In minimally displaced Weber B ankle fractures, the distal fibular fracture fragment can be externally rotated. This malrotation is difficult to detect on radiographs and, when left malreduced through nonoperative treatment, may contribute to altered joint mechanics, predisposing to posttraumatic osteoarthritis. This study evaluates the effects of fibular malrotation on tibiotalar joint contact mechanics.

Six cadaveric ankles were tested using a materials testing system (MTS) machine. A tibiotalar joint sensor recorded contact area and pressure. Samples were tested in the intact, neutrally rotated, and malrotated state. Each trial applied a 686N axial load and a 147N Achilles tendon load in neutral position, 15° dorsiflexion, and 15° plantarflexion.

In the comparison of malrotated to intact ankles, peak contact pressure was found to be significantly greater at neutral flexion (intact 5.56 MPa ± 1.39, malrotated 7.21 MPa ± 1.07, P = .03), not significantly different in dorsiflexion, and significantly decreased in plantarflexion (intact 11.2 MPa ± 3.04, malrotated 9.01 MPa ± 1.84, P = .01). Significant differences in contact area were not found between conditions.

The findings suggest that fibular malrotation contributes to significant alterations in tibiotalar joint contact pressures, which may contribute to the development of posttraumatic osteoarthritis. When malrotation of the fibula is suspected on plain radiographs, a computer tomography (CT) scan should be obtained to evaluate its extent and further consideration should be given to surgical treatment.

Level V: Bench testing.

A 17-year-old girl sprained her left ankle and was diagnosed with a lateral malleolar fracture. She was treated conservatively for six months but had medial ankle pain with activity. Imaging revealed an oblique lateral malleolar fracture, with posterolateral displacement and partial fusion of the bone fragments, and bone marrow edema on the medial articular surface of the talus and medial malleolus. We diagnosed ankle instability due to delayed union with a displacement of the lateral malleolus, which caused an osteochondral lesion. We performed arthroscopic and open surgery eight months after the injury, reducted the lateral malleolus anatomically, and fixed it with a plate. Postoperatively, the pain improved rapidly, and the bone marrow edema had almost disappeared on an MRI. In this case, we think rotational instability of the ankle mortise caused abnormal pressure and continuous stress on the medial malleolus after injury, which may have contributed to persistent medial ankle pain.

The purpose of this study was to apply both the fragility index (FI) and fragility quotient (FQ) to evaluate the degree of statistical fragility in the distal fibular fracture (DFF) literature. We hypothesized that the dichotomous outcomes within the DFF literature are statistically fragile.

We performed a PubMed search for distal fibular fractures clinical trials from 2000 to 2022 reporting dichotomous outcomes. The FI of each outcome was calculated through the reversal of a single outcome event until significance was reversed. The FQ was calculated by dividing each fragility index by study sample size. The interquartile range (IQR) was also calculated for the FI and FQ.

Of the 1158 articles screened, 23 met the search criteria, with six RCTs included for analysis. Forty-five outcome events with 5 significant (p < 0.05) outcomes and 40 nonsignificant (p ≥ 0.05) outcomes were identified. The overall FI and FQ was 5 (IQR 4-6) and 0.089 (IQR 0.061-0.107), respectively.

The randomized controlled trials in the peer-reviewed distal fibular fracture literature may not be as robust as previously thought, as incorporating statistical analyses solely on a P value threshold is misleading. Standardized reporting of the P value, FI and FQ can help the clinician reliably draw conclusions based on the fragility of outcome measures.

The goal of open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is to reconstitute ankle anatomy. The most commonly used radiological parameters to assess adequacy of reduction are talocrural angle (TCA), medial clear space (MCS), tibiofibular overlap (TFO) and tibiofibular clear space (TFCS). There is little research about the radiological outcomes of surgery in bimalleolar fractures. We aimed at assessing the adequacy of ORIF and the factors involved in anatomical restoration (specifically time to surgery), postoperatively and at follow-up.

TCA, MCS, TFO and TFCS were measured in preoperative and postoperative radiographs of 107 bimalleolar ankle fractures and in 83 follow-up radiographs, accounting for a total of 297 radiographs and 1182 measurements. Preoperative radiographs were categorized according to Danis-Weber classification. For all included cases, basic demographic data, dates of radiographs and surgery, and type of fixation used were acquired. Variables associated with postoperative and follow-up total anatomical reconstitution (i.e., when the four assessed radiological parameters were normalized), normalization of each radiological parameter, and improvement in the number of normalized radiological parameters were identified through univariable Cox regression analysis.

In our sample, 23.8% of the ankle fractures in postoperative radiographs and 28% in follow-up radiographs achieved a complete anatomical restoration. Type C fractures (hazard ratio [HR]=0.1, 95% confidence interval [CI]=0.02-0.7, P=0.021) were associated with lower chances of total anatomical reconstitution. The use of reconstruction plates (HR=0.1, 95% CI=0.03-0.7, P=0.014) and one third tubular plates (HR=0.2, 95% CI=0.03-0.8, P=0.026) decreased the chances of improving the number of normalized radiological parameters. Waiting days until surgery impaired total anatomical reconstitution (HR=0.8, 95% CI=0.6-0.9, P=0.012) and also reduced the chances of improving the number of normalized radiological parameters (HR=0.9, 95% CI=0.9-1.0, P=0.045).

