Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture.

BACKGROUND: Whether surgical repair of an acute Achilles' tendon rupture by an open-repair or minimally invasive approach is associated with better outcomes than nonsurgical treatment is not clear. METHODS: We performed a multicenter, randomized, controlled trial that compared nonoperative treatment, open repair, and minimally invasive surgery in adults with acute Achilles' tendon rupture who presented to four trial centers. The primary outcome was the change from baseline in the Achilles' tendon Total Rupture Score (scores range from 0 to 100, with higher scores indicating better health status) at 12 months. Secondary outcomes included the incidence of tendon rerupture. RESULTS: A total of 554 patients underwent randomization, and 526 patients were included in the final analysis. The mean changes in the Achilles' tendon Total Rupture Score were -17.0 points in the nonoperative group, -16.0 points in the open-repair group, and -14.7 points in the minimally invasive surgery group (P = 0.57). Pairwise comparisons provided no evidence of differences between the groups. The changes from baseline in physical performance and patient-reported physical function were similar in the three groups. The number of tendon reruptures was higher in the nonoperative group (6.2%) than in the open-repair or minimally invasive surgery group (0.6% in each). There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%). CONCLUSIONS: In patients with Achilles' tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months. (Funded by the South-Eastern Norway Regional Health Authority and Akershus University Hospital; ClinicalTrials.gov number, NCT01785264.).

Comparative Analysis of Intramedullary Nail versus Plate Fixation for Fibula Fracture in Supination External Rotation Type IV Ankle Injury.

BACKGROUND Lateral malleolus fractures, typically from trauma, sports, or accidents, are common, with supination external rotation (SER) injuries being most prevalent. SER injuries involve complex joint mechanics and often necessitate surgical intervention for instability. This study compares intramedullary nail and plate fixation for fibula fractures in SER type IV ankle injuries, considering their biomechanical properties and influence on fracture healing. MATERIAL AND METHODS A prospective, randomized study was conducted between January 2021 and December 2021. A total of 81 patients with SER injuries were included in the study. Surgical procedures were performed using either intramedullary nails or plates. The following parameters were recorded and analyzed: postoperative complications, operation times, bone healing times, American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores for pain, and ankle range of motion. RESULTS Out of the 81 cases, 42 were treated with intramedullary nails, while 39 received plate fixation. Statistical analysis revealed a significantly lower rate of postoperative complications in the intramedullary nail group than in the the plate fixation group (9.52% vs 30.77%, P<0.0164). However, there were no significant differences between the 2 groups in terms of operation time, bone healing time, AOFAS scores, VAS scores, and functional evaluations (P>0.05). CONCLUSIONS Plate fixation and intramedullary nail fixation are effective techniques for treating fibula fractures in SER type IV injuries. However, intramedullary nail fixation demonstrates a lower rate of complications. Therefore, intramedullary nails may be preferable to plate fixation for the management of fibula fractures in SER type IV ankle injuries.

Bone marrow edema at ligament insertion is an accurate MRI sign of deltoid ligament injury.

BACKGROUND: Magnetic resonance imaging (MRI) is effective in diagnosing deltoid ligament (DL) injury but its sensitivity in chronic cases is low. Additional diagnostic signs are required to reduce the risk of a false negative diagnosis. PURPOSE: To evaluate the added diagnostic value of bone marrow edema at the ligament insertion (BMELI) of DL to the MRI assessment of chronic DL injury. MATERIAL AND METHODS: One hundred patients who consecutively came to our institution between November 2018 and December 2021 and underwent arthroscopic surgery for chronic ankle instability (CAI) were enrolled in the present study. Preoperative MR images were retrospectively reviewed by two orthopedic surgeons to evaluate the sensitivity, specificity and interobserver reliability of three MRI signs in diagnosing chronic DL injury, namely, abnormal ligamentous morphological characteristics (ALMC), BMELI and medial clear space (MCS). RESULTS: Taking arthroscopy as the reference standard, there were 34 patients with and 66 without DL injury. ALMC had 64.71% (22/34; 46.47-79.70) sensitivity and 83.33% (55/66; 71.71-91.00) specificity, BMELI had 70.59% (24/34; 52.33-84.29) sensitivity and 95.45% (63/66; 86.44-98.82) specificity and MCS had 26.47% (9/34; 13.51-44.65) sensitivity and 92.42% (61/66; 82.50-97.18) specificity. Compared with ALMC, BMELI had similar efficacy in superficial cases (P = 0.06) and greater efficacy in deep cases (P = 0.04). All three signs showed good interobserver agreement (kappa values all above 0.7). CONCLUSION: BMELI can reliably indicate concomitant injury to the DL in CAI patients. Using BMELI as a sign of chronic DL injury when ALMC is unclear may reduce the risk of a false negative diagnosis.

