Background: Ankle fractures are among the most common injuries requiring surgical intervention. Standard radiographs are typically used for postoperative assessment; however, some patients continue to experience residual symptoms despite satisfactory radiographic outcomes. Weight-bearing computed tomography (WBCT), though not yet widely integrated into clinical practice, offers potential advantages in evaluating lower-limb deformities, injuries, and arthritis. This study explores the utility of WBCT for the midterm assessment following ankle fracture fixation and compares its findings with those obtained from standard radiographs. Methods: In this retrospective case study, we analyzed the correlations between the functional outcome scores approximately one year post-surgery and parameters assessed using WBCT. Pearson's correlation coefficient was used to evaluate these correlations, and a t-test was performed to assess their statistical significance, with a threshold p-value of 0.05. Additionally, Spearman's rank correlation coefficient was calculated as a supplementary descriptive measure, without significance testing. These correlations were then compared with those obtained from standard ankle radiographic views (anteroposterior, lateral, and mortise). Results: Several correlations were identified between WBCT parameters and functional scales, with certain parameters demonstrating high statistical significance (p < 0.05). Overall, the correlations observed for WBCT were stronger than those for standard radiographs. Conclusions: Although the study cohort was limited, the findings suggest that WBCT may provide additional insights beyond conventional radiography. Further research with larger patient groups is needed to establish its clinical relevance.

Fluoroscopic guidance is an integral tool in modern orthopedic surgery often used to track bones and/or bone fragments during a surgical procedure. However, relying upon this intra-operative 2D projective imaging modality for this purpose can challenge a surgeon's ability to interpret 3D position and orientation of any but the simplest bony anatomy. A number of object-tracking technologies have been developed to aid surgeons, but they have failed to be generalizable to a wider array of procedures, have required an unrealistic amount of time and effort to implement, or have unacceptably changed the flow of the surgery. This work describes a novel, general-purpose system for markerless, intra-operative bone tracking that seamlessly integrates into a surgical setting. The system uses a unique calibration object placed next to the patient, which provides a common reference for aligning multiple fluoroscopic images. This approach enables robust and expedient 3D object registration from only two semi-orthogonal 2D fluoroscopic images.

With the increased use of computed tomography scans in cases with trimalleolar ankle fractures, bone fragments between the posterior malleolus and the rest of the articular surface tibial plafond surface - described as intercalary fragments (ICFs) - can be recognized. The aim of this study was to determine the ICF size threshold for a significant change in the pressure distribution at the ankle joint, having a considerable impact on the remaining cartilage of the joint.

Eight human cadaveric lower legs were used, and a posterior malleolus Bartoniček/Rammelt II fracture was created with sequential 2 mm, 4 mm, 6 mm, and 8 mm ICFs. The posterior malleolus was fixed with a 3.5 mm one-third tube buttress plate and each specimen was mounted in a custom-made frame for axial loading under 700 N in neutral position, 30° plantar flexion, and 30° dorsiflexion of the foot. Using electronic foil sensors, pressure measurements were performed to define the contact area, centre of force, and peak pressure at the ankle joint in loaded condition.

Compared to the situation without ICF, contact area decreased significantly after 4 mm, 6 mm and 8 mm ICFs. Anteroposterior center of force shift was significant after 6 mm and 8 mm ICFs. Mediolateral center of force shift was significant after 2 mm, 4 mm, 6 mm and 8 mm ICFs.

Posterolateral defects of the tibial plafond alter ankle joint pressure characteristics. Regardless of the direction of ankle joint flexion, increasing the ICF defect size results in decreased contact area, increased mediolateral center of force migration and higher peak joint forces. Malreduction or removal of ICFs larger than 2 mm should be avoided to preserve physiological ankle pressure characteristics.

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 represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilizing the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

The purpose of this study was to define the utility of CT scans for detecting articular extension in tibial shaft fractures and determine whether radiographic parameters can predict the presence of operative distal tibial articular fractures (DTAFs).

Retrospective cohort study.

Single level I trauma center.