The radiological results for the treatment of bimalleolar fractures are time sensitive, and surgery should thus be performed as soon as possible, using adequate fixation materials, in order to achieve a better restoration of ankle anatomy.

IV, retrospective study.

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

An unsatisfactory reduction and internal fixation of an ankle fracture can result in an alteration of the anatomical axes and distribution of the load on the ankle, with consequent development of chronic pain and articular degeneration. The aim of this study is to evaluate the results of the articular re-balancing with realignment and lengthening of the fibula in case of malunited distal fibular fractures.

A review of prospectively collected data was performed for all patients with a diagnosis of malunion of the fibula and underwent ankle joint re-balancing with fibular lengthening. Twenty-three patients, with a mean age of 39.4 ± 13.1 years, have been evaluated using radiographic parameters, American Orthopaedic Foot and Ankle Surgeons ankle-hindfoot, Ankle Activity scale, and SF-36 score at six, 12, 24, and 36 months post-operatively.

All cases treated showed at follow-up the osteotomy healed in good correction of the deformities. Clinical scores showed a clear improvement: final 36-month mean AOFAS was 74.0 ± 8.9 point, final 36-month mean HALASI score was 4.9 ± 0.9 points, 36-month follow-up SF-36 score showed an average score of 73.2 ± 10.7 points. Pre- and post-operative radiographic parameters have been registered and described.

The ankle joint is a complex structure, and even minor changes of the structure of this joint can significantly compromise its functionality. Ankle joint re-balancing is an effective surgical procedure in case of fibular malunion. This procedure, in patients carefully selected, could procrastinate more disabling surgical procedure, as arthrodesis or prosthesis.

The medial collateral ligament (MCL) complex is characterized by a complex anatomical arrangement of the individual ligamentous structures including three joints and the spring ligament complex. Biomechanically it serves as the main stabilizing structure in the ankle region against rotational and pronating forces. Lesions in the region of the MCL complex are more frequent than previously thought and like lesions of the spring ligament complex can lead to pain and instability. A thorough examination including the patient history with possible injury mechanisms often yields valuable information on the diagnosis of injuries to the MCL or spring ligament complex. In many cases these are primarily overlooked and concomitant lesions, such as fractures, syndesmotic and lateral ligament lesions frequently occur; however, the clinical assessment of stability is often primarily impossible in an acute setting. High-resolution magnetic resonance imaging (MRI) plays a key role in identifying the ligamentous components. In addition, MRI plays a supportive role in the preoperative planning before reconstruction of acute and especially chronic lesions. In most cases the surgical treatment of acute ruptures of the MCL is not indicated. Various options for treatment of acute and chronic lesions of the MCL and spring ligament complex are available including the use of free tendon grafts. Controversy exists regarding the operative treatment of MCL lesions in the case of ankle fractures. It is recommended for cases with impinging tissue in the medial gutter serving as a barrier to adequate reduction of the joint and in cases of unstable fractures after reduction.

This study aimed to identify factors from standard radiographs that contributed to the stability of the ankle mortise in patients with isolated supination-external rotation fractures of the lateral malleolus (OTA/AO 44-B).

Non-stress radiographs of the mortise and lateral views, without medial clear space widening or incongruity, were prospectively collected for 286 consecutive patients (mean age, 45 years [range, 16 to 85 years]), including 144 female patients (mean age, 50 years [range, 17 to 85 years]) and 142 male patients (mean age, 40 years [range, 16 to 84 years]) from 2 trauma centers. The radiographs were analyzed for fracture morphology by 2 orthopaedic surgeons, who were blinded to each other's measurements and to the results of external rotation stress radiographs (the reference for stability). Factors significantly associated with ankle mortise stability were tested in multiple logistic regression. Receiver operating characteristic analyses were performed for continuous variables to determine optimal thresholds. A sensitivity of >90% was used as the criterion for an optimal threshold.

According to external rotation stress radiographs, 217 patients (75.9%) had a stable injury, defined as that with a medial clear space of <5 mm. Independent factors that predicted stable ankle mortise were female sex (odds ratio [OR], 2.5 [95% confidence interval (CI), 1.4 to 4.6]), a posterior diastasis of <2 mm (corresponding with a sensitivity of 0.94 and specificity of 0.39) on lateral radiographs (OR, 10.8 [95% CI, 3.7 to 31.5]), and only 2 fracture fragments (OR, 7.3 [95% CI, 2.1 to 26.3]). When the posterior diastasis was <2 mm and only 2 fracture fragments were present, the probability of a stable ankle mortise was 0.98 for 48 female patients (16.8%) and 0.94 for 37 male patients (12.9%).

