexes include: the time spent in fracture reduction and fixation, the length of surgical incision, the operative blood loss of fracture operation, the incidence of incision skin necrosis, the incidence of fracture end splitting during reduction, the quality of fracture reduction, the time of fracture healing, infection rate, and The American Orthopedic Foot and Ankle Society score at the last follow-up. There were statistical differences between the 2 groups in the time spent in the reduction and fixation of fractures, the incidence of fracture end splitting during reduction, the quality of anatomical reduction of fractures, and the healing time of fractures. The experimental group was better than the control group. In addition, for patients with long spiral fracture, comminuted fracture, osteoporotic fracture and preoperative delay time for operation more than 2 weeks, the time spent in the reduction and fixation of fracture, the operative blood loss of fracture operation, the incidence of fracture end splitting during reduction, the quality of anatomical reduction of fracture, and the healing time of fracture in the experimental group are also better than those in the control group. The pin distractor assisted reduction of fibular fracture has the advantages of simple operation, less trauma, short operation time, less operative blood loss, and fewer complications. It is especially suitable for patients with long spiral fibular fracture, comminuted fracture, osteoporotic fracture, and long preoperative delay time in ankle fracture.

Ankle fractures involving the distal fibula are common injuries. Malreductions and subsequent malunions of the distal fibula can result in worse clinical outcomes and posttraumatic arthritis. The ability to accurately evaluate and identify malreductions and malunions of the distal fibula is important. A number of different radiographic and CT measurements have been described to assess fibular length and rotation. This review highlights various radiologic measures and discusses their advantages and limitations.

Ankle fractures are increasingly common in frail patients, with hospitalization being the principal cost driver, particularly for the elderly who often need referral to nursing facilities. This study aims to identify factors affecting resource utilization per admission (hospital and nursing) in the fixation of low-energy ankle fractures.

This retrospective cohort study examined patients undergoing fixation for low-energy ankle fractures. The primary outcome was the length of hospitalization. Secondary outcomes included delays in fixation and the need for referral to a nursing institution. Multiple linear and logistic regression models were used to determine predictors related to patient demographics, injury characteristics, and treatment.

We analyzed 651 patients with a median age of 58years. The median hospitalization duration was 9days, primarily before surgery. Extended hospitalization was associated with antithrombotic treatment (b=4.08), fracture-dislocation (2.26), skin compromise (7.56), complications (9.90), and discharge to a nursing center (5.56). Referral to a nursing facility occurred in 17.2%, associated with older age (OR=1.10) and an ASA score ≥III (6.96).

Prolonged hospitalization was mainly due to surgical delays and was related to fracture-dislocations, skin compromise, and complications. Older and comorbid patients were more likely to need nursing facilities, and delays in these facilities' availability contributed to extended hospital stays.

Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).

The effects of preoperative depression following ankle fracture surgery remains unknown. The purpose of this study is to investigate the relationship between preoperative depression and outcomes following ankle fracture surgery.

This retrospective study used the Truven MarketScan database to identify patients who underwent ankle fracture surgery from January 2009 to December 2018. Patients with and without a diagnosis of preoperative depression were identified based on International Classification of Diseases (ICD) codes. Chi-squared and multivariate analyses were performed to determine the association between preoperative depression and postoperative complications following ankle fracture surgery. Results. In total, 107,897 patients were identified for analysis, 13,981 of whom were diagnosed with depression (13%). Preoperative depression was associated with the increased odds for postoperative infection (odds ratio [OR]: 1.33, confidence interval [CI]: 1.20-1.46), wound complications (OR: 1.13, CI: 1.00-1.28), pain-related postoperative emergency department visits (OR: 1.58, CI: 1.30-19.1), 30-day and 90-day readmissions (OR: 1.08, CI: 1.03-1.21 and OR: 1.13, CI: 1.07-1.18), sepsis (OR: 1.39, CI: 1.12-1.72), and postoperative development of complex regional pain syndrome (OR: 1.46, CI: 1.18-1.81).