Patients age 18 years and older who were treated operatively for tibial shaft fractures occurring at or below the tibial isthmus were included. Patients were excluded for extension of the main tibial shaft fracture into the tibial plafond (AO/OTA 43 B/C), ballistic injuries, and absence of a preoperative CT scan.

The primary outcome was CT utility, defined as the presence of a DTAF or DTAF displacement on CT that was not recognized on plain radiographs on secondary analysis at the time of the study by a senior-level resident. Secondary outcome was the association between radiographic parameters and operative DTAFs. Variables with P ≤ 0.2 on univariate testing were included in a multiple binary logistic regression model to determine independent predictors of operative DTAFs.

One hundred forty-four patients were included, with a mean age of 52 years. Seventy-six patients (53%) were men. CT utility was 41% for the identification of unrecognized DTAFs. CT utility was 79% for isolated pDTAF, 57% for medial DTAF, 83% for isolated anterolateral DTAF, and 100% for multiple DTAFs. Operative DTAFs were independently associated with spiral tibial shaft fracture type (P < 0.001) and low fibular fracture (P = 0.04). In patients who had both spiral tibial shaft fracture type and low fibula fracture, the rate of operative DTAF was 46% (22/48).

CT scans identified DTAFs that were unrecognized on plain radiographs in 41% of cases. CT scans were most useful in identifying nonposterior DTAFs. CT scans may be considered for all distal third tibial fractures, but especially those with spiral tibial shaft patterns and low fibular fractures, to avoid missing operative articular injury.

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

Ankle fractures represent up to 9% of all fractures, with an increased incidence in the elderly population. Among these fractures, isolated fractures of the lateral malleolus are the most common, representing 65-70% of all cases. The therapeutic decision-making primarily relies on the stability of the ankle ring, considering it stable if affected at one point and unstable if two or more points are affected. Surgical treatment focuses on restoring the length of the fibula, joint reconstruction, stabilising the syndesmosis, and providing a stable fixation. It is crucial to rule out associated injuries that may influence therapeutic management. This article reviews the evaluation and management of lateral malleolus fractures, proposes a decision-making algorithm, and examines several fibular fixation options.

The aim of this study was to describe the incidence and a complex pathoanatomy of posterior malleolus fractures in a Maisonneuve fracture.

The study included 100 prospectively collected patients with a complete clinical and radiological documentation of an ankle fracture or fracture-dislocation including a fracture of the proximal quarter of the fibula.

A posterior malleolus fracture was identified in 74 patients, and in 27% of these cases it carried more than one quarter of the fibular notch. Displacement of the posterior fragment by more than 2 mm was shown by scans in 72% of cases. Small intercalary fragments were identified in 43% of cases. Fractures of the Tillaux-Chaput tubercle were identified in 20 patients.

Our study has proved a high rate of posterior malleolus fractures associated with a Maisonneuve fracture, and documented their considerable variability in terms of involvement of the fibular notch, tibiotalar contact area, direction of displacement and frequency of intercalary fragments. Of no less importance is a combination of Tillaux-Chaput fractures with a Maisonneuve fracture.

To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation.

A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning.

The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75).

The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care.

Retrospective Comparative Study.

Chaput tubercle fractures, located at the attachment site of the anterior inferior tibiofibular ligament (AITFL) on the distal tibia, have the potential to destabilize the syndesmosis joint. This study aims to assess the effectiveness of tension band wiring (TBW) as a surgical intervention for managing Chaput fractures and the consequent syndesmosis instability.

A retrospective review of patient charts was undertaken for those who had undergone ankle fracture surgery from April 2019 through May 2022. The surgical procedure involved direct fixation of the Chaput fractures using the TBW method. Radiological assessments were performed using postoperative simple radiographs and computed tomography (CT) scans, while clinical outcomes were evaluated using the Olerud-Molander Ankle Score (OMAS) and the visual analog scale (VAS).

The study included 21 patients. The average OMAS improved significantly, rising from 5.95 preoperatively to 83.57 postoperatively. Similarly, the average VAS score dropped from 7.95 before the surgery to 0.19 thereafter. Minor wound complications were reported by three patients, and one case of superficial infection was resolved with antibiotic therapy.

