Implementing screening for myocardial injury in non-cardiac surgery: perspectives of an ad-hoc interdisciplinary expert group.

Objectives. Perioperative myocardial injury (PMI) is increasingly recognised as an important complication of non-cardiac surgery, with often clinically silent presentation, but detrimental prognosis. Active screening for PMI, involving the detection of dynamic and elevated levels of cardiac troponin, has recently been advocated by an increasing number of guidelines; however, active PMI screening has not been reflected in clinical practice. Design. As consensus on a common screening and management pathway is lacking, we synthesise the current evidence to provide suggestions on the selection of patients for screening, organisation of a screening program, and a potential management pathway, building upon a recently published perioperative screening algorithm. Results. Screening should be performed using high-sensitivity assays both preoperatively and postoperatively (postoperative Days 1 and 2) in patients at high-risk of experiencing perioperative complications. Conclusion. This expert opinion piece by an interdisciplinary group of predominantly Norwegian clinicians aims to assist healthcare professionals planning to implement guideline-recommended PMI screening at a local level in order to improve patient outcomes following non-cardiac surgery.

[Lateral ankle ligament injuries]. / Laterale ankelligamentskader.

Lateral ankle ligament injuries occur in connection with inversion traumas and are one of the most common injuries, both in the general population and among athletes. A lateral ankle ligament injury weakens the stabilising structures in the ankle and disposes the ankle joint to prolonged instability. Acute lateral ankle ligament injuries with no suspicion of fracture can be treated and followed up conservatively in the primary health service. In this clinical review article, we emphasise the importance of adequate physical training before referral to an MRI and orthopaedic surgeon for further assessment. Patients with chronic instability who fail to respond to adequate conservative treatment should be referred for surgical assessment.

Long-term Functional Outcomes and Complications in Operative Versus Nonoperative Treatment for Displaced Midshaft Clavicle Fractures in Adolescents: A Retrospective Comparative Study.

INTRODUCTION: Traditionally, midshaft clavicular fractures in adolescents are treated nonoperatively. In later years, a trend toward operative treatment can be observed. Documentation of the benefit of surgery in this group is scarce. The purpose of this study is to evaluate the long-term patient reported functional outcomes and complications for patients treated operatively and nonoperatively for displaced midshaft clavicular fractures. Using the same outcomes we also compared the operative methods. METHODS: One hundred nine adolescents aged 12 to 18 years sustaining displaced midshaft clavicular fractures in the period 2010 to 2016 were identified in our computerized files. Sixty-one were treated nonoperatively, 48 operatively (22 plate and 26 intramedullary nail). Their radiographs and patient journals were examined for fracture classification, wound infection, sensory affection, surgery duration, hardware removal, and nonunion (n=109). Long-term function, pain, and satisfaction were measured with Quick Disability of Arm, Shoulder, and Hand (QuickDASH), Oxford Shoulder Score and Visual Analogue Scale (n=87). RESULTS: Operative treatment: We could find no difference in functional score outcomes. The main outcome QuickDASH was excellent in both groups (median 0 nail vs. 2.26 plate). Surgery duration was shorter with intramedullary nail. We found 2 infections and 2 sensory affections in the plate group, and 1 infection and 1 sensory affection in the intramedullary nail group. There were 2 refractures in the nail group. Operative versus nonoperative treatment: there were no differences in functional outcomes between the operative and nonoperative groups. For the main outcome QuickDASH both groups scored excellently (median 1.12 operative vs. 0 nonoperative). The nonoperative group was more satisfied with the cosmetic result. There was 1 nonunion in the nonoperative group that later was operated. CONCLUSIONS: Adolescents aged 12 to 18 years with displaced midshaft clavicular fractures show good long-term functional results after plate fixation, intramedullary nail, and nonoperative treatment. No additional benefit is demonstrated for surgery in our material. Nonoperatively treated patients are more satisfied with the cosmetic results. Little difference is seen between the operative methods in our study. We conclude that surgery should rarely be the choice of treatment for displaced midshaft clavicular fractures in adolescents. LEVEL OF EVIDENCE: Level III study-retrospective comparative study.

Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial.