Preoperative depression is associated with increased complications following ankle fracture surgery. Further studies are warranted to investigate the degree to which depression is a modifiable risk factor.

3.

Introduction A trimalleolar fracture is a complex unstable fracture that usually occurs as the result of rotational injuries of the ankle. Management and understanding of these fractures have evolved greatly over the last decade. Our study aimed to assess the postoperative outcomes following the fixation of these fractures using fragment-specific low profile anatomical fixation implants. Methods We retrospectively analyzed patients admitted to our multidisciplinary team unit with a trimalleolar fracture between October 2021 and February 2024. Each fracture was classified using CT imaging and subsequently fixed using fragment-specific implantation (VolitionTM). In the postoperative period, patients were followed up and assessed functionally and radiologically. Results A total of 40 skeletally mature patients were included in this study, each requiring surgical fixation for a tri-malleolar ankle fracture. Patient-reported outcome data collected showed an average Manchester-Oxford Foot Questionnaire (MOXFQ) score of 34.3 (±24.6) and a Foot and Ankle Disability Index (FADI) score of 77.9 (±22.1). All but one fracture successfully achieved radiological union with a mean time to union of 7.4 weeks (5-16 weeks). Conclusions Our study is an early demonstration of the promising results that can be observed through the use of fragment-specific low-profile anatomical fixation. Further comparative studies would provide a further understanding of the effectiveness.

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications.

Background: The effect of tibial fixation on the movement of the talus during the tibiotarsal axial traction technique (TATT) is unknown. The aim was to evaluate the effect on the tibiotarsus when applying three different intensities of TATT force with or without tibial fixation in healthy subjects, and to assess the reliability of detecting the different forces applied. Also, the discomfort generated during the technique would be analysed. Methods: A cross-sectional study was conducted in thirty lower limbs. Three magnitudes of TATT force in an open-packed position were applied in tibial fixation and non-fixation conditions. The axial traction movement was measured by ultrasound, and the magnitudes of the force applied during low-medium and high TATT force were recorded in both conditions. Patients were asked about the level of discomfort perceived during the technique. Results: The most significant distance increase (mm) was observed in the tibial fixation condition at all magnitudes of the TATT (F = 102.693, p < 0.001). The discomfort sensation (numeric rating scale, "NRS") was higher in the non-fixation condition (p > 0.05). The application of the technique showed good reliability (>0.75 ICC) for the detection of the applied force. Conclusions: The TATT in the tibial fixation condition produced more significant axial movement of the talus (mm) relative to the tibia than the non-tibial fixation condition did. The detection of the magnitudes of movement showed good reliability (ICC: 0.75 to 0.92). The technique was well tolerated at all force magnitudes, with the tibial fixation condition being the most tolerable.

Although shear-wave elastography (SWE) can be used to assess muscle stiffness, SWE assessments are expensive. Echo intensity (EI) is an indicator of muscle quality and can potentially be used to assess muscle stiffness. This study aimed to determine the relationship between the EI and Young's modulus of the soleus (SOL) muscle after ankle fracture surgery.

Eighteen participants who had undergone ankle fracture surgery were evaluated (mean age: 48.8 ± 20.6 years). Three months post-surgery, Young's modulus and EI of the SOL muscle were measured using SWE and the combination of B-mode ultrasound and ImageJ software, respectively. EI and Young's modulus measurements were obtained with the participant kneeling with knees bent 90°, upper body supported on a table, and ankles dorsiflexed 10°. The regions of interest used to measure EI and Young's modulus were identical. The EI value corrected for the subcutaneous fat thickness was also calculated. Pearson's correlation coefficients were calculated to examine the relationship of Young's modulus with the uncorrected and corrected EI.

Although the uncorrected EI was correlated with Young's modulus of the SOL muscle (r = 0.567; p = 0.014), the corrected EI showed a stronger correlation (r = 0.637; p = 0.005). High intra-rater was also found reliability for the EI and Young's modulus measurements of the SOL muscle in participants after ankle fracture surgery.