Our findings suggest that the TBW technique is an effective surgical approach for treating Chaput fractures and associated syndesmosis instability. It provides reliable fixation strength and leads to improved long-term functional outcomes. Further research is needed to compare the TBW technique with alternative methods and optimize the treatment strategies for these complex ankle fractures.

The contribution of Lauge-Hansen to the understanding and treatment of ankle fractures cannot be underestimated, an unquestionable merit being the analysis of the ligamentous component of these injuries that are considered as equivalent to the respective malleolar fractures. In numerous clinical and biomechanical studies, the lateral ankle ligaments are ruptured either together with or instead of the syndesmotic ligaments, as predicted by the Lauge-Hansen stages. A ligament-based view on malleolar fractures may deepen the understanding of the mechanism of injury and lead to a stability-based evaluation and treatment of the 4 osteoligamentous pillars (malleoli) at the ankle.

The anterolateral distal tibial rim (anterior malleolus, AM) is frequently fractured in malleolar fractures. The aim of this study was to evaluate the medium-term outcomes of malleolar fractures involving the AM.

Among 100 patients with AM fractures that were treated over a 10-year period, 50 patients were available for follow-up. Outcome was assessed with the Olerud Molander Ankle Score (OMAS), the Foot Function Index (FFI-D), the EuroQol (EQ)-5D-5L Index, the EQ-VAS and the AOFAS Ankle-Hindfoot Score. Type 1 AM fractures (bony syndesmotic avulsions) were fixed surgically with either a suture anchor or a transosseous suture in 11 of 22 cases (50%). Among type 2 AM fractures (with incisura and joint involvement), 68% were treated surgically with screw fixation. All three type 3 AM fractures (anterolateral tibial plafond impaction) were treated surgically with either screw or plate fixation.

At follow-up, the median OMAS was 75, the FFI-D 19, the EQ-5D-5L-Index 0.88, the EQ-VAS 70, and the AOFAS score 93. Assuming that the fracture severity increases from Supination-External Rotation to Pronation-External Rotation and Pronation-Abduction injuries, the AOFAS score (p < 0.001), OMAS score (p = 0.009), and FFI-D (p = 0.041) all showed a significantly inferior clinical outcome with increasing fracture severity. Patients who required surgical revision (n = 5) showed a significantly inferior outcome with the OMAS (p = 0.019).

A differentiated treatment protocol tailored to dislocation, size, incisura involvement and joint impaction leads to favourable outcomes in complex malleolar fractures involving the AM. More data are needed on the outcome of AM fractures that are still commonly underestimated and overlooked.

During study of anatomy of a fractured posterior malleolus of the ankle on CT scans, the authors noticed a prominent crest on the lateral malleolus, which they termed the lateral malleolar crest (LMC). As, in their view, LMC is a clinically important structure which was only briefly mentioned by a few authors without an official term, they focused on the anatomy of this structure.

A total of 352 dry fibulae were analyzed and the following parameters recorded: (F) length of the fibula, (LMC) total length of LMC, (A) length of the part of the examined crest from the superior border of the articular facet of the lateral malleolus (AFLM) to its most proximal intersection with the midline of the fibula, (B) height of the medial triangular rough surface, and (A/F) A/F ratio.

The crest was observed in all specimens. (F) was 346.5 ± 26 mm (95% confidence interval [CI] 344-349), (LMC) was 85.4 ± 11.6 mm (95% CI 84.2-86.6), (A/F) was 25% ± 3% (95% CI 24.7-25.3) in the whole group. (A) was 25.9 ± 6.5 mm (95% CI 24.8-26.8) in the whole group, (B) was 34.9 ± 4.7 mm (95% CI 34.3-35.5) in the whole group, 36 ± 6.1 mm (95% CI 35.1-36.9).

LMC is an important structure on the lateral malleolus. The knowledge of its anatomy is essential for placement of syndesmotic screws or/and the fibular plate.