Outcome of flexible fixation for acute isolated syndesmotic injuries.

BACKGROUND: Management of syndesmotic injuries with screw fixation has potential disadvantages, which may lead to the loss of some of the ankle functions. The use of the suture-button system instead can overcome these disadvantages. PATIENTS AND METHODS: In a prospective study, 32 patients with acute isolated syndesmotic injuries were treated with a suture-button device. Follow-up was for a minimum of 2 years, regarding the Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, patient satisfaction at 3, 12, and 24 months, and radiological assessment. RESULT: A significant improvement regarding pain (VAS during rest 5.6 and during walking 6.1 preoperative improved to 0.1 and 0.2 postoperatively, respectively. (P values were < 0.0001 for both pain during rest and walking) and AOFAS score (improved significantly from 44 ± 7.5 pre- to 99 ± 8.7 points postoperatively (P value was 0.0034). The improved VAS and AOFAS scores of the repaired ankles gradually reached the values of the contralateral uninjured ankle (evaluated at 3,12, and 24 months, postoperatively). Radiographs and CT of both ankles - repaired and healthy ankles - were similar at the 3 months follow-up. Early full weight-bearing and early return to work and sport characterized all patients. There was no need for hardware removal. CONCLUSION: Suture-button treatment for acute isolated ankle syndesmotic injuries leads to favorable clinical and radiological outcomes. Postoperative radiographs and CT denoted maintained ankle stability. Patients can do early full weight-bearing and early return to work and sport.

Standing on single foot-binding test yields satisfactory results as a novel method for the diagnosis of distal tibiofibular syndesmosis instability: a prospective, cross-sectional diagnostic-accuracy study.

BACKGROUND: Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury. METHODS: 85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests. Sensitivity, specificity, PPV, NPV, LR+, LR - and their 95% CIs were calculated for each of the clinical tests as well as for the positive clinical diagnosis. RESULTS: The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR- (0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test. According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical practice for the prediction of DTSI. CONCLUSION: This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal tibiofibular syndesmosis instability (DTSI). LEVEL OF EVIDENCE: II.

Outcomes comparison of elastic bandage versus lower-leg cast immobilization after anterior talofibular ligament repair.

PURPOSE: The aim of this study was to compare the clinical outcomes between patients with chronic ankle instability (CAI) undergoing arthroscopic anterior talofibular ligament (ATFL) repair who received elastic bandage treatment and those who received lower-leg cast immobilization. METHODS: CAI patients with isolated ATFL injury undergoing arthroscopic ATFL repair from January 2017 and August 2019 were included in the study. The visual analogue scale (VAS) at rest and during activities, American Orthopedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (Karlsson score), and time of returning to walk, walk normally, work and sports were evaluated preoperatively, and at 6 months and 12 months follow-up. RESULTS: A total of 41 patients were included in this study. Among them, 24 patients accepted lower-leg cast fixation, and the other 17 patients were immobilized with elastic bandage. Compared to patients with lower-leg immobilization, patients with elastic bandage fixation had significantly lower VAS during activities (P = 0.021) and higher AOFAS score (P = 0.015) at 12 months follow-up. The Karlsson score at 6 months follow-up were significantly higher in elastic bandage group than those in lower-leg group (P = 0.011). However, no significant difference was observed in time of returning to walk, work and sports between the two groups. CONCLUSION: Elastic bandage treatment was better than lower-leg cast immobilization in terms of eliminating pain symptom at 12 months follow-up, and improving ankle functional outcome at 6 months follow-up. Moreover, the present study emphasized that lower-leg cast immobilization offered no advantages in arthroscopic ATFL repair postoperative immobilization. STUDY DESIGN: Cohort study; Level of evidence, 3.