The EI and Young's modulus of the SOL muscle were positively correlated. In particular, the corrected EI showed a stronger correlation with Young's modulus than the uncorrected EI. Clinically, EI measurements may facilitate objective evaluation of muscle stiffness.

Although the ankle is often involved in low energy trauma, high-energy trauma may occur, being this considered more serious and more common of affecting young and active men. The purpose of the present study was to evaluate and compare the functionality, pain and quality of life of active and inactive adult individuals whose ankle fracture was surgically treated. Seventy-six patients split into two groups (active, n = 58 X inactive, n = 18), of the men (active, n = 38; inactive, n = 9) and women (active, n = 20; inactive, n = 9) gender participated in this prospective study. The IPAQ, MMSE, SF-36, VAS, sociodemographic and clinical questionnaires were applied in person right after surgery. The SF-36 and VAS questionnaires were reapplied 3 months in average after the surgery. Active and inactive patients of both genders show significant differences (p ≤ 0.05) in the functional capacity and physical aspect domains; and the bodily pain domain revealed significant difference in active and inactive men (p ≤ 0.05) between the periods post-surgical and 3 months after surgery (on average). Moderate and significant correlations were found (p ≤ 0.05) between functional capacity, physical aspect and bodily pain domains of the SF-36 and the VAS pain scores for active and inactive patients of both genders in the final follow-up period. Other significant correlations (p < 0.05) for inactive men (physical aspect and bodily pain) and inactive women (functional capacity and bodily pain) are observed (after 3 months of surgery). Three months after surgery (on average), active and inactive men had functional limitations and pain symptoms. These factors seem to have negatively influenced the patient's social involvement, worsening their quality of life. Most active and inactive patients had a positive self-perception of their general health status, emotional aspects and mental health domains. Regarding active women, we observed lower energy and vitality after the same postoperative period.

Orthopedic injuries to the foot constitute a significant portion of lower extremity injuries, necessitating an understanding of trends for effective preventive strategies and resource allocation. Demographic shifts, improved traffic safety, and lifelong physical activity may alter incidence rates, trauma mechanisms, and fracture distribution. This study explores the prevalence of foot fractures in Sweden using publicly available data.

Utilizing data from the Swedish National Board of Health and Welfare (SNBHW) spanning 2008-2022, retrospective study focuses on foot fractures in Sweden. Analysis includes calculating annual incidence rates per 100,000 person-years, assessing temporal trends, and exploring seasonal variations. Poisson regression analysis was used for projections into 2035.

Between 2008-2022, the average annual foot fracture incidence was 11,942, with notable fluctuations influenced by the COVID-19 pandemic. Age and sex disparities impact rates, and seasonal variance highlights increased incidence in summer. By 2035, foot fractures will decreasae amongst several demographic groups.

This study provides insights into temporal trends, sex differences, and seasonal variations foot fracture patterns in Sweden. The identified trends suggest the utilization of targeted preventive strategies, efficient resource allocation, and informed healthcare planning. Despite limitations, this research offers valuable insights into foot fractures within the Swedish population, utilizing publicly aggregated data.

Existing primary evidence comparing fibular intramedullary fixation (IMF) with traditional plate fixation (PF) for the treatment of distal fibular fractures remains limited by modest sample sizes. Using a large national database, this study aims to compare use rates, fracture patterns, patient characteristics, time to surgery, complication rates, and cost between fibular IMF and PF within the United States. Adults treated with fibular IMF or PF between October 2015 and October 2021 were identified within the PearlDiver Database. The ratio of IMF-treated to PF-treated patients was tracked temporally to compare use rates. Fracture patterns were determined using fracture diagnoses within one-month preceding surgery. Further comparisons of IMF- and PF-treated groups only included patients with at least 12 months of follow-up, and patients with upper tibia or tibia shaft fractures were excluded. An analysis of cohorts matched at a 1 : 4 (IMF: PF) ratio to control for risk factors was performed to compare time to surgery, complication rates (infection, nonunion, malunion, revision, hardware removal, pulmonary embolism, and deep vein thrombosis), and cost. 39329 patients (2294 IMF and 37035 PF) were identified. IMF use trended upwards relative to PF use over time. Tibia and fibula shaft fractures were the most common injuries in IMF patients versus bimalleolar and trimalleolar fractures in PF patients. A higher proportion of IMF patients had open fractures. IMF patients were younger, with higher mean ECI, fewer female patients, and higher rates of CKD. Percutaneous approaches were more common among IMF patients. There were no significant differences in time to surgery or complication rates. IMF was less costly. The popularity of IMF trended upwards across the study period. IMF was used more commonly in injuries involving higher energy trauma and soft tissue disruption. Overall, IMF patients were younger with more comorbidities. When used in similar populations, IMF appears to be a cost-effective alternative to PF.