Radiographs are first-line imaging in ankle trauma but lack sensitivity to detect ligamentous injuries and undisplaced fractures. Our hypothesis was that ankle injuries occur in predefined sequences along two osteoligamentous rings, so that occult injuries non-visible on initial radiographs can be predicted. We, therefore, aimed to validate a ring model of progressive damages in the interpretation of ankle trauma radiographs.

This study retrospectively enrolled 277 adult patients that presented an acute fibular fracture on ankle radiographs between May and November 2019. Four different types of fibula fracture were differentiated, each being considered to correspond to a different mechanism of injury. Patients were classified into four groups, upon the appearance of their fibular fracture. Then, injuries to the distal tibiofibular syndesmosis, medial malleolus, and deltoid ligament (medial clear space) were assessed in each patient radiographs. Traumatic injuries were independently evaluated by a resident and an experienced MSK radiologist. For each patient, observed features were compared to those predicted by the ring concept. Inter- and intraobserver agreements were calculated.

Injuries were observed according to the predictable sequence in 266 of the 277 patients (96%). In the 11 remaining patients, discordances were presumably due to undisplaced injuries to the syndesmosis or deltoid ligament. Agreements were considered very good for each evaluated item.

The Lauge-Hansen ring concept was found to be highly accurate and reproducible for radiographic assessment of ankle injuries. Discordances to the predicted sequence might reflect occult injuries, especially of the syndesmosis or deltoid ligament.

Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.

The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).

The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.

Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.

Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

The anterior distal tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered a fourth, or anterior, malleolus (AM). Fractures of the AM may extend into the tibial incisura and tibial plafond. The purpose of this study was to analyze the pathoanatomy of AM fractures and associated ankle injuries.

One hundred and forty patients (median age, 61.0 years) with a total of 140 acute malleolar fractures (OTA/AO 44) involving the anterolateral distal tibial rim were analyzed with computed tomography (CT) imaging. All components of the malleolar fractures were analyzed and classified. Fracture patterns were compared with those of all patients with malleolar fractures treated during the same 9-year period. Patients with fractures of the tibial pilon (OTA/AO 43) and patients <18 years of age were excluded.

Of the 140 AM fractures, 52.9% were classified as type 1 (extra-articular avulsion); 35.7%, type 2 (incisura and plafond involvement); and 11.4%, type 3 (impaction of the anterolateral plafond). The fibula was fractured in 87.1%; the medial malleolus, in 66.4%; and the posterior malleolus, in 68.6%. An isolated AM fracture was seen in 4.3%. The size of the AM fractures correlated negatively with that of the posterior malleolar fractures. The proportion of pronation-abduction fractures increased and the proportion of supination-external rotation fractures decreased as the type of AM fracture increased. A fracture involving the AM occurred in 12.6% of all ankle fractures and occurred significantly more frequently in pronation-type injuries and elderly patients. No supination-adduction fractures with AM involvement were seen. The intraclass correlation coefficient for the proposed classification of the AM fractures was 0.961 (95% confidence interval [CI] = 0.933 to 0.980) for interobserver agreement and 0.941 (95% CI = 0.867 to 0.974) for intraobserver agreement.

Knowledge of the 3D pathoanatomy of AM fractures and associated malleolar fractures may help with surgical decision-making and planning. CT imaging should be employed generously in the diagnosis of complex ankle fractures, in particular with pronation-type injuries.

Depending on the individual 3D fracture pattern, fixation of displaced anterolateral distal tibial fragments potentially contributes to the restoration of joint congruity, tibiofibular alignment, and syndesmotic stability in complex malleolar fractures.

This study aimed to introduce the circle drawing method for the evaluation of marginal impaction associated with posterior malleolar fractures (PMFs) on computed tomography (CT) images and evaluate the marginal impaction based on PMF patterns (Bartonícek classification) in rotational ankle fractures.

From January 2014 to December 2019, A total of 299 patients were reviewed retrospectively. The circle drawing method consists of matching the articular surface of the intact tibial plafond with a best-fitted circle on the sagittal CT image. The mismatch gap between the circle and the articular surface indicates the presence of marginal impaction. To validate the circle drawing method, we assessed CT images of 60 ankles without fracture at the medial, central, and lateral parts using the new method.