Adult Tillaux-Chaput tubercle fracture of the ankle with rupture of the peroneus tertius muscle: a case report.

BACKGROUND: Tillaux-Chaput tubercle fractures occur in adolescents, which are often associated with the separation of the distal tibial growth plate. These types of fractures are rare in adults and even rarer when accompanied by a rupture of the peroneus tertius muscle. Given the limited number of reported cases, there is limited clinical awareness, resulting in missed diagnoses and delayed treatment, ultimately affecting ankle function. CASE PRESENTATION: We report a case of an adult patient who experienced a right ankle injury resulting in swelling and pain after a traffic accident. Initial examination failed to identify the rupture of the peroneus tertius muscle, but the patient was observed to have restricted dorsiflexion and eversion of the foot. Surgical exploration through an anterolateral incision confirmed the rupture and the muscle was then repaired. The patient received four weeks of cast immobilization and then engaged in progressive rehabilitation exercises. DISCUSSION AND CONCLUSION: This report shares the diagnostic and therapeutic experiences of an adult with a Tillaux-Chaput tubercle fracture associated with peroneus tertius muscle rupture to improve clinical recognition of such injuries, thus preventing misdiagnosis and treatment delays.

Neural interfacing architecture enables enhanced motor control and residual limb functionality postamputation.

Despite advancements in prosthetic technologies, patients with amputation today suffer great diminution in mobility and quality of life. We have developed a modified below-knee amputation (BKA) procedure that incorporates agonist-antagonist myoneural interfaces (AMIs), which surgically preserve and couple agonist-antagonist muscle pairs for the subtalar and ankle joints. AMIs are designed to restore physiological neuromuscular dynamics, enable bidirectional neural signaling, and offer greater neuroprosthetic controllability compared to traditional amputation techniques. In this prospective, nonrandomized, unmasked study design, 15 subjects with AMI below-knee amputation (AB) were matched with 7 subjects who underwent a traditional below-knee amputation (TB). AB subjects demonstrated significantly greater control of their residual limb musculature, production of more differentiable efferent control signals, and greater precision of movement compared to TB subjects (P < 0.008). This may be due to the presence of greater proprioceptive inputs facilitated by the significantly higher fascicle strains resulting from coordinated muscle excursion in AB subjects (P < 0.05). AB subjects reported significantly greater phantom range of motion postamputation (AB: 12.47 ± 2.41, TB: 10.14 ± 1.45 degrees) when compared to TB subjects (P < 0.05). Furthermore, AB subjects also reported less pain (12.25 ± 5.37) than TB subjects (17.29 ± 10.22) and a significant reduction when compared to their preoperative baseline (P < 0.05). Compared with traditional amputation, the construction of AMIs during amputation confers the benefits of enhanced physiological neuromuscular dynamics, proprioception, and phantom limb perception. Subjects' activation of the AMIs produces more differentiable electromyography (EMG) for myoelectric prosthesis control and demonstrates more positive clinical outcomes.

Quantitative assessment of anterior talofibular ligament quality in chronic lateral ankle instability using magnetic resonance imaging T2* value.

