PATHOPHYSIOLOGY OF POSTTRAUMATIC ANKLE OSTEOARTHRITIS: A MULTICENTER PERSPECTIVE.

Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. OBJECTIVE: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. METHODS: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. RESULTS: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. CONCLUSION: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.

A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.

Paratenon preserving repair of the midsubstance acute Achilles tendon rupture: a systematic review and meta-analysis with best- and worst-case analyses for rerupture rates.

INTRODUCTION: Paratenon preserving techniques to facilitate acute Achilles tendon rupture repair (AATR) functions by maintaining vascularity and biology for optimal healing response. Therefore, the purpose is to evaluate the outcomes following paratenon preserving repair of the midsubstance AATR. The hypothesis was that paratenon-preserving techniques demonstrate high return to play rates and low complication rates for the repair of the midsubstance AATR. MATERIALS AND METHODS: A systematic review of the PubMed, Embase, and the Cochrane Library databases was performed by two authors using specific search terms and eligibility criteria. The assessment of the evidence was two-fold: level and quality of evidence. A meta-analysis of proportions for the various complication rates was performed using the restricted maximum likelihood method following the Freeman-Tukey double-arcsine transformation. Fixed effects models were employed if I2 < 25% (low heterogeneity), and random effects models were employed if I2 ≥ 25% (moderate to high heterogeneity). RESULTS: The pooled return to play rate was 90.3%. The pooled rerupture rate as reported was 0.9% (best-case scenario 0.8% and worst-case scenario 6.8%). No meaningful subgroup analysis for rerupture rates could be performed based on the meta-regression. The pooled complication rate other than reruptures was 4.8%. The pooled infection rates were 0.3%, DVT rates were 1.6%, and sural nerve injury rates were 0.3%. CONCLUSIONS: Paratenon preserving techniques that are minimally invasive in nature demonstrated safe and favorable outcomes with high return to play rates and low complication rates for the repair of the midsubstance AATR.

["Calcaneogenesis" with secondary Achilles tendon-bone allograft for repair of the loss of hindfoot function : A 12-year case report]. / "Kalkanogenese" mit sekundärer Achillessehnen-Knochenblock-Alloplastik zur Wiedergewinnung der Rückfußfunktion : Eine 12-Jahres-Kasuistik.

BACKGROUND: Calcanectomy and Achilles tendon resection are very hard to repair. OBJECTIVE: Ilizarov's "calcaneogenesis" is possible with ankle joint preservation. Even after 3.5 years of functio laesa of the triceps surae muscle it can be rebuilt. MATERIAL AND METHODS: A 25-year-old motorcyclist suffered a 3rd degree open calcaneal dislocation fracture (type 5). Osteitis and necrosis required calcanectomy, resection of the Achilles tendon and a latissimus dorsi muscle transfer. A talus corpus osteotomy with Ilizarov distraction created in the 1st step a "neo-calcaneus". In a delayed 2nd step a fresh-frozen Achilles tendon-bone block allograft was transplanted to regain active plantar flexion. RESULTS: The initial AOFAS score of 35 points was significantly improved to 70 points 12 years after step 1. After both operations the patient could walk without an orthosis and regained 88% of normal plantar flexion strength. Quantitative measure of health outcome according to EQ-5D-5L was marked by the patient with 80 out of 100 points. DISCUSSION: "Calcaneogenesis" with preservation of the ankle joint is possible and innovative. Despite 3.5 years of disconnection of the triceps surae muscle, an Achilles tendon-bone block allograft could restore 88% of the push-off force even attached to a neo-calcaneus that is 1/3 smaller than normal, which is also new.

Bosworth ankle fracture-dislocation: current concept review.

Bosworth fracture (BF) is a special type of locked ankle fracture-dislocation, characterized by displacement of a fragment of the fractured fibula from the fibular notch behind the posterior surface of the distal tibia. BF is a complex injury affecting multiple structures of the ankle joint, which is still frequently misjudged even today, potentially leading to severe complications. CT examination, including 3D reconstructions, should be the diagnostic standard in BF, as it provides a complete picture of the fracture pathoanatomy, most prominently the morphology of the frequently associated posterior malleolar fracture. BF requires early reduction of the displaced fibular fragment without repeated attempts on closed reduction. Non-operative treatment of BF almost always fails. The standard treatment procedure is early open reduction internal fixation. Due to the relative severity and paucity of the injury, BF seems to be particularly prone to soft tissue complications, including compartment syndrome. The results of operative treatment are mixed. Many studies report persistent pain even after a short time interval, with limitations of the range of motion or even stiffness of the ankle joint, and development of degenerative changes. Larger studies with long-term results are still missing.