Background Applying topical vancomycin has shown a decrease in the likelihood of surgical site infections (SSIs) in surgeries linked to a heightened risk of severe and resistant infections. Nevertheless, the effectiveness of this prophylactic approach has not been assessed in open ankle surgeries with internal fixation. Objective This study aimed to assess whether topical vancomycin diminishes the risk of SSI in patients with ankle fractures undergoing open reduction with internal fixation. Methods A randomized, controlled, double-blind clinical trial was carried out. Patients were divided into two groups in a 1:1 ratio. The control group received the standard prophylactic treatment with IV cephalothin 1 g, while the intervention group was administered topical vancomycin (1 g) in addition to the standard prophylactic treatment. The main outcomes were the SSI rates at 14 days, 28 days, and three months post-surgery, based on relevant clinical signs and laboratory tests. Results One hundred thirty-two patients were randomized (51.2% female), with 66 subjects included in each intervention arm. A total of 97.7% of them completed the study. Both groups were homogeneous in baseline characteristics. There were two SSIs in both the vancomycin group (3.3%) and the control group (3.5%), with no statistical differences (p = 0.945). The microorganisms isolated as causal agents were Staphylococcus aureus and Acinetobacter baumannii. By the three-month follow-up, no infections were noted in both intervention groups. Conclusion These results indicate that the topical administration of vancomycin may not represent an advantage in preventing SSI in ankle fractures requiring open reduction with internal fixation at the three-month postoperative stage.

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

In total, 663 patients of median age 59 years were analyzed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR=1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

Rotational ankle fractures are common, have diverse personalities and affect both robust and fragile patients. Postoperative complications are frequent, creating a sizeable economic burden. The primary purpose of this study was to expand current knowledge on predictors of postoperative complications after low-energy ankle fracture fixation.

A retrospective single-center cohort study was completed of patients undergoing internal fixation OF low-energy ankle fractures. The primary outcome was first-year postoperative complications, classified as major (surgical) or minor (non-surgical). Data on patients, their injuries, and treatments were collected. To identify potential predictors of outcomes, logistic regression methods were used, with a backward-stepwise method used for model fitting.

In total, 663 patients of median age 59 years were analysed. We found a high rate of complications (28.4%), with wound-healing issues and infections predominant. Overall, 14.8% had minor complications, while 13.6% required an unplanned reoperation. On multivariable analysis, the most consistent predictors of complications were older age (OR: 1.02 per year), longer operating time (3.32 per hour), and smoking (2.91).

Older patients and smokers who sustain fractures requiring more complex surgery are at higher risk of postoperative complications.

Ankle fractures are one of the more common musculoskeletal injuries that are treated by foot and ankle specialists. A thorough understanding of managing these injuries requires the ability to differentiate between stable and unstable fractures. The current literature supports the nonoperative management of stable Weber B ankle fractures, whereas unstable fractures have much better outcomes with surgical intervention. Specifically, we review the fixation strategies for the lateral, medial, and posterior malleolar fractures respectively. Finally, we discuss the current trends in postoperative management of some of the more common fracture patterns, and the safety in early weight-bearing protocols.

Ankle fractures are frequent, and despite numerous publications on their treatment and outcome, there is a lack of precise data on the functional results in young, healthy and physically active patients. We hypothesized that patients who underwent open reduction and internal fixation (ORIF) for simple ankle fractures would have similar function compared to a healthy control group, whereas patients with complex fractures will have significant functional deficits. Furthermore, we postulate that there is a discrepancy between the radiological and the functional outcomes.