OBJECTIVE: To determine T2* normal reference values for anterior talofibular ligament (ATFL) and to investigate the feasibility of the quantitative ATFL quality evaluation in chronic lateral ankle instability (CLAI) using T2* values. MATERIALS AND METHODS: This study enrolled 15 patients with CLAI and 30 healthy volunteers. The entire ATFL T2* values from the MRI T2* mapping were measured. The prediction equation (variables: age, height, and weight) in a multiple linear regression model was used to calculate the T2* normal reference value in the healthy group. T2* ratio was defined as the ratio of the actual T2* value of the patient's ATFL to the normal reference value for each patient. A Telos device was used to measure the talar tilt angle (TTA) from the stress radiograph. RESULTS: T2* values of ATFL in the healthy and CLAI groups were 10.82 ± 1.84 ms and 14.36 ± 4.30 ms, respectively, which are significantly higher in the CLAI group (P < 0.05). The prediction equation of the normal reference T2* value was [14.9 + 0.14 × age (years) - 4.7 × height (m) - 0.03 × weight (kg)] (R2 = 0.65, P < 0.0001). A significant positive correlation was found between the T2* ratio and TTA (r = 0.66, P = 0.007). CONCLUSION: MRI T2* values in patients with CLAI were higher than those in healthy participants, and the T2* ratio correlated with TTA, suggesting that T2* values are promising for quantitative assessment of ATFL quality preoperatively.

A hypertrophic distal fascicle of the anterior tibiofibular ligament is associated with a high rate of osteochondral lesions of the talus.

PURPOSE: The purpose of this retrospective review was to determine the prevalence of osteochondral lesions (OCLs) of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament. METHODS: Retrospective chart review identified 40 patients who underwent anterior ankle arthroscopy for the management of anterior ankle impingement. Clinical outcomes assessed included pre- and postoperative foot and ankle outcome score (FAOS), visual analogue scale (VAS), complications, failures, secondary surgical procedures, return-to-work data and return-to-sport data. RESULTS: Thirty-two patients with a mean follow-up time of 29.3 ± 10.4 months were included. The hypertrophic distal fascicle of the anterior tibio-fibular ligament was hypertrophic in 29 patients (90.6%), with a mean thickness of 2.5 ± 0.4 mm on MRI. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament visualized during arthroscopy. The international cartilage repair society gradings of the lesions included 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from preoperative to postoperative (p < 0.001). No cases of syndesmotic instability were observed following resection of hypertrophic distal fascicle of the anterior tibio-fibular ligament. CONCLUSION: This retrospective case series demonstrated that a hypertrophic distal fascicle of the anterior tibio-fibular ligament was associated with an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, preoperative MRI demonstrated poor sensitivity for the detection of these OCLs. Heightened awareness is warranted for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf identified on preoperative MRI in the absence of an associated OCLs. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Fibular morphology is not associated with incidence of peroneal tendon dislocation.

PURPOSE: The association of peroneal tendon dislocation with peroneal bone morphology and postoperative redislocation rates remains unknown. This study compared the fibula morphology in patients with peroneal tendon dislocation with that in a control population. METHODS: The study enrolled 48 patients who underwent surgery for peroneal tendon dislocation at our institution during between 2018 and 2023. Thirty-five patients with preoperative magnetic resonance imaging of the ankle were defined as Group D and 35 with magnetic resonance imaging of the ankle for other reasons and with similar background data were selected as the control group (Group C). The posterior tilting angle of the fibula, posterolateral angle and posterolateral edge angle were evaluated at the plafond level. The posterior tilting angle, posterolateral angle and retromalleolar bone shape according to the Rosenberg classification (flat, convex, concave) were evaluated at the midpoint between the plafond and the tip. RESULTS: At the plafond level, the posterior tilting, posterolateral and posterolateral edge angles were 57.7 ± 11.1°, 123.8 ± 12.3° and 90.8 ± 13.7°, respectively, in Group D and 64.1 ± 15.4°, 121.1 ± 12.3° and 88.7 ± 12.2°, respectively, in Group C, with no significant differences. No significant between-group differences existed in the posterior tilting and posterolateral angles at the midpoint level. Moreover, no significant differences existed in distribution of the bone geometry according to the Rosenberg classification. CONCLUSION: There were no differences in morphology between patients with peroneal tendon dislocation and controls. This study provides useful information on the indications for primary surgery and whether bony approach is useful for peroneal tendon dislocation. LEVEL OF EVIDENCE: Level IV.