Parameters That Can Be Used to Quantify Reduction Accuracy in Talar Neck Fractures and Malunions: A PRISMA-Compliant Scoping Review and Meta-Analysis.

Understanding the three-dimensional anatomy of the talar neck is essential in assessing the accuracy of reduction in talar neck fractures as well as for planning surgical correction for talar malunions. However, the geometrical parameters that describe this anatomy are sparsely reported in the orthopedics literature. We aimed to identify from the existing literature, geometrical parameters that describe the anatomy of the talar neck, determine how these are measured, and their normative values. A scoping literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines. The primary searches were conducted on the PubMed, Embase, and Scopus databases. Any original research study looking at the human talus neck geometry was included. Parameters that described the anatomy of the talar neck were identified, and pooled estimates were determined by the random-effects meta-analysis model. Heterogeneity was assessed by the I2 test and leave-one-out meta-analysis. Subgroup analysis was done to compare the values of parameters between the Asian and Non-Asian populations. The risk of bias was assessed by the National Institutes of Health (NIH) Case Series Tool. The combined searches yielded 6326 results, of which 21 studies were included in the review and 15 in six different sets of metanalysis. The majority of the studies (n=19, 90.5%) evaluated adult tali, and only two (9.5%) evaluated pediatric tali. In most of the studies (n=13, 61.9%), talus neck geometry was evaluated on dry bones or anatomical specimens; evaluation by imaging techniques (radiographs, CT, MRI, and radiostereometric analysis) was used in eight studies, (39.1%). A total of eight different geometrical parameters (neck length, height, width, declination angle, inclination angle, torsion angle, circumference, and cross-sectional area) were identified. Except for talar torsion, variability was noted in methods of measurement of all other parameters. Subgroup analysis revealed that Asians had a higher neck height as compared to non-Asians; other parameters were not significantly different. Although the literature reports geometrical parameters to assess the talar geometry, the methods of measurement of these parameters are variable. Most of the available literature describes measurement techniques on cadaveric tali, and there is no literature on how these parameters should be measured on conventional CT or MRI slices. Further research needs to focus on the standardization of measurement techniques for these parameters on conventional CT and/or MRI scans.

The role of computed tomography with external rotation and dorsiflexion in decision making for acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II: a prospective study.

PURPOSE: Our objective was to evaluate the syndesmotic and fracture instability using conventional ankle computed tomography (CT) with stress maneuvers. METHODS: A consecutive sample of 123 individuals with an ankle sprain was assessed for eligibility. In total, 33 patients met the inclusion criteria. All patients underwent a magnetic resonance imaging (MRI) and CT scan with stress maneuvers (CTSM). The patterns of ligament tears f were classified using West Point grades I, IIA, IIB, III. Mann-Whitney test was used to test the differences in the numerical variables between injured and uninjured syndesmoses. The Spearman correlation tested the strength of the association between the tibial joint surface involved in posterior malleolus fracture and syndesmotic instability. RESULTS: In MRI, two patterns of syndesmotic ligament injury predominated. A completely torn anterior inferior tibiofibular (AITFL) and interosseous tibiofibular ligaments (ITFL) and a completely torn AITFL were combined with a partially torn ITFL. In the neutral phase CTSM and during the stress phase the median difference of the narrowest tibiofibular distance between injured and uninjured syndesmoses was 0.2 mm (P = 0.057) and 2.3 mm (P < 0.0001), respectively. There was no association between the percentage of involvement of the posterior tibial joint surface in the posterior malleolar fracture and syndesmotic instability as measured with CTSM. CONCLUSION: The conventional computed tomography with external rotation and dorsiflexion represents a reproducible and accurate diagnostic option for detecting syndesmosis instability and fracture instability in acute isolated non-displaced posterior malleolar fractures Bartonícek and Rammelt type II. LEVEL OF EVIDENCE: Prospective study among consecutive patients (Diagnosis); Level of evidence, 2.

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study.

BACKGROUND: Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction. METHODS: Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up. RESULTS: No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees. CONCLUSION: In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common. LEVEL OF EVIDENCE: Level III, prospective study.

Current Lack of Evidence on Treatment Strategies and Clinical Outcomes for Osteochondral Lesions of the Subtalar, Talonavicular, and Calcaneocuboid Joints: A Systematic Review.