Patients with noncomminuted lateral malleolar fractures (85 patients [29.7%]) could be diagnosed with a stable ankle mortise without further stress testing, when the fracture line widths were <2 mm on lateral radiographs.

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operative fixation of medial malleolar fractures, whether isolated or in the setting of bi- or trimalleolar fractures, remains controversial. Increasingly, anatomic reduction and internal fixation is used to treat medial malleolar fractures to avoid long-term sequelae of symptomatic nonunion and posttraumatic osteoarthritis. However, outcomes have not been significantly different between operative and nonoperative cohorts. Repair of associated deltoid ligament disruption is not common because of reportedly poor outcomes. This review provides an overview of the literature on medial malleolar fracture fixation and current treatment options. [Orthopedics. 2017; 40(2):e216-e222.].

Stability of isolated Weber B ankle fractures can be difficult to determine. Using weight-bearing radiographs, a reliable method to determine the stability of isolated Weber B ankle fractures is described.

A retrospective review of prospectively gathered data was performed. Weber B ankle fractures were defined as stable when having a medial clear space (MCS) of <7 mm on initial gravity stress radiographs and a normal mortise relationship on weight-bearing radiographs. Fifty-one patients meeting these criteria were treated nonsurgically with protected weight bearing and serial radiography for 1 year.

Average functional score results were: American Orthopaedic Foot and Ankle Society Hindfoot, 93.2; Foot and Ankle Ability Measure for Activities of Daily Living, 93.2; Olerud-Molander Ankle Score, 91.0; and visual analog scale pain score, 0.57. Despite a mean gravity stress MCS of 4.42 mm, no patient demonstrated subsequent MCS widening. Mean MCS on 1-year follow-up weight-bearing radiographs was 2.64 mm.

Weight-bearing ankle radiographs are predictive of stability in isolated Weber B ankle fractures. Gravity stress radiographs using traditional measurement criteria may overestimate instability in these injuries. Nonsurgical treatment with protected weight bearing shows good early outcomes.

IV.

This prospective diagnostic study assessed the utility of MRI (magnetic resonance imaging) findings for the deep aspect of the deltoid ligament in evaluating the stability of the ankle mortise in patients who have an SER (supination-external rotation)-type lateral malleolar fracture with no widening of the medial clear space.

Sixty-one patients with a unilateral lateral malleolar fracture resulting from an SER mechanism were enrolled. Two surgeons assessed the stability of the ankle mortise with use of an external-rotation stress test. The anterior and posterior parts of the deep deltoid ligament were investigated with 3.0-T MRI and were graded (as normal, edematous, partial tear, or complete tear) by two musculoskeletal radiologists. The medial clear space was measured and compared with the MRI findings for the deep deltoid ligament in stable and unstable injuries. Interobserver reliability was calculated for both external-rotation stress testing and MRI assessment.

Thirty-three patients had a medial clear space of ≥ 5 mm in the external-rotation stress test. According to MRI, all of these patients had an injury involving the deep deltoid ligament (an edematous ligament in five, a partial tear in twenty-six, and a total tear in two). Twenty-eight patients had a medial clear space of <5 mm, and MRI indicated a deep deltoid ligament injury in all of these patients as well (an edematous ligament in nine and a partial tear in nineteen). The medial clear space increased according to the severity of the deep deltoid ligament injury as indicated by MRI (p < 0.001). The interobserver agreement of the external-rotation stress test was excellent (94% agreement; kappa = 0.87), whereas the interobserver reliability of the MRI assessments by the two musculoskeletal radiologists was fair to moderate (72% agreement for the posterior part of the deep deltoid ligament and 56% for the anterior part; kappa = 0.46 and 0.22, respectively).

On the basis of the study results, we do not recommend the use of MRI when choosing between operative and nonoperative treatment of an SER-type ankle fracture.

There is a growing need to develop tools that allow for better reductions of difficult to treat fractures in minimally disruptive ways. One such technique has been developed using the inflatable bone tamp and a fast setting calcium phosphate. KYPHON(®) XPANDER Inflatable Bone Tamp and the KYPHON(®) Osteo Introducer(®) System were used to reduce the articular fractures and a fast-setting calcium phosphate was introduced into those voids and metal hardware was applied as deemed necessary. Subjects were skeletally mature patients treated for articular fractures of the calcaneus, tibial plateau, tibial pilon, or distal radius. Post-operative day zero and week 12 radiographs were objectively and subjectively evaluated by three independent orthopaedic surgeons. Their objective scores were then translated into subjective categories based on the Heiney-Redfern scaled scoring (H-R score) system established herein. Overall, the thorough radiographic analysis by independent reviewers indicates that the technique is capable of obtaining and maintaining articular reductions in a good or adequate manner at 12-weeks post-operatively. Introduced is a potential novel evaluation scale scoring system for these articular fractures that evaluates the important anatomic considerations reproducibly in fracture reductions. There are many potential benefits that remain speculative to this type of tool within a procedure, and therefore this tool and technique warrants further research.