Based on the review of the preoperative CT scan, 153 out of 299 patients (51.2%) were identified as having PMFs. Among them, 57 patients (37.3%) had marginal impaction associated with PMFs. For small posterolateral type 2 fractures, 58% of patients (47/81) had marginal impaction, and its incidence was most frequent among all types (P<.01). For posteromedial extended type 3 fractures, 27% of patients (8/30) had marginal impaction. Extraincisural type 1 and large posterolateral triangular type 4 fractures were rarely associated with marginal impaction. Among the 180 zones of 60 ankles without fracture, 171 zones (95%) were perfectly fitted to a best-fitted circle.

The marginal impaction associated with PMFs is often observed in rotational ankle fractures, particularly in small posterolateral and posteromedial extended fractures.

The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population.

One hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček-Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern.

Internal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031).

With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.

The management of an ankle malunion involving the posterior malleolus remains challenging, and only a few published studies described the operative treatment of complex posterior malleolar malunion. A transfibular approach allows for direct visualization of the articular reduction of the posterior malleolus, but the reports of its use for correcting posterior malleolar malunion are rare. This study aims to evaluate the results of the intra-articular osteotomy via a transfibular approach for correcting an ankle malunion involving the posterior malleolus.

We conducted a retrospective review of 26 patients with a symptomatic malunited ankle fracture involving posterior malleolus were treated with the intra-articular osteotomy via a transfibular approach in our department. Radiographic assessments were performed using plain radiographs and computed tomographic (CT) scans. Clinical outcomes were assessed using the AOFAS ankle-hindfoot score, visual analog scale (VAS), active range of motion of ankle, and the 36-Item Short-Form Health Survey score.

Postoperatively, anatomic correction of articular surface and anatomic reduction of syndesmosis were achieved in all patients as judged by CT scans. No evidence of progression had been found in 18 of 26 patients (69.2%) at final follow-up. The median AOFAS score improved from 42.0 to 81.5 (P < .001). Median pain VAS score decreased from 6.0 to 1.0 (P < .001). A favorable clinical outcome was associated with a short time interval from original injury to correction surgery and a lower grade of preoperative arthritis, but not with the posterior malleolar fragment size. However, time interval, the posterior malleolar fragment size, and the grade of preoperative arthritis showed no correlation with the progression of arthritis grade after surgery.

An intra-articular osteotomy via a transfibular approach demonstrated an improved function and pain after operative treatment of malunited ankle fracture with a displaced posterior malleolar fragment.

Level IV, retrospective case series.

In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.

Knowledge of the physiological and pathological processes, taking place in bone during fracture healing or defect regeneration, is essential in order to develop strategies to enhance bone healing under normal and critical conditions. Preclinical testing allows a wide range of imaging modalities that may be applied both simultaneously and longitudinally, which will in turn lower the number of animals needed to allow a comprehensive assessment of the healing process. This work provides an up-to-date review on morphological, functional, optical, biochemical, and biophysical imaging techniques including their advantages, disadvantages and potential for combining them in a multimodal and multiscale manner. The focus lies on preclinical testing of biomaterials modified with artificial extracellular matrices in various animal models to enhance bone remodeling and regeneration.

We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle ("quadrimalleolar") or anterior fibular rim ("quadrimalleolar equivalent"). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15-156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45-100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39-100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction.

Computerized tomography (CT) imaging is increasingly being used to evaluate patients with ankle trauma. However, conventional CT (C CT) has a significantly higher radiation dose (RD) than plain radiography. This study aimed to evaluate the diagnostic accuracy and reliability of ultra-low-dose CT (ULDCT) protocol for ankle fractures.

Ninety-eight consecutive patients who had ankle CT for suspected ankle fracture were included in our prospective study. C CT and ULDCT protocols were simultaneously performed on these 98 patients. Two observers independently evaluated ULDCT and C CT images. The effective RD of the ULDCT and C CT groups was calculated.