OBJECTIVE: In contrast to osteochondral lesion (OCL) of the ankle, OCLs in other joints of the foot, such as subtalar joint, talonavicular joint, calcaneocuboid joint, and the midfoot, are rare conditions, but they can also lead to significant morbidity. The objective of this systematic review was to summarize the clinical evidence for the treatment of OCLs of the subtalar, talonavicular, calcaneocuboid, and the other midfoot joints. DESIGN: A systematic search of the MEDLINE, EMBASE, and Cochrane Library databases was performed in January 2021 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by 2 independent reviewers. Included studies were evaluated with regard to LOE (level of evidence) and QOE (quality of evidence). Variable reporting outcome data, clinical outcomes, and complications were evaluated. RESULTS: Seventeen studies with 21 patients were included, all of which were case reports (level 5) without any case series reporting greater than 3 patients. There were 5 patients with OCL in the subtalar joint, 15 patients in the talonavicular joint, and 1 patient in the calcaneocuboid joint. Thirteen case reports (4 subtalar joint, 8 talonavicular joint, and 1 calcaneocuboid joint) reported surgical treatment. Surgical procedures mainly included debridement, bone marrow stimulation, fixation, and bone grafting, through open or arthroscopy, all of which resulted in successful outcomes. Four case reports (1 subtalar joint, 3 talonavicular joint) reported successful conservative treatment. Other 13 case reports reported successful surgery after failed conservative treatment. No complications and reoperations were reported. CONCLUSIONS: The current systematic review revealed that there is no available evidence to ascertain clinical outcomes of both conservative and surgical treatments for cartilage lesions in the talonavicular joint, subtalar joint, and the midfoot joints, owing to the extreme paucity of literature. Both nonoperative and operative treatments can be considered, but no treatment strategies have been established.

History of proximal femur fractures in the German literature.

INTRODUCTION: German-speaking surgeons have left a deep imprint on the history of diagnostics and treatment of proximal femur fractures. Some of the studies published in German have fell into oblivion, others are cited until today, although sometimes quite inaccurately. The cause of such inaccuracies are citations from secondary sources due to unavailability of the original or inability to read it because of a language barrier. In the current literature, globally predominated by English articles, the "German history" of treatment of proximal femur fractures remains undervalued. The aim of the present article is to point out its contribution. MATERIALS AND METHODS: Literature search was performed in original publications and historical sources. RESULTS: The German-speaking surgeons have considerably contributed to the development of the treatment of proximal femur fractures. The analyzed period between 1847 and 1970 may be divided into three basic periods. In the first period (1847-1896), the German-speaking surgeons (Langenbeck, Trendelenburg, König, Heine, Dolinger) were the first worldwide to start treating the fractures of proximal femur operatively. In the second period (1897-1935), mainly in the 1930s, the initiative in Europe was taken over by surgeons publishing studies in France and in Belgium. Overseas, American surgeons were coming to the forefront. In Germany, only Pauwels developed the first biomechanical classification of femoral neck fractures. In the third period (1936-1970), mainly in the 1940s and 1950s, implants were designed (Pohl, Künstcher), based on close collaboration between German engineers and surgeons, that served as a model for a dynamic hip screw and a proximal femoral nail, which are currently the implants of choice in the treatment of trochanteric fractures. CONCLUSION: The historical contribution of German-speaking surgeons to understanding the issue of proximal femur fractures and their operative treatment is far more significant than presented in the historical studies published in English.

Early history of posterior malleolus fractures in ankle fractures.

INTRODUCTION: No comprehensive treatise on the early history of fractures of posterior malleolus (PM) has yet been published, and many substantial discoveries have fallen into oblivion-particularly if not having been published in English originally. MATERIALS AND METHODS: Literature search was performed in original publications and historical sources. RESULTS: Early history of PM fractures from their first description up to the beginnings of their operative treatment may be divided into three basic periods, covering the era between 1828 and 1940. In the pre-radiological period (1828-1895), description of PM injuries was based merely on the autopsy findings in deceased patients. The first mentions of this injury were published by the British authors. In the radiologic period (1899-1916), the x-ray examination started a revolution also in diagnostics of ankle fractures, with the first radiographs performed as early as in 1899. Radiographic examination had subsequently become an integral part of the diagnostics of these injuries and initiated a number of significant studies of PM fractures. The first detailed mention of a PM injury may be found in the French and German literature. The period of early operative treatment (1918-1940), i.e., open reduction and internal fixation of PM, was started by the younger post-WWI generation, primarily the French surgeons, represented by Gaston Picot. His operative technique and the first six cases treated operatively between 1918 and 1921 were described in 1921 by Edouard Huc. Picot himself published his technique in great detail in 1923. CONCLUSION: The early history of diagnostics and treatment of PM fractures witnesses the remarkable body of knowledge gathered about that topic by numerous visionary surgeons predominantly French and German surgeons immediately before and after World War I. They substantially contributed to the radiological examination and operative treatment of this injury.