The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The sensitivity and specificity of both clinical tests were calculated using the standard 7.5-Nm external rotation stress test as reference. Outcome was assessed after a minimum of one year of follow-up. Olerud-Molander (OM) scoring system, RAND 36-Item Health Survey, and VAS to measure pain and function were used as outcome measures in all studies. In study 1, 85 (53%) fractures were treated operatively using the stability based fracture classification. Non-operatively treated patients reported less pain and better OM (good or excellent 89% vs. 71%) and VAS functional scores compared to operatively treated patients although they experienced more displacement of the distal fibula (0 mm 30% vs. 69%; 0-2 mm 65% vs. 25%) after treatment. No non-operatively treated patients required operative fracture fixation during follow-up. In study 2, AITFL exploration and suture lead to equal functional outcome (OM mean, 77 vs. 73) to no exploration or fixation. In study 3, the hook test had a sensitivity of 0.25 and a specificity of 0.98. The external rotation stress test had a sensitivity of 0.58 and a specificity of 0.9. Both tests had excellent interobserver reliability; the agreement was 99% for the hook test and 98% for the stress test. There was no statistically significant difference in functional scores (OM mean, 79.6 vs. 83.6) or pain between syndesmosis transfixation and no fixation groups (Study 4). Our results suggest that a simple stability-based fracture classification is useful in choosing between non-operative and operative treatment of ankle fractures; approximately half of the ankle fractures can be treated non-operatively with success. Our observations also suggest that relevant syndesmosis injuries are rare in ankle fractures due to an SER mechanism of injury. According to our research, syndesmotic repair or fixation in SER ankle fracture has no influence on functional outcome or pain after minimum one year compared with no fixation.

Despite the isolated lateral malleolar ankle fracture being one of the most common injuries treated by orthopaedic surgeons it remains an injury that is widely misunderstood. Treatment protocols are compounded by the contemporary literature being divided on its optimal management. This review takes the reader through a process of how the historical literature on this subject has been formed, it critiques the main responsible papers and leads one to question the current dogma attached to both this injury and to current research in general.

With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.

Differentiating supination external rotation (SER) type II and IV ankle injuries is challenging in the absence of a medial malleolar fracture or talar shift on radiographs. The accurate differentiation between a stable SER-II from an unstable SER-IV injury would allow implementation of the appropriate management plan from diagnosis. The aim of this study was to ascertain the practice of orthopaedic surgeons in dealing with these injuries.

A postal survey was undertaken on 216 orthopaedic consultants from three regions.

In the presence of medial-sided clinical signs (tenderness, swelling, ecchymosis), 22% of consultants would perform surgical fixation. 53% would choose non-operative treatment and the majority would monitor these fractures through serial radiographs. The remaining 25% of consultants would perform an examination under anaesthesia (EUA; 15%), request stress radiographs (9%) or an MRI scan (1%). Without medial-sided signs, 85% would advocate non-operative treatment and, of these, 74% would perform weekly radiographs. Interestingly, 6% would perform immediate surgical fixation. Stress radiographs (6%) and EUAs (2%) were advocated in the remaining group of consultants. Foot and ankle surgeons utilised stress radiographs more frequently and were more likely to proceed to surgical fixation should talar shift be demonstrated.

Clinical practice is varied amongst the orthopaedic community. This may lead to unnecessary surgery in SER-II injuries and delay in diagnosis and operative management of SER-IV injuries. We have highlighted the various investigative modalities available that may be used in conjunction with clinical signs to make a more accurate diagnosis.

We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Anatomic reduction and fixation of unstable ankle fractures is necessary to prevent posttraumatic arthritis. Malunion of the distal fibula in unstable ankle fractures may lead to progressive talar instability. Ankle fracture malunions often present with concomitant syndesmotic widening, which can cause surgeons to overlook changes in fibula length and rotation. The decision to proceed with surgery should be made only after a careful diagnostic workup and detailed preoperative discussion with the patient. Considerations for surgical management include location and orientation of a corrective osteotomy, use of structural graft, widening of the syndesmosis, assessment of reduction, and the need for medial exposure. Good and excellent clinical results after fibular reconstruction have been reported in 67% to 92% of ankles. Proper patient selection is critical, because ankle malunions can be complicated, with coexisting fibular, syndesmotic, medial, and posterior malleolar malalignment, along with degenerative joint disease. Understanding the indications and surgical technique for revising fibular malunions may obviate a future salvage procedure.

Ankle fractures are common and 'stable' ankle fractures comprise 40-75% of this group. Studies show that these injuries can be managed successfully in a functional brace, with no need for further radiographs and minimal out-patient follow-up. We aimed to audit current practice and introduce change in order to improve treatment and produce financial savings.

A retrospective 6-month audit was carried out to establish practice. Guidelines were then drawn up and widely distributed in the accident and emergency (A&E) and orthopaedic departments. These included criteria for diagnosis of stable ankle fractures, a management protocol for treatment of these injuries in a brace and also a follow-up algorithm in the out-patient clinic. A prospective 6-month audit was then carried out to assess the effectiveness of the guidelines.