The interobserver agreement was 1 (perfect). ULDCT and C CT group images showed no significant difference in image quality. The effective RD of the ULDCT was significantly lower than the C CT (p < 0.001).

By evaluating the results of this study, ULDCT proved to be a reliable diagnostic imaging method for fractures of the ankle. The satisfactory diagnostic image quality of the ULDCT protocol provides promising results.

Level II/lesser quality RCT or prospective comparative study.

Stabilization of the syndesmotic complex by open reduction and internal fixation (ORIF) of the posterior malleolus, restoration of the tibial articular surface, stability of the ankle, posterior tibiofibular ligament and the incisura tibiae, reduction of the fibula into the incisura tibiae by ligamentotaxis.

Unstable ankle fractures (OTA/AO type 44-B3, C1.3, C2.3, C3.3) with involvement of the posterior malleolus (type II-IV according to Bartoníček and Rammelt).

Critical general condition, circulatory disorders, severe soft tissue swelling (if necessary, first external fixator), percutaneous treatment the better alternative.

Positioning in unstable lateral position, dorsolateral approach dorsally of the peroneal tendons, incision of the superficial and deep fascia, retraction of the flexor hallucis longus tendon medially, visualization of the posterior malleolus, reduction and fixation. To treat the lateral malleolus fracture, preparation of a full-thickness flap above the peroneal tendons on the fibula, treatment according to AO principles. For the treatment of the medial malleolus positioning in supine position without changing the sterile covers, medial approach for the medial malleolus, wound closure.

Six weeks partial weight bearing (20 kg), early functional exercise, exercise of the flexor hallucis longus muscle; transition to full weight bearing after clinical and radiological follow-up after 6 weeks RESULTS: Few clinical results on open ORIF of the posterior malleolus have been published. However, most studies found that ORIF resulted in better reconstruction of the distal articular surface and the tibial incisura, better reduction of the fibula into the tibial incisura, stabilization of the distal tibiofibular joint and better clinical results, regardless of fragment size, when compared to closed reduction or untreated fragments.

The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura.

Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura.

Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities.

Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3).

Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance.

Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

Malleolar ankle fractures have been classified using plain radiographs, and there is no consensus regarding the role of computed tomography (CT) scans in preoperative planning. We analyzed critical aspects, such as limits of standard radiographs, types of injury, classification methods and cost/benefit evaluations. CT scans allow a 3D analysis of the fracture to be obtained and consequently assess the indication for surgical procedure, surgical access and the type of fixation devices required. This exam is useful for detecting lesions that may go unnoticed on radiographs and will help surgeons to clarify the pathoanatomy of ankle fractures. According to Arbeitsgemeinschaft fur Osteosynthesefragen/ Orthopaedic Trauma Association (AO/OTA) classification, CT scan is recommended in medial malleolar fractures with vertical rim, type 44B fractures with posterior malleolar involvement and all type 44C fractures (according to AO/OTA). Also Tillaux-Chaput fractures (43-B1 according to AO/OTA), malleolar fractures in the presence of distal tibial fractures (43 according to AO/OTA) and distal tibia fractures in adolescents should be studied with CT scans.

Minimally invasive osteosynthesis of distal fibula fractures serves as a biomechanically stable and soft-tissue-friendly fixation method in the case of an unstable fracture, poor bone quality, and/or critical soft tissue conditions with restoration of the length, axis and rotation of the distal fibula as well as stabilization of the ankle mortise. The goal is to reduce and stabilize the distal fibular fracture in a quick and stable manner that protects the soft tissues in ankle fractures.

Unstable malleolar fractures and fracture dislocations; fibular fractures in combination with distal tibia fractures; critical soft tissue conditions around the ankle.

No consent to surgery by the patient. Overall critical (life-threatening) general condition preventing surgery to the extremities. Very narrow medullary canal of the fibula (less than 3 mm, depending on the implant).