OBJECTIVE: To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures. DESIGN: The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist. SETTING: This study was done at a level 1 trauma centre. SUBJECTS: One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study. INTERVENTIONS: Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer. MAIN MEASURES: Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered. RESULTS: Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) (P = 0.021). At one-year follow-up, there was no difference between the groups (P = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group (P = 0.026). CONCLUSION: The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot.

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot.

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.

Posterior tibial tendon transfer improves function for foot drop after knee dislocation.

BACKGROUND: Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop. QUESTIONS/PURPOSES: We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer. METHODS: Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution's database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM. RESULTS: Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001). CONCLUSIONS: Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Results after gastrocnemius recession in 73 patients.

BACKGROUND: Very few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession. PURPOSE: To survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions. MATERIAL AND METHODS: 93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result. RESULTS: 45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p=0.015) after surgery for patients with plantar fasciitis (n=18) and from 5.6 to 2.3 (p<0.01) for patients with metatarsalgia (n=28). CONCLUSION: Patients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.

Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up.

BACKGROUND: Evidence from prospective short-term studies suggest that proximal medial gastrocnemius recession is a safe and efficient procedure to treat chronic plantar fasciitis resistant to nonoperative treatment. The aim of this study was to evaluate the long-term clinical outcomes of proximal medial gastrocnemius recession and stretching compared to a stretching exercise protocol for patients with chronic plantar fasciitis and an isolated gastrocnemius contracture (IGC). METHODS: Forty patients with plantar fasciitis lasting more than 1 year were prospectively randomized to a home stretching exercise program only, or to proximal medial gastrocnemius recession in addition to the stretching program. Clinical and functional data in this study were obtained at baseline and 6-year follow-up. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes were the visual analog scale (VAS) for pain, the Manchester Oxford Foot Questionnaire (MOxFQ), ankle dorsiflexion, and Achilles complex performance. RESULTS: Thirty-three of 40 patients completed the 6-year follow-up. Seven patients had crossed over from nonoperative treatment to operative treatment. At 6 years, the operative group demonstrated significantly better outcomes with AOFAS (88.9 vs 78.6, P = .012), for pain measured by VAS (2.5 vs 5.5, P < .001) and with the MOxFQ total score (24.4 vs 45.9, P = .05) (per protocol analysis excluding crossovers). No between-group differences were observed for ankle dorsiflexion or Achilles complex performance at 6 years. CONCLUSION: This study demonstrates that the improved function and reduced level of pain by proximal medial gastrocnemius recession and stretching is better compared to stretching alone after 6 years of follow-up for patients with chronic plantar fasciitis and a concomitant isolated gastrocnemius contracture. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Non-operative versus operative treatment of suprasyndesmotic ankle fractures: protocol for a prospective, multicentre, randomised controlled trial.

INTRODUCTION: Surgery is widely recognised as the treatment of choice for suprasyndesmotic ankle fractures, because of the assumption that these injuries yield instability of the ankle joint. Stability assessment of ankle fractures using weightbearing radiographs is now used regularly to guide the treatment of transsyndesmotic and infrasyndesmotic ankle fractures. Patients with a congruent ankle joint on weightbearing radiographs can be treated non-operatively with excellent results. Weightbearing radiographs are, however, rarely performed on suprasyndesmotic fractures due to the assumed unstable nature of these fractures. If weightbearing radiographs can be used to identify suprasyndesmotic fractures suitable for non-operative treatment, we may save patients from the potential burdens of surgery.Our aim is to compare the efficacy of operative and non-operative treatment of patients with suprasyndesmotic ankle fractures that reduce on weightbearing radiographs. METHODS AND ANALYSIS: A non-inferiority randomised controlled trial involving 120 patients will be conducted. A total of 120 patients with suprasyndesmotic ankle fractures with an initial radiographic medial clear space of <7 mm will be subjected to weightbearing radiographs. If the tibio-talar joint is completely reduced, we will randomise in a 1:1 ratio to either operative treatment including reduction and fixation of the syndesmosis or non-operative treatment with an orthosis. The primary study outcome is patient-reported ankle function and symptoms as measured by the Olerud-Molander Ankle Score at 2-year follow-up. Secondary outcomes include the Manchester-Oxford Foot Questionnaire, range of motion, radiographic results and rates of adverse events. ETHICS AND DISSEMINATION: The Regional Committee for Medical and Health Research South East, group A (permission number: 169307), has granted ethics approval. The results of this study will provide valuable insights for developing future diagnostic and treatment strategies for a common fracture type. The findings will be shared through publication in peer-reviewed journals and presentations at conferences. TRIAL REGISTRATION NUMBER: NCT04615650.

