The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture.

BACKGROUND: Our aim in this study was to identify the fibular footprint of the Anterior Inferior Tibiofibular Ligament (AITFL) and its relation to Wagstaffe fracture fragment size. METHODS: We examined 25 cadaveric lower limbs which were carefully dissected to identify the lateral ankle ligaments. The AITFL anatomy was compared to 40 Wagstaffe fractures identified from our ankle fracture database. RESULTS: The AITFL origin was from the anterior fibular tubercle with an average length of 21.61 mm (95% CI 20.22, 22.99). The average distance of the distal aspect of the AITFL footprint to the distal fibula margin was 11.60 mm (95% CI 10.49, 12.71). In the ankle fractures analyzed, the average length of the Wagstaffe fragment was 17.88 mm (95% CI 16.21, 19.54). The average distance from the distal tip of the fibula to the Wagstaffe fracture fragment was 21.40 mm (95% CI 19.78, 23.01). In total there were 22 syndesmosis injuries. There was no statistical difference in Wagstaffe fragment size between stable and unstable groups. CONCLUSION: The AITFL fibular origin was both larger and more distal than the Wagstaffe fracture fragments seen in our institution. Therefore, this suggests that a ligamentous failure will also have to occur to result in syndesmotic instability. The size of fracture fragment also did not confer to syndesmotic instability on testing. Level of Evidence - 3.

Evaluating Short-Term Outcomes Post-Intra-Articular Calcaneal Fracture Fixation via a Sinus Tarsi Approach in a Non-Exclusively Selected Cohort.

Management of intra-articular calcaneal fractures remains a debated topic in orthopedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures. All patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and postoperative fracture geometry with computed tomography used for preoperative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score. Fifty-eight intra-articular calcaneal fractures (53 patients; 5 bilateral, mean age = 46.91 years) with a mean follow-up of 35.4 months (6-57) were included. Five patients (9.4%) had wound complications; 2 superficial (3.7%), 3 deep (5.6%); 4 of whom were smokers. Smokers were statistically more likely to have wound infections than nonsmokers (p = .04). Intra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of postoperative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.

The lateral transligamentous approach to the talar dome.

INTRODUCTION: Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated 43% talar body access with a single incision and without malleolar osteotomy. The aim of this study was to investigate the percentage talar body exposure when using the lateral transligamentous approach. METHODS: The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion. A mark was made on the talar dome where an instrument could be placed 90 degrees to the talar surface. The talus was subsequently disarticulated and high-resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid was documented using the mark made on the talar surface. ImageJ software was used to calculate the surface area exposed with each approach. RESULTS: The mean percentage area of talar dome available through the transligamentous approach was 77.3% (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1, 2, 3, 5 & 6 with partial access to Zones 4, 8 & 9. CONCLUSION: The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zones 4,7 and 8, the posteromedial corner. LEVEL OF CLINICAL EVIDENCE: V.

Gas forming infection of the spine: a systematic and narrative review.

PURPOSE: Gas forming infection (GFI) of the spine is a rapidly progressive and potentially life-threatening infection. It can be a consequence of aetiologies such as Emphysematous Osteomyelitis (EOM), Necrotizing Fasciitis (NF), and Gas-containing Spinal Epidural Abscess (Gas-containing SEA). This review aims to summarize the characteristics of these subtypes of GFI, describing their aetiology, diagnosis, management, and prognosis. METHODS: PubMed, Embase, Web of Science and the Cochrane Database were systematically searched for studies reporting on gas forming infections of the spine or a known subtype. Cases of post-operative and iatrogenic spinal infection were excluded. RESULTS: The literature review revealed 35 studies reporting on 28 cases of EOM, three cases of NF involving the spine and seven cases of Gas-containing SEA. Thirty studies reporting on 32 cases of GFI were available for data analysis. The mean age of the patients was 60.9 years and a concomitant diagnosis of diabetes mellitus was reported in 57.5% of patients infected. Fever and back pain were the most common presenting symptoms. The lumbar spine was the most commonly affected spinal segment. Mortality from EOM, NF and Gas-containing SEA were 34.8, 100 and 28.5%, respectively. DISCUSSION: Gas forming infection of the spine is a rare condition with an extremely poor prognosis, requiring early and aggressive surgical treatment. A multi-disciplinary approach is necessary for management. Nonetheless, even in cases of early recognition and optimal management, multisystem failure may still occur, and mortality rates remain high due to the aggressive nature of this infection. LEVEL OF EVIDENCE: Systematic review of level IV studies.

Ankle stability in ankle fracture.

Restoration of normal ankle kinematics should be the all-encompassing ethos in the approach to management of ankle fractures. To do this, the ligamentous stabilisers must also form part of its assessment and definitive management and be considered during index fracture fixation surgery. This article is a review of the anatomy, mechanics and clinical testing of instability in ankle fractures.