Percutaneous placement of a guidewire into the distal fibular tip, opening the medullary canal and drilling the medullary canal in the distal fragment. Reduction of the axis by introduction of the fibular nail, with additional percutaneous use of reduction clamps for restoration of fibular length and rotation, if necessary. Placement of distal locking screws over the targeting device while maintaining rotation and length, in addition proximal static locking is mandatory to maintain the length of the fibula. In case of residual syndesmotic instability after fracture fixation, syndesmotic screws are inserted through the fibular nail via the aiming device.

Following surgery, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (15-20 kg) in an ankle foot orthosis or plaster/cast for 6 weeks.

Minimally invasive fibular fixation with an intramedullary nail results in a significantly lower rate of wound healing complications compared with lateral plating. Reported union rates range from 97.4 to 100% with current nail designs. The quality of reduction and functional outcome is comparable to that after plate fixation. A certain learning curve has to be respected.

Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.

Unstable injuries of the deltoid ligament complex can have a substantial negative effect on the prognosis and treatment of ankle injuries. Lesions of the deltoid ligament are often overlooked at the initial presentation, both as isolated ruptures and in combination with more complex injuries of the ankle. Neglected unstable injuries of medial ankle ligaments may result in chronic instability, especially following correct treatment of fractures and lateral ligament injuries. These are accompanied by reduced ankle mobility, persisting pain, reduced load bearing and osteoarthritis. Despite the possible subsequent damage, the need for surgical repair of the deltoid ligament in patients with ankle fractures is controversially discussed. Although in most cases of ligament injuries of the upper ankle joint conservative treatment leads to very good results, there is increased interest in acute surgical treatment particularly for unstable injuries in order to avoid secondary instability and the associated sequelae. When surgical treatment should be given priority over conservative treatment has not yet been sufficiently clarified. This article gives an overview of the diagnosis and treatment of injuries of the deltoid ligament complex in patients with ankle fractures based on the current literature.

The anterolateral tibial rim with the anterior tibial tubercle (Tubercule de Tillaux-Chaput) serves as an insertion site of the anterior inferior tibiofibular ligament (AITFL). It can also be termed the anterior malleolus or fourth malleolus. Fractures of the anterolateral tibial rim typically result from an external rotation or abduction mechanism of the talus within the ankle mortise. They are frequently overlooked in plain radiographs. Computed tomography (CT) is needed for an exact visualization of the fracture anatomy and treatment planning. A total of three main types can be differentiated: (1) extra-articular avulsion fracture of the AITFL, (2) fracture of the anterolateral distal tibia with involvement of the joint and tibial incisura and (3) impaction fracture of the anterolateral tibial plafond. Surgical fixation of displaced anterolateral distal tibial fractures aims at bone-to-bone stabilization of the anterior syndesmosis, restoration of the tibial incisura for the distal fibula and joint surface. Displaced extra-articular avulsion fractures (type 1) are fixed with a suture anchor or transosseal suture. Larger fragments involving the tibial incisura and plafond (type 2) are mostly fixed with screws. Impression fractures of the anterolateral tibial plafond (type 3) necessitate elevation with restoration of the joint surface, bone grafting of the impaction zone as needed and anterior buttress plating. Only a few studies have reported the treatment results of anterolateral tibial rim fractures in adults. Conservative treatment of dislocated fragments reportedly leads to non-union and malposition of the distal fibula with incongruence of the ankle mortise requiring revision. Impaction fractures (type 3) can lead to secondary avascular necrosis of the anterolateral tibial plafond.

"Chronic syndesmotic injury covers a broad range of symptoms and pathologies. Anterolateral ankle impingement without instability is treated by arthroscopic debridement. Subacute, unstable, syndesmotic injuries are treated by arthroscopic or open debridement followed by secondary stabilization using suture button device or permanent screw placement. Chronic syndesmotic instability is treated by a near-anatomic ligamentoplasty supplemented by screw fixation. In case of poor bone stock, failed ligament reconstruction, or comorbidities, tibiofibular fusion with bone grafting is preferred. Malleolar malunions and particularly anterior or posterior syndesmotic avulsions must be corrected in order to achieve a stable and congruent ankle mortise."