Effects of Fibular Plate Fixation on Ankle Stability in a Weber B Fracture Model With Partial Deltoid Ligament Sectioning.

BACKGROUND: Weber B fractures with concomitant deltoid ligament injury have traditionally been operated with open reduction and internal fixation of the fibular fracture. More recently, clinical studies have suggested that some fractures have concomitant partial deltoid ligament injury with the deep posterior tibiotalar ligament intact (SER4a), allowing for nonoperative treatment in this subgroup. This study explores whether plate fixation of the fibula improves ankle stability in an SER4a injury model. And if so, does it restore native ankle stability? METHODS: Fifteen cadaver ankle specimens were tested in 3 states using an industrial robot: intact joint, SER4a models without plate fixation of the fibula, and SER4a models with plate fixation of the fibula. The robot measured ankle stability in lateral translation, valgus, and internal and external rotation in 3 talocrural joint positions: 10 degrees dorsiflexion, neutral, and 20 degrees plantar flexion. Furthermore, fluoroscopic mortise view radiographs were taken to measure isolated talar shift and talar tilt. RESULTS: The talar shift and tilt tests showed no differences between the SER4a injury model with and without fibular plate fixation at neutral ankle position with a mean difference of -0.16 mm (95% CI -0.33 to 0.01 mm, P = .071) for talar shift and -0.15 degrees (95% CI -0.01 to 0.30 degrees, P = .068) for talar tilt. However, plate fixation increased external rotation stability, with mean improvements ranging from -7.43 to -9.52 degrees (P < .001 for all comparisons), but did not restore intact ankle stability. For internal rotation, plate fixation resulted in minor differences. CONCLUSION: The results of this suggest that plate fixation of the fibular fracture primarily improves external rotation stability but does not substantially improve lateral translation, valgus, or internal rotation stability in SER4a injury models. In this robotic cadaver model, fibular plate fixation did not fully restore intact ankle stability after simulated SER4a injury. CLINICAL RELEVANCE: This study offers insights into the effects of fibular plate fixation on Weber B/SER4a injury models and may assist informed decisions when selecting treatments for these types of fractures.

Concomitant Unstable and Stable Gravity Stress Tests on Weight-Bearing Stable Weber B Ankle Fractures Treated Nonoperatively: A 2-Year Outcome Study.

BACKGROUND: Replacing gravity stress tests with weight-bearing radiographs to evaluate the stability of Weber B (also called Lauge-Hansen supination-external rotation [SER]) ankle fractures results in a lower surgery rate, thus avoiding associated risks and complications. Still, nonoperative treatment of weight-bearing stable fractures is controversial because of the scarcity of strong evidence. We investigated the influence of a concomitant unstable gravity stress test compared with a stable gravity stress test on outcomes after nonoperative treatment of weight-bearing stable fractures. METHODS: We performed a prospective, noninferiority study on 149 patients with Weber B ankle fractures and stable weight-bearing radiographs. Gravity stress radiographs classified fractures as stable (SER2 [n = 88]) or partially unstable (SER4a [n = 61]). All were treated with a functional orthosis and weight-bearing was allowed; patients were followed for 2 years. The primary outcome was the Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), with a range from 0 to 100, in which lower scores indicate fewer symptoms. A noninferiority margin was prospectively defined as 7.5 points. The secondary outcomes included the Olerud-Molander Ankle Score, assessment of ankle congruence, and treatment-related adverse events. RESULTS: The primary outcome data were available for 144 (96.6%) of 149 participants at 2 years. The between-group difference in the MOXFQ score was 1.0 point (95% confidence interval, -1.4 to 3.4 points; p = 0.397) in favor of the SER2 group, consistent with noninferiority. We found no appreciable between-group differences for any other outcome. CONCLUSIONS: In Weber B/SER ankle fractures that are stable on weight-bearing radiographs, are treated with removable orthoses, and are allowed to bear weight, a concomitant unstable gravity stress test (SER4a) was not associated with worse patient-reported or radiographic outcomes compared with a stable gravity stress test (SER2) at the 2-year follow-up. Thus, the identification of stress instability seems redundant, which questions the applicability of stress instability for surgical decision-making. LEVEL OF EVIDENCE: Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue.