Of patients presenting in the second 6-month period, 91% were managed in a functional brace. The mean number of out-patient follow-up appointments, weeks until discharge and repeat radiographs all decreased significantly (P < 0.05) after the implementation of the guidelines. The cost of treating a patient with a stable ankle fracture dropped from 310.75 pounds to 129.80 pounds.

Previous studies have shown that stable ankle fractures are more effectively treated in a functional brace than a plaster cast, do not displace and, therefore, do not need repeat radiographs. A previous audit demonstrated that 60% of patients with stable fractures could be treated in a brace. We have shown that, with effective and persistent education of colleagues, the vast majority (91%) of patients can be managed in this way and this results in a significant cost saving. We have also shown that an evidence-based treatment protocol can produce significant improvements in management for patients and savings for healthcare organisations.

Ankle syndesmotic injury does not necessarily lead to ankle instability; however, the coexistence of deltoid ligament injury critically destabilizes the ankle joint. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. Radiographic findings usually include increased tibiofibular clear space decreased tibiofibular overlap, and increased medial clear space. However, syndesmotic injury may not be apparent radiographically; thus, routine stress testing is necessary for detecting syndesmotic instability. The goals of management are to restore and maintain the normal tibiofibular relationship to allow for healing of the ligamentous structures of the syndesmosis. Fixation of the syndesmosis is indicated when evidence of a diastasis is present. This may be detected preoperatively, in the absence of fracture, or intraoperatively, after rigid fixation of the medial malleolus and fibula fractures. Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.

Neither of the ankle fracture classification systems (Lauge-Hansen or Weber) in widespread use today is prognostic. To test the hypothesis that ankle fracture prognosis is dependent on initial biomechanical stability, an alternative classification system created using stability-based treatment criteria was developed on the basis of a structured analysis of the ankle fracture literature.

All English-language papers reporting on ankle fractures (searched using the terms "ankle + fracture") published between 1966 and 2005 with available online abstracts via PubMed were screened.

Abstracts were manually screened for inclusion using the following criteria: (1) there were at least 2 groups of patients categorized on the basis of either fracture configuration or treatment and (2) data was reported in sufficient detail to permit interstudy comparisons.

Each included paper was abstracted into a computerized database for consistent data capture. Data elements included the following: fracture classification, stability definitions, surgical indications, patient follow-up parameters, and outcome measures. Ankle fractures were also stratified into stable and unstable groups using predefined stability criteria, and the outcome measures were re-analyzed.

Wilcoxon matched-pairs signed-rank test was used for statistical comparisons, assigning statistical significance to 2-tailed tests with P < 0.05.

The results support the hypothesis that a stability-based ankle fracture classification system can be prognostic. For unstable ankle fractures, the radiographic outcomes were better after surgery, when the decision for surgery was made on the basis of stability (P = 0.0173). Overall, non-operative treatment results were also better with stability-based treatment (P = 0.0299).

Ankle fractures are common and many require surgical intervention. It has been well documented that a delay in fracture fixation results in increased length of hospital stay and increased complication rate. Initial delay can also allow swelling or blistering to develop which may necessitate a further delay in operative fixation for up to 1 week. The aim of the current study was to review the length of hospital in-patient stay for operative ankle fractures over the previous 12-month period at our hospital and compare this to the length of hospital stay following the introduction of a fast-track system for the fixation of these fractures (all fractures fixed within 48 h).

A retrospective review of all ankle fractures managed by open reduction and internal fixation over a 12-month period was undertaken. A protocol was then agreed to openly reduce and fix these fractures at the earliest possible opportunity over the next 6-month period. We then collected the data on all ankle fractures that needed open reduction and internal fixation over this 6-month period. The pre-protocol and post-protocol groups were then compared for total hospital length of stay and complication rate.

In the 12-month retrospective review, there were 83 ankle fractures that required surgical intervention. Sixty-two of these had surgery within 48 h (mean length of stay, 5.4 days), and 21 had surgery after 48 h (mean length of stay, 9.5 days). There were 39 ankle fractures in the post-protocol group who all had surgery within 48 h (mean length of stay, 5 days). There was no increase in complication rate after implementation of the fast-track system.

This study shows that early operative intervention for ankle fractures reduces the length of hospital stay. Intensive physiotherapy and co-ordinated discharge planning are also essential ingredients for early discharge. Early operative fixation for unstable ankle fractures has substantial cost-saving implications with no increase in complication rate.