Joint-spanning transfixation of the ankle joint aims at mostly temporary retention of the reduction, i.e. restoring length and axial alignment and stabilization of the ankle mortise in highly unstable fractures around the ankle and under critical soft tissue conditions. In selected cases, external fixation serves as an additional stabilization also following completed internal fixation or the fracture can be treated in the external fixator. The goal of surgery is to allow quick soft tissue recovery, prevention of redislocation and stabilization of the ankle and adjacent structures.

a) Fractures of the tibial pilon; b) very distal, extra-articular lower leg fractures (without the option for pin positioning in the distal fragment); c) highly unstable malleolar fractures with tendency to subluxation and dislocation fractures; d) critical soft tissue conditions around the ankle; e) dislocation fractures of the talus, Chopart and Lisfranc joints (if necessary with additional transarticular transfixation).

Missing consent to surgery by the conscious patient, life-threatening general condition by other prioritized injuries.

Percutaneous pin placement of the appropriate caliber into so-called safe zones of the tibia, metatarsus and calcaneus, as needed. Additional transfixation of the Chopart and Lisfranc joints with K‑wires as needed. Fixation of the struts with the foot in a neutral position. Besides consideration of biomechanical principles, pin placement must be done in anticipation of the definitive stabilization and future approaches respecting the anatomical structures while achieving maximum stability and soft tissue protection.

Following initial transfixation, elevation of the injured leg for soft tissue protection, local cooling and bed rest are indicated. In cases of compartment syndrome and open fractures with temporary soft tissue coverage, second look surgery after 24-72 h is mandatory. For exact fracture analysis and optimal planning of the definitive surgical strategy, the indications for CT imaging should be generously considered. The timing of definitive care depends on the local soft tissue status and the overall condition of the patient.

The presence of a dislocation at the time of the accident represents a negative prognostic factor for ankle fractures. Higher rates of posttraumatic arthrosis are also found in pilon fractures and trimalleolar fractures, direct cartilage damage and rupture of the syndesmosis. In cases of anatomic reconstruction of the mortice and ankle joint congruence, good to excellent results can be achieved in 75-89%.

Even minor residual fragment malpositioning after internal fixation of ankle fractures is associated with a worse prognosis. Frequent causes for non-anatomical reduction are fibular shortening due to comminuted fractures or poor bone quality, translational or rotational malpositioning of the distal fibula within the tibial incisura with unstable syndesmosis injuries, and inadequately addressed bony avulsions of the tibiofibular syndesmosis. After operative treatment of fracture dislocations with syndesmotic fixation, in case of complex fracture pathoanatomy, and with suspected non-anatomic reduction in postoperative radiographs, computed tomography imaging of both ankles should be performed. Correction of relevant malreductions should be performed as early as possible in order to speed up rehabilitation and to avoid late sequelae due to a load shift or instability in a weight-bearing joint.

The aim of this study was to present outcomes of operative treatment of the posterior malleolus fractures of type four of the Bartoníček/Rammelt classification.

In 19 patients, direct reduction and fixation of the posterior malleolus was performed from the posterolateral or posteromedial approaches. The accuracy of reduction was assessed with the use of postoperative CT scans.

The mean size of the avulsed articular surface carried by posterior malleolus amounted to 36%. Reduction of the posterior malleolus fracture was assessed as anatomical in 14 cases and as satisfactory in five cases. Position of the distal fibula was assessed as anatomical in 15 cases. The mean AOFAS score was 89.4 points. All nine patients with anatomical reduction of all lesions achieved the mean AOFAS score of 93.1 points, five patients with malposition of posterior malleolus 89.1 points and five patients with malposition of the fibula in the fibular notch 87.8 points. A total of six patients developed osteoarthritic changes of grades one and two according to the Kellgren and Lawrence classification.

Outcomes of the study demonstrated good mid-term results in type four fractures of the posterior malleolus treated by direct reduction from posterior approaches. Postoperative CT examination allowed evaluation of the accuracy of reduction of all fractures and reduction of the distal fibula into the fibular notch. Based on postoperative CT examination, it will be possible to assess the effect of reduction of individual lesions on the functional results.