BACKGROUND: Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively. METHODS: A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated. RESULTS: Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure. CONCLUSIONS: After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication. LEVEL OF EVIDENCE: Level IV: Case series without control.

Effects of Progressive Deltoid Ligament Sectioning on Weber B Ankle Fracture Stability.

BACKGROUND: Conventionally, transsyndesmotic fibula fractures with concomitant signs of deltoid ligament injury have been considered unstable and thus treated operatively. Recent studies have indicated that partial deltoid ligament rupture is common and may allow for nonoperative treatment of stress-unstable ankles if normal tibiotalar alignment is obtained in the weightbearing position. Biomechanical support for this principle is scarce. The purpose of this study was to evaluate the biomechanical effects of gradually increasing deltoid ligament injury in transsyndesmotic fibula fractures. METHODS: Fifteen cadaveric ankle specimens were tested using an industrial robot. All specimens were tested in 4 states: native, SER2, SER4a, and SER4b models. Ankle stability was measured in lateral translation, valgus, and internal and external rotation stress in 3 talocrural joint positions: 20 degrees plantarflexion, neutral, and 10 degrees dorsiflexion. Talar shift and talar valgus tilt in the talocrural joint was measured using fluoroscopy. RESULTS: In most tests, SER2 and SER4a models resulted in a small instability increase compared to native joints and thus were deemed stable according to our predefined margins. However, SER4a models were unstable when tested in the plantarflexed position and for external rotation in all positions. In contrast, SER4b models had large-magnitude instability in all directions and all tested positions and were thus deemed unstable. CONCLUSION: This study demonstrated substantial increases in instability between the SER4a and SER4b states. This controlled cadaveric simulation suggests a significant ankle-stabilizing role of the deep posterior deltoid after oblique transsyndesmotic fibular fracture and transection of the superficial and anterior deep deltoid ligaments. CLINICAL RELEVANCE: The study provides new insights into how the heterogenicity of deltoid ligament injuries can affect the natural stability of the ankle after Weber B fractures. These findings may be useful in developing more targeted and better treatment strategies.

Higher complication rate after nail compared with plate fixation of ankle fractures in patients aged 60 years or older: a prospective, randomized controlled trial.

AIMS: The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. METHODS: In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. RESULTS: At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. CONCLUSION: The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly.Cite this article: Bone Joint J 2023;105-B(1):72-81.

Functional orthosis versus cast immobilization for weightbearing stable Weber B ankle fractures with concomitant unstable gravity stress tests.

Aims: Treatment of Weber B ankle fractures that are stable on weightbearing radiographs but unstable on concomitant stress tests (classified SER4a) is controversial. Recent studies indicate that these fractures should be treated nonoperatively, but no studies have compared alternative nonoperative options. This study aims to evaluate patient-reported outcomes and the safety of fracture treatment using functional orthosis versus cast immobilization. Methods: A total of 110 patients with Weber B/SER4a ankle fractures will be randomized (1:1 ratio) to receive six weeks of functional orthosis treatment or cast immobilization with a two-year follow-up. The primary outcome is patient-reported ankle function and symptoms measured by the Manchester-Oxford Foot and Ankle Questionnaire (MOxFQ); secondary outcomes include Olerud-Molander Ankle Score, radiological evaluation of ankle congruence in weightbearing and gravity stress tests, and rates of treatment-related adverse events. The Regional Committee for Medical and Health Research (approval number 277693) has granted ethical approval, and the study is funded by South-Eastern Norway Regional Health Authority (grant number 2023014). Discussion: Randomized controlled trials are needed to evaluate alternative nonoperative treatment options for Weber B/SER4a ankle fractures, as current clinical guidelines are based on biomechanical reasoning. The findings will be shared through publication in peer-reviewed journals and presentations at conferences.

Weightbearing Stable Bimalleolar Ankle Fractures-Bony Equivalents to the Ligamentous Weber B/SER4a Fracture Type? A Prospective Case Series.