The ankle fractures continue to be a topical issue in orthopedic surgery. X-ray diagnostics, but primarily also other modem diagnostic procedures such as CT, MRI, and arthroscopy enable detection of not only fractures but also osteocartilaginous fractures and soft-tissue ligamentary lesions, which are frequent causes of pain and instability of the ankle. The key segment is the posterio-lateral segment and tibio-fibular syndesmosis whose integrity is sometimes only surgically establishable. In the ankle treatment, stable fixation - since recently by means of resorptive osteofixation materials - and early rehabilitation of the operated ankle are aimed at. The open and pylon fractures, as the most severe forms of ankle fractures, are treated by external fixation with minimum internal fixation (hybrid fixation) of the ankle with conversion of the rigid into a dynamic (articulated) external fixator enabling movement and nutrition of the damaged articular cartilage.

Categories of displaced and undisplaced stable ankle fracture are well recognised. We report on a further group of ankle fractures which are undisplaced at presentation, but do not fulfil criteria for stable injuries, and therefore, may be at risk of displacement. The Blackburn Foot and Ankle Service operates evidence-based guidelines for ankle fractures, introduced in 1998. These were prospectively applied to 306 skeletally mature patients (308 fractures) following classification of the ankle fracture based upon clinical examination and radiography (mortise and lateral views). One hundred and forty-eight (48.4%) of fractures were stable, including 63 male and 85 women, median age 53 years (14-92). Eighty-eight (28.8%) of fractures were undisplaced but potentially unstable based on criteria, including 53 men and 35 women, median age 42 years (14-93). Seventy (22.9%) of fractures were displaced, including 41 men and 29 women, median age 44 years (16-94). Undisplaced, unstable fractures were treated mostly in below-knee casts with immediate weight-bearing and follow-up radiography. Two fractures in this group subsequently displaced requiring fixation according to AO principles. The risk of displacement in potentially unstable fractures is 2.3%. The unstable fracture groups, whether displaced or not, were similar in age/sex profile.

Fifty-three patients with ankle fractures presenting to a trauma clinic at a busy district general hospital were used for this study. All subjects sustained fibular fractures at the syndesmosis without demonstrable medial instability or mortice incongruity. All cases were collected consecutively. Radiographs and case notes were studied for each patient. All fractures were categorised as Weber B [Pratique de l'osteosynthese. Les fractures malleolaires (1949)] without medial malleolar fracture. Data collected included the number of radiographs taken per patient and clinic reviews until discharge. Duration of immobilisation was recorded as well as weight bearing status. None of the 53 fractures showed any change in position following serial radiology. No patient underwent manipulation or internal fixation of the fracture. For Weber B fractures there was an average of six radiographs and 4.3 clinic reviews until discharge. There was a median time of 5.7 weeks spent in plaster immobilisation for these fractures. We conclude that once the decision is made to treat Weber B fractures as stable injuries they do not require regular review and serial radiographs. They require only one initial radiograph. Significant reductions in the number of trauma clinic consultations can be achieved as well as a national cost saving in the order of half a million pounds for the X-rays alone.

Stable ankle fracture patients form a distinct, clinically benign group in which functional treatment can be used. An initial retrospective audit of the fracture clinic records of our institution for 1 calendar year demonstrated that recognition and functional treatment of stable ankle fractures was rarely followed. After the introduction of formal departmental evidence-based guidelines, subsequent audits have showed progressive improvements with significant reductions of time spent immobilised in plaster, time spent non-weight bearing and number of routine check radiographs, without compromising patient safety. This study illustrates the value of evidence-based guidelines in maintaining high standards of care over time.

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.

Although classically the fibula has been reported to be in external rotation after supination-external rotation (SER) or pronation-external rotation (PER) ankle fractures, a previous CT study demonstrated that what had traditionally been interpreted as external rotation of the distal fibular fracture fragment is actually internal rotation of the proximal fibular fragment. The purpose of this study was to evaluate a series of CT scans in patients who have suffered type IV SER or PER ankle fractures to assess the rotational deformity of the fibular fragment.

CT scans of the injured and uninjured extremities were performed on 30 extremities which had sustained either SER (21) or PER (9) injuries. The rotational relationship between the tibia and fibula was determined by a measured rotational ratio. A qualitative assessment of the rotational relationship between the tibia and fibula above, at, and below the fracture site at the level of the mortise was also performed. The difference in the ratio (calculated by subtracting the rotation ratio of the normal side from the fracture side) demonstrated whether the fractured fibula is externally or internally rotated compared to the uninjured side.

The average rotational ratio difference above the fracture compared to below the fracture for the SER group demonstrated significant external rotation (p < .001). The PER fracture also demonstrated external rotation of the distal fragment compared to the proximal fragment (p = .002). Additionally, qualitative assessment of the relationship demonstrated no obvious change in the rotational relationship in any patient above the fracture site except one where mild internal rotation of the proximal fragment was noted. However, at the level of the mortise, all had a normal talofibular rotational relationship while 24 of 30 had widening of the medial clear space with external rotation clearly evident on 15 of these 24 scans.

Our study demonstrated that the distal fibular fragment in both SER and PER fractures is externally rotated relative to both the contralateral normal side and compared to the proximal fibular fragment.

To assess the outcomes of the surgical management of "isolated" displaced lateral malleolar fractures, comparing the techniques of lateral plating and antiglide plating as described previously.