A set of specific provocation tests was developed to evaluate the postoperative possibility of weight bearing, stop-and-go activities and range of motion. In combination with three questionnaires and a radiographic evaluation, the true functional outcome and the possibility of participating in sporting activities were investigated and compared with those of an age- and sex-matched control group.

A significant impairment was found in unilateral and simple ankle fractures. This impairment increased in tests including stop-and-go activities in combination with load bearing and with the complexity of the fractures. Concerning the subjective outcome, there was a significant adverse effect for daily activities without any difference in preoperative or postoperative sporting activity between the groups. No difference was found in the radiological assessment.

Both simple and complex ankle fractures treated with ORIF have a significant and long-lasting impact on functional outcome in young and active patients. The radiological result is not associated with a good functional outcome.

BASEC-Nr. 2018 - 01124.

Uncertainty regarding the timing of weight bearing following ankle open reduction internal fixation (ORIF) in patients with different ankle fracture patterns remains. Traditional rehabilitation methods, including six weeks of non-weight bearing (NWB), is still a common approach in many hospitals, while some previous evidence has shown immediate weight bearing (IWB) to be beneficial.

32 adult participants with unimalleolar, bimalleolar or trimalleolar ankle fractures and stable fixation following ankle ORIF will be randomly allocated to either Immediate Weight Bearing (IWB) or Delayed Weight Bearing (DWB) groups. Stability of fixation is a subjective assessment made by the operating surgeon at the completion of fixation and is independent of fracture pattern. Participants in the IWB group will be allowed to weight bear as tolerated within 24 h, while participants in the DWB group will remain non-weight bearing for six weeks. Participants' data including Olerud and Molander Ankle Score, Self-Reported Foot and Ankle Score, SF-36 health survey, time to return to work will be collected. X-rays will be assessed by orthopaedic team members for fixation-related complications including reduction loss, malreduction/malunion, implant failure and non-union. Participants data will be collected at six weeks, three and six-months post-surgery. We will determine the feasibility of a full RCT through assessing the recruitment rate, adherence rate, and drop-out rate.

Not applicable.This pilot RCT will endeavour to optimise standard rehabilitation protocols post ankle ORIF.

Patient-reported outcome measures (PROMs) following ankle fractures, including all fracture types, have not been reported. It is therefore unclear whether fracture morphology correlates with outcome. We aimed to analyze PROMs in patients with an ankle fracture in relation to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification using population-based register data from the Swedish Fracture Register (SFR).

All patients aged ≥ 18 years with an ankle fracture (AO/OTA 44A1-C3) registered in the SFR between 2012 and 2019 were retrieved from the register. Patients with completed PROM questionnaires (Short Musculoskeletal Function Assessment and EuroQol-Visual Analogue Scale) on both day 0 (pre-trauma) and 1-year post-trauma were included. The difference in PROMs between day 0 and 1 year was calculated for each patient (delta value) and mean delta values were calculated at group level, based on the AO/OTA fracture classification.

11,733 patients with 11,751 fractures with complete PROMs were included. According to the AO/OTA classification, 21% were A fractures, 67% were B fractures and 12% were C fractures. All groups of patients, regardless of fracture class (A1-C3), displayed an impairment in PROMs after 1 year compared with day 0. Type C fractures displayed a larger impairment in PROMs at group level than type B, which in turn had a greater impairment than type A. The same pattern was seen in groups 3, 2, and 1 for A and B fractures.

We found that the AO/OTA classification is prognostic, where more complex fractures were associated with poorer PROMs.