BACKGROUND: In a recent study, we documented that partially unstable Weber B/SER4a fracture types reach union with preserved normal ankle congruence after treatment with a functional orthosis and weightbearing allowed. In the present article, we present a case series of weightbearing stable bimalleolar fractures treated nonoperatively that extends our previously published research. METHODS: We included 5 patients with primarily nondisplaced bimalleolar ankle fractures that were stable on weightbearing radiographs. Participants were treated with a walking boot or cast with weightbearing allowed. We also provide a qualitative anatomical analysis of fracture morphology on computed tomographic scans. RESULTS: Median medial clear space (MCS) of fractured ankles after union were 2.4 mm (range, 1.5-3.1). Qualitative descriptions of fracture morphology showed that all fractures were oblique starting at the intercollicular groove of the medial malleolus and extended anteriorly and proximally. CONCLUSION: MCS measurements after fracture union of nonoperatively treated weightbearing stable bimalleolar fractures seemed consistent with normative data of ankle congruence in our previous study. We consistently recorded oblique fracture patterns involving the anterior colliculus, leaving the origin of posterior deep deltoid ligament intact. We present our material as an argument for the existence of a bony (bimalleolar) equivalent to the ligamentous SER4a fracture. LEVEL OF EVIDENCE: Level IV, prospective case series.

A Cadaveric Study Verifying the Potential of a Rotational Biplanar Chevron Osteotomy to Correct the 3-Dimensional Hallux Valgus Deformity.

INTRODUCTION: Metatarsal pronation is present in 87% of patients with hallux valgus (HV) deformity. The chevron osteotomy is commonly used worldwide to correct mild to moderate HV deformities. Many modifications have been described, but few address the rotational deformity of the first metatarsal. The rotational biplanar chevron osteotomy (RBCO), described by M. Prado et al, presents a variation of a biplanar chevron osteotomy that can be used to address first metatarsal rotation. The objective of this study is to investigate and verify the technique of the RBCO. METHODS: We conducted our study performing an RBCO on 9 cadaveric limbs. The technique uses a medial-based wedge parallel to the plantar limb of the osteotomy to make the distal fragment free to correct rotation. A goniometer was used by 2 individual surgeons to control the rotational correction achieved. RESULTS: The osteotomy was considered simple to perform and we experienced no complications, such as fractures or instability. The result was satisfactory alignment and adequate stability. On average, a 2 mm wedge resulted in 11° of rotational correction. CONCLUSION: We predict that RBCO can safely be used for correcting the metatarsal rotation when necessary in mild to moderate HV deformity foot. LEVELS OF EVIDENCE: Level IV.

The Anatomy and Function of the Individual Bands of the Deltoid Ligament-and Implications for Stability Assessment of SER Ankle Fractures.

Background: Deltoid ligament injury occurs often with supination-external rotation (SER) ankle trauma. SER fibula fractures with concomitant deltoid ligament injury are considered unstable-requiring operative fixation. Recent studies have questioned this general practice with emphasis on better defining the medial side ankle ligamentous injury. The function of the individual bands of the deltoid ligament, and the interplay between them, are not fully understood. We undertook this study to develop a better understanding of these complex ligamentous structures and ultimately aid assessment and treatment choice of SER ankle fractures with concomitant deltoid ligament injuries. Methods: Ten fresh-frozen cadaveric foot and ankle specimens were studied. We identified the various ligament bands and did a functional analysis by assessment of ligament length and tension at predefined angles of ankle dorsi-plantarflexion combined with valgus/varus and rotation. The results were determined by manual evaluation with calipers and goniometers, manual stress, and direct visualization. Results: We recorded primarily 5 different bands of the deltoid ligament: the tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL; 10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar ligaments were tense in dorsiflexion. The superficial layer ligaments and the deep anterior tibiotalar ligament length and tension were largely affected by changes in varus/valgus and rotation. The deep posterior tibiotalar ligament length and tension was altered predominantly by changes in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this band. Conclusions: We confirmed the finding of previous studies that dorsi-plantarflexion affects the tensile engagement of the separate ligament bands differently. Likewise, combined movements with varus/valgus and rotation seem to affect the separate ligament bands differently. Our results suggest that the TNL, TSL, and dATTL are at risk of injury, whereas the TCL and particularly the dPTTL are protected in the event of an SER-type ankle fracture mechanism of injury. Level of Evidence: Level V, cadaveric study.