This is a retrospective review, being largely a surgeon-randomized comparative study.

The study was carried out at a university teaching hospital that serves as a provincial trauma referral service and provides local community care. The senior surgeons are all orthopaedic trauma subspecialists.

A total of 193 patients meeting our inclusion criteria, with isolated lateral malleolus fractures surgically treated at the Vancouver General Hospital between 1987 and 1998, were studied.

Eighty-five were treated with antiglide plating, whereas the remaining 108 patients underwent traditional lateral plating.

The functional results were evaluated with the ankle scoring system described previously. We also compared the complication rates, including failure of fixation, infection, wound dehiscence, and need for hardware removal.

Both groups were comparable for age, sex distribution, mechanism of injury, and occupation. There was no difference in ankle score, function, and infection rate. The incidence of wound dehiscence and reoperation for hardware removal was slightly higher in the lateral plate group, but the difference was not statistically significant.

The outcome of the surgical management of a displaced lateral malleolus fracture is comparable with both techniques. Although few studies have reported some advantages using the antiglide technique, our data do not support one technique over the other.

The success of the medial displacement calcaneal osteotomy in correcting flatfoot deformities is likely to be the result of a shift of the Achilles tendon forces on the hindfoot. The purpose of this study was twofold: 1) to define the contribution of the Achilles tendon to the flatfoot deformity, and 2) to define the effect of a calcaneal medial displacement osteotomy.

We used six different experimental dynamic stages: 1) intact foot without Achilles loading; 2) intact foot with Achilles loading; 3) flatfoot without medial calcaneal displacement osteotomy and without Achilles loading; 4) flatfoot without medial calcaneal displacement osteotomy but with Achilles loading; 5) flatfoot with medial calcaneal displacement osteotomy but without Achilles loading; and 6) flatfoot with medial calcaneal displacement osteotomy and with Achilles loading. The experimental flaffoot was developed by releasing the posterior tibial tendon, spring ligament, and plantar fascia and applying 7,000 cycles of axial fatigue load (range, 700 to 1,400 N; 1-Hz frequency). To simulate the phase of midstance, the peroneus longus, peroneus brevis, flexor digitorum longus, and flexor hallucis longus tendons were grasped by clamps, connected to pneumatic actuators, and loaded with precalculated forces. Anteroposterior and lateral radiographs were obtained for each stage on which the following measurements were made: talonavicular coverage angle, talar-first metatarsal angle, talocalcaneal angle, and height of the medial cuneiform. These measurements were compared with a one-way ANOVA.

Between stages 1 and 2, all measurements were statistically insignificant. Between stages 3 and 4, for all measurements, Achilles tendon loading aggravated the flatfoot deformity (p < 0.05). After medial calcaneal osteotomy (stages 5 and 6), the Achilles tendon contributed less to the arch-flattening. We found that the medial displacement osteotomy plays an important role in reducing and/or delaying the progress of flatfoot deformity.

In the flatfoot, loading of the Achilles tendon increases the deformity. Medial calcaneal osteotomy significantly decreases the arch-flattening effect of this tendon and therefore limits the potential increase of the deformity.

Ankle fractures are one of the most frequently treated injuries in orthopedic traumatology. The simple injuries often are forgiving and are managed easily and appropriately by closed treatment, but more complex injuries require recognition of possible associated injuries and anatomic internal fixation. Although adherence to general guidelines of fracture management usually suffices, some cases do not fall into a well-defined category, and clinicians are called on to use their experience and clinical knowledge to make treatment decisions that best ensure good clinical outcomes.

The ANK device was developed for the treatment of fractures of the lateral malleolus occurring with rupture of the syndesmosis. While it provides the anatomic reduction of the fracture and the syndesmosis, it allows the physiologic movements of the fibula. It is not used for comminuted fractures of the lateral malleolus and in cases where fibular medullary canal is narrow. We included forty-nine patients who had the ANK device applied and at least 2 years follow-up. The mean follow-up was 41 months (range 24-124). The fractures were evaluated according to the Lauge-Hansen classification; 25 cases were evaluated as supination-external rotation, 11 cases were pronation-abduction, and 13 cases were pronation-external rotation type fractures. There were also 46 fractures of the medial malleolus and three ruptures of the deltoid ligament. Twenty-nine (59,2%) patients were evaluated as excellent, 12 (24,5%) as good, 5 (10.2%) as fair and 3 (6.1%) as poor. Arthrosis was observed in 3 (6.1%) of the patients.

Spiral CT is a fast and effective modality for evaluating a wide variety of musculoskeletal abnormalities in the emergency department setting. The role of spiral CT in evaluating musculoskeletal trauma and musculoskeletal inflammation and infections is discussed, as is the use of multiplanar and three-dimensional imaging.