The high occurrence of distal fibula fractures among older women suggests a potential link to impaired bone health. Here we used a multiscale imaging approach to investigate the microarchitecture, mineralization, and biomechanics of the human distal fibula in relation to age and sex. Micro-computed tomography was performed to analyze the local volumetric bone mineral density and various microarchitectural parameters of the trabecular and the cortical compartment. Bone mineral density distribution and osteocyte lacunar parameters were quantified using quantitative backscattered electron imaging in periosteal, endocortical, and trabecular regions. Additionally, cortical hardness and Young's modulus were assessed by nanoindentation. While cortical porosity strongly increased with age independent of sex, trabecular microarchitecture remained stable. Notably, nearly half of the specimens showed non-bony hypermineralized tissue located at the periosteum, similar to that previously detected in the femoral neck, with no consistent association with advanced age. Independent of this finding, cortical and trabecular mineralization, i.e., mean calcium content, as well as endocortical tissue hardness increased with age in males but not females. Importantly, we also observed mineralized osteocyte lacunae that increased with age specifically in females. In conclusion, our results indicate that skeletal aging of the distal fibula is signified not only by pronounced cortical porosity but also by an increase in mineralized osteocyte lacunae in females. These findings may provide an explanation for the increased occurrence of ankle fractures in older women.

Background The repair of trimalleolar fractures can be challenging for surgeons and may be managed as an inpatient or an outpatient. However, it is often unclear whether these patients should be admitted immediately or sent home from the emergency department (ED). This study aims to evaluate trimalleolar fractures treated surgically in the inpatient or outpatient settings to evaluate differences in outcomes for these patients. Methods A retrospective chart review of 223 patients undergoing open reduction internal fixation of a trimalleolar ankle fracture was performed from January 2015 to August 2022. Patients were classified by whether the fixation was performed as an inpatient or outpatient. Outcomes of interest included time from injury to surgery, complications, ED returns, and readmissions within 90 days. Results Inpatients had significantly higher ASA scores, BMI, and rates of comorbidities. Inpatient treatment was associated with faster time to surgery (median 2.0 vs. 9.0 days) and fewer delayed surgeries more than seven days from injury (18.4 vs. 67.9%). There were no differences in complications, 90-day ED returns, readmissions, or reoperation between groups. Conclusions Inpatient admission of patients presenting with trimalleolar ankle fractures resulted in faster time to surgery and fewer surgical delays than outpatient surgery. Despite having more preoperative risk factors, inpatients experienced similar postoperative outcomes as patients discharged home to return for outpatient surgery. Less restrictive admission criteria may improve the patient experience by providing more patients with support and pain control in the hospital setting while decreasing the time to surgery.

The standard surgical procedure for unstable ankle fractures is fixation of the lateral malleolus with a plate and screws. This method has a high risk of complications, especially among patients with fragile skin conditions. The aim of this study was to estimate the re-operation rates and identify complications in patients with an unstable ankle fracture, surgically treated with an intramedullary screw or rush pin.

We identified all patients who were surgically treated with either a 3.5-mm screw or rush pin at Aarhus University Hospital, Denmark, from 2012 to 2018. Major complications were re-operations within three months. We included 80 patients, of which 55 (69%) were treated with a 3.5-mm intramedullary screw and 25 (31%) with a rush pin. The majority of the study population was female (59) and the mean age was 75 (range 24 to 100) years. Of the 80 patients included, 41 patients had more than 2 comorbidities.

Three patients underwent re-operation within three months due to either fracture displacement or hardware cutout. Radiographs obtained after six weeks showed that nine patients had loss of reduction. Additionally, four patients had superficial wound infections and six patients had delayed wound healing.

Intramedullary fixation of distal fibula fractures with either a screw or rush pin has low re-operation rates. However, the high proportion of patients with radiological loss of reduction is concerning.

Early mobilization following ankle fracture open reduction and internal fixation (ORIF) improves long-term patient functionality. Because of this, numerous resources have been spent to increase patient adherence to post-operative mobilization, with range of motion (ROM) measurements generally considered an important outcome in patient recovery. In this study we investigated how ankle ROM correlates to patient function, self-sufficiency in performing activities of daily living (ADLs), and pain in the early post-operative period.