Pathophysiology of posttraumatic ankle osteoarthritis: a multicenter perspective / Fisiopatologia da osteoartrite pós-traumática do tornozelo: perspectiva multicêntrica

ABSTRACT Besides the acute injury and trauma-induced macroscopic alterations, the evolution to posttraumatic ankle osteoarthritis (PTOA) is a complex process progressing at the tissue and molecular level. Furthermore, changes in the molecular pathways affect chondrocyte viability. Treatment modalities for PTOA focal or confined disease include innovative techniques. Objective: Our purpose is to increase medical awareness based on scientific evidence of pathophysiology, molecular biology, and treatment of post-traumatic ankle osteoarthritis. Methods: To support the perspectives of the experts, evidence from the scientific literature respected the PRISMA guidelines and the PICOS search strategy was used. We included case-control, cohort, experimental studies and case reports, written in English. Results: The authors were homogeneously exposed to 282 selected abstracts and 114 full articles directly related to post-traumatic osteoarthritis after malleolar fractures. Conclusion: The pathophysiological factors involved in posttraumatic ankle osteoarthritis, such as biological, structural, mechanical, and molecular changes must be studied together, as the interaction between these factors determines the risk of progression of PTOA. Inhibition of a single catabolic molecule or cascade probably is not sufficient to alter the natural progression of the pathological process. Evidence level V, expert opinion.

RESUMO A evolução para a osteoartrite pós-traumática do tornozelo (PTOA) a partir da lesão aguda e das alterações macroscópicas induzidas pelo trauma é um processo complexo, que progride em nível tecidual e molecular. Além disso, as alterações nas vias moleculares afetam a viabilidade dos condrócitos. As modalidades focais ou confinadas de tratamento para PTOA incluem técnicas inovadoras. Objetivo: Nosso objetivo é aumentar a conscientização médica, com base em evidências científicas de fisiopatologia, biologia molecular e tratamento da osteoartrite pós-traumática do tornozelo. Métodos: Para o embasamento das perspectivas dos autores experts, as evidências da literatura científica respeitaram as diretrizes Prisma e a estratégia de busca Picos foi empregada. Incluímos estudos de caso-controle, de coorte, experimentais e relatos de caso, escritos em inglês. Resultados: Os autores foram expostos de forma homogênea a 282 resumos e 114 artigos completos, diretamente relacionados à osteoartrite pós-traumática após fraturas maleolares. Conclusão: Os fatores fisiopatológicos envolvidos na osteoartrite pós-traumática do tornozelo, como alterações biológicas, estruturais, mecânicas e moleculares, devem ser estudados em conjunto, pois a interação entre esses fatores determina o risco de progressão da PTOA. A inibição de uma única molécula catabólica ou cascata provavelmente não é suficiente para alterar a progressão natural do processo patológico. Nível de evidência V, opinião do especialista.

Injury to the posterior malleolus in Maisonneuve fractures.

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

Prevalence and Predictors of Peroneal Tendon Instability Accompanying Calcaneal Fractures.

BACKGROUND: We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning. METHODS: In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated. RESULTS: In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle (P = .03), dislocated peroneal tendons (P < .001), calcaneal fracture-dislocation (P < .001), SPR avulsion fracture (P < .001), and Sanders type IV of calcaneal fracture (P = .02). There was no statistically significant relationship between PTI and the mechanism of injury (P = .98), side of fracture (P = .30), uni- or bilateral calcaneal fractures (P = .27), a fracture at the tip of lateral malleolus (P = .69), shape of the retromalleolar groove (P = .78), or excessive displacement of the lateral calcaneal wall (P = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%). CONCLUSION: Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Benign tumours of foot and ankle.

Musculoskeletal tumours of foot or ankle make up about 4-5% of all musculoskeletal tumours. Fortunately, about 80% of them are benign. However, due to the rarity and low prevalence of each single tumour entity, diagnosis is often difficult and delayed. Ultrasonography is an important diagnostic tool to safely recognize ganglion cysts as a frequently encountered 'bump' in the foot. In suspicious lesions, malignancy must be excluded histologically in a tumour center by biopsy after imaging procedures using x-ray, computed tomography (CT) and magnetic resonance imaging (MRI). Most of the benign tumours do not require any further surgical therapy. Resection should be performed in the case of locally aggressive tumour growth or local symptoms of discomfort. In contrast to malignant tumours, the primary purpose in the resection is the least possible loss of function.

Ligament Ruptures in Ankle Fractures-Was Lauge-Hansen Right?

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.