Thirty-two cases of ankle fractures associated with fibular fractures above the distal tibiofibular syndesmosis were studied. All were treated with open reduction and internal fixation. The average follow-up was 25 months. The results of the postoperative evaluation were rated, based on subjective clinical criteria, as good, fair, and poor. According to the Lauge-Hansen classification, there were 17 (53%) cases of supination-external rotation injury (2 stage 2 and 15 stage 4), 9 (28%) cases of stage 3 pronation-abduction injury, and 6 (19%) cases of pronation-external rotation injury (3 stage 3 and 3 stage 4). All cases could be classified as Weber type C or as suprasyndesmotic, fibular diaphyseal fracture (44-C) according to the Orthopaedic Trauma Association classification. In 18 (56%) cases, the fracture was associated with ankle dislocation. There were seven (22%) open fractures, (two grade I, four grade II, and one grade IIIA). Syndesmotic screws were used in 23 (72%) cases (12 supination-external rotation injury, 6 pronation-external rotation injury, and 5 pronation-abduction injury). The syndesmotic screw was removed after an average of 9 weeks. Four (13%) nonunions and two (6%) delayed unions of the fibula were treated with bone grafting and/or hardware revision and eventually healed. Three of the nonunions had poor clinical results because of degenerative ankle joint arthritis in two (one of them ended in arthrodesis) and deep infection, which was eventually cured, in the third. The fourth nonunion had a fair result. One of the delayed unions had a fair result (an obese patient) and the other had a good result. Two patients developed deep infections; one ended in gangrene and amputation in a diabetic patient, and the other was a patient with fibular nonunion that eventually healed. Three patients had superficial infections that were treated successfully. Of the 32 cases, 23 (72%) showed good results, 4 (13%) showed fair results, and 5 (16%) showed poor results. The cases with poor results included three fibular nonunions, one deep infection, and one recurrent superficial infection and wound dehiscence after hardware removal. A syndesmotic screw is usually needed in cases of fracture-dislocations. Two patients with occult fibular nonunions developed diastasis of the syndesmosis after removal of the syndesmotic screw. It was found that reduction and temporary pinning of the distal tibiofibular joint helps achieve fibular length, which is crucial to restoring the biomechanics of the ankle joint. It seems advisable not to remove the syndesmotic screw until there are signs of healing of fibular fracture to avoid diastasis of the distal tibiofibular joint. Bone grafting should be considered in high energy fractures with comminution. These complex injuries are associated with higher rates of complications. Poor results can be attributed to fracture factors, e.g., open fractures, infections; patient factors, e.g., obesity, lowered immunity as in diabetes, and noncompliance; and iatrogenic factors, e.g., early removal of syndesmotic screws.

Fractures of the ankle are one of the most commonly treated injuries by orthopedic surgeons. The adequacy of closed treatment of stable lateral malleolar ankle fractures is frequently assessed by repeated roentgenograms. There are no standards, nor studies, however, that provide guidelines as to the necessity of such roentgenograms. This study was designed to determine the average frequency of follow-up roentgenograms in ankle fractures treated by casting, as well as the clinical impact of these roentgenograms. The clinical radiographic data base of a university hospital was reviewed to identify all ankle fractures treated between January 1, 1992 and June 30, 1993. A total of 82 patients satisfied the study criteria of having sustained a stable ankle fracture that was treated by closed means, with sufficient clinical and radiographic follow-up to assess healing of the fracture. All patients healed their fractures at an average of 8.4 weeks (+/- 3.0 weeks), with weight-bearing initiated at 4.0 weeks (+/- 2.7 weeks). No patients developed radiographic evidence of a talar shift during treatment, and none required surgery for a failure of closed treatment. At no time did any ankle exhibit a significant change in fibular alignment relative to the initial injury films. Each patient had an average of 4.5 (+/- 2.0) radiographic studies performed throughout their treatment. This study indicates that secondary displacement of either the talus or fibula in a stable ankle fracture is very unusual. In conjunction with the generally excellent outcome for such fractures, this suggests that frequent roentgenograms are not justified on clinical grounds.(ABSTRACT TRUNCATED AT 250 WORDS)

Eighteen patients with ankle injuries presenting as short oblique fractures of the distal fibula with no clinical or radiographic evidence of injury to the medial ankle were studied for fracture displacement. Plain radiographs and computed tomography were used for analysis. All fractures were clinically diagnosed as supination-external rotation stage 2 (SE-II) injuries under the Lauge-Hansen scheme. All exhibited slight displacement on plain radiographs and were treated nonoperatively. Computerized tomography using axial cuts across the fracture site and ankle mortise revealed normal positioning of the talus beneath the tibial plafond, as evidenced by no abnormality of the medial joint space in all patients. In the majority of patients, the relationship between the talus and distal fibula also appeared undisturbed, with fracture displacement being confined to a change in position of the proximal fibular fragment relative to the tibia as compared with the contralateral ankle. In a minority of cases, in addition to the above-described displacement of the proximal fibular fragment, the distal fibular fragment was noted to shift slightly laterally relative to the talus, with mild widening of the lateral joint space. Occult-associated avulsion fractures off the distal tibia were present in 39% of the cases.