This was a prospective, observational study on patients undergoing ORIF of ankle fractures. We collected patient reported outcome measures (PROMs) and ROM measurements at the 2-week, 6-week, 12-week, and 6 month post-operative visit. We collected three PROMs: pain intensity (VAS), pain self-efficacy questionnaire (PSEQ-2), and foot and ankle ability measurement (FAAM). ROM of the ankle was measured by goniometer. ANOVA and post-hoc Tukey tests were used to examine statistical differences in PROMs over time. Pearson correlation tests were used to examine the association between ROM and PROMs.

One-hundred and twenty-three participants enrolled in this study in the perioperative period. Pain intensity was higher at enrollment compared to week 6 (post-hoc p = 0.006), after which pain intensity did not differ significantly. FAAM scores for activities or daily living (ADL) were increased at all study visits compared to enrollment (post-hoc p < 0.001). FAAM-Sports scores were higher compared to enrollment at the week 12 and 6 month visits (post-hoc p < 0.001). No significant improvements in goniometer measurements were noted across any timepoints. There were no significant correlations between ROM and PROMs at any of the study visits.

In our cohort of patients, there was no correlation between ROM and patient pain, self-efficacy or functionality in the early post-operative period following ankle ORIF. The lack of correlation between PROMs and ROM indicates that ROM may be both a poor indicator of patient improvement for physicians to guide post-operative treatment as well as a poor motivator for patient adherence to post-operative exercises. In the future, it is important to study reliable outcome measures in early recovery that can be utilized to track patient recovery from ankle ORIF.

Ankle fractures are prevalent injuries that necessitate precise diagnostic tools. Traditional diagnostic methods have limitations that can be addressed using machine learning techniques, with the potential to improve accuracy and expedite diagnoses.

We trained various deep learning architectures, notably the Adapted ResNet50 with SENet capabilities, to identify ankle fractures using a curated dataset of radiographic images. Model performance was evaluated using common metrics like accuracy, precision, and recall. Additionally, Grad-CAM visualizations were employed to interpret model decisions.

The Adapted ResNet50 with SENet capabilities consistently outperformed other models, achieving an accuracy of 93%, AUC of 95%, and recall of 92%. Grad-CAM visualizations provided insights into areas of the radiographs that the model deemed significant in its decisions.

The Adapted ResNet50 model enhanced with SENet capabilities demonstrated superior performance in detecting ankle fractures, offering a promising tool to complement traditional diagnostic methods. However, continuous refinement and expert validation are essential to ensure optimal application in clinical settings.

Anterior ankle impingement syndrome (AAIS) has been reported to account for a high percentage of complications following ankle fracture surgery. The soft tissue etiology of AAIS is thought to be thickening and inflammation of the anterior ankle soft tissues intervening anteriorly at the tibiotalar joint, causing pain and functional limitation during dorsiflexion. However, the effects of anterior ankle soft tissue dynamics and stiffness on AAIS have yet to be clarified. This study aimed to determine the relationship between AAIS and the anterior ankle soft tissue thickness change ratio and shear modulus using ultrasonography (US). The participants were 20 patients with ankle joint fractures (AO classification A, B) who had undergone open reduction and internal fixation and 20 healthy adults. The evaluation periods were 3 months and 6 months postoperatively. US was used to delineate the tibialis anterior tendon, extensor hallucis longus tendon, and the extensor digitorum longus tendon over the talus and tibia on a long-axis image. Anterior ankle soft tissue thickness was measured as the shortest distance from the most convex part of the talus to the tendon directly above it. The Anterior ankle soft tissue thickness change ratio was determined by dividing the value at 0° dorsiflexion by the value at 10° plantarflexion. The same images as for the anterior soft tissue thickness measurement were drawn for the shear modulus measurement, and the average shear modulus (kPa) was calculated using shear-wave elastography. There was no significant difference in the thickness change ratio between the postoperative and healthy groups. Compared with the healthy group, the shear modulus was significantly higher at 3 and 6 months in the postoperative group (p < 0.01). The shear elastic modulus at 6-month postoperative group was significantly lower than at 3-month postoperative group (p < 0.01). Anterior ankle joint soft tissue stiffness may increase after surgery for an ankle fracture.