Anterior talofibular ligament's superior fascicle as a cause of ankle microinstability can be routinely identified by ultrasound.

PURPOSE: Chronic pain can affect up to 40% of patients after ankle inversion sprains. The current hypothesis to explain this high percentage of chronic pain is a partial/total rupture of anterior talofibular ligament (ATFL) superior fascicle, a structure that has recently been described as intra-articular and as having a different function than ATFL's inferior fascicle. This has created the need for diagnosing ATFL superior and inferior fascicles independently. Therefore, the objective of this study is to investigate if the ATFL's superior fascicle can be visualized on ultrasound, and to describe its ultrasonographic appearance. METHODS: Twenty fresh-frozen ankle specimens were used in this 4-phases study. First, the specimens were scanned on US to identify what was believed to be ATFL's superior fascicle. Second, ATFL's superior fascicle was sutured under direct arthroscopic vision. Next, the specimens were scanned on US to obtain an image of the sutured structure. Finally, the specimens were dissected to confirm that the suture was indeed placed on ATFL's superior fascicle. RESULTS: On the 20 specimens studied, full correlation was obtained between US, arthroscopic suture and specimen dissection. ATFL's superior fascicle US appearance is provided. CONCLUSION: ATFL's superior fascicle can be visualized on US, which will allow to undergo diagnosis of isolated injuries to that fascicle, a common finding in ankle microinstability. The results of this study will facilitate the diagnosis of partial or complete rupture of ATFL's superior fascicle, likely increasing the amount of ankle microinstability diagnosis, impacting clinical management of ankle sprain consequences.

Propeller flap's assisted recipient site closure after free SCIP flap coverage of medial ankle defect: A case report.

Defects in the distal lower limbs are common in the field of orthoplastic reconstruction. The ankle area presents little subcutaneous tissue and is often affected by high-energy traumas and bone fractures. Wounds in this region are frequently associated with severe edema that might prevent primary closure. Due to its thinness and tension, the skin overlying both the medial and lateral malleoli is prone to necrosis, which can further lead to large soft tissue defects. Vessels, nerves, and tendons can easily become exposed. The reconstructive approach should aim to provide high-quality tissue that is durable enough to withstand the weight-bearing pressures and the friction from shoes, while remaining sufficiently elastic to conform to the shape of the ankle and to permit the foot movement. In this study, we describe the use of an additional propeller flap to reduce skin tension at the recipient site. A superficial circumflex iliac artery perforator (SCIP) flap was utilized to cover a defect below the medial malleolus. However, after flap inset, achieving a primary closure of the proximal wound without tension was not possible. During the dissection of the posterior tibial artery, perforator vessels were identified and preserved. The larger of these vessels was then used to vascularize a propeller flap, which was then rotated toward the defect to aid a tension-free closure. The postoperative course was uneventful. This case may provide a valuable insight into the challenges often faced during wound closure, even after flap inset. Since the flap itself may increase the width of the dissection area, the present case shows the importance of preserving perforator vessels during the proximal dissection since they can allow the harvest of an additional flap to achieve primary closure and further alleviate tension.

Postural Stability and Pedobarography After Reconstruction of Peroneus Brevis Tendon Split Lesion.

PURPOSE: Lesions of the peroneal tendons are frequently overseen after ankle sprain. The symptoms consist of stress-dependent pain that extends from the inframalleolar to the proximal part along the course of the peroneal tendons as well as ankle instability and soft-tissue swelling. In case of unsuccessful conservative treatment, surgical therapy is recommended. The aim of the study was to evaluate the clinical and functional outcome after open reconstruction of the peroneus brevis tendon. METHODS: 13 patients were included in this retrospective study. All of them received a single reconstruction of the peroneus brevis tendon in open technique. Postoperative results were evaluated with the AOFAS score, a functional and perdobargraphic analysis as well as measuring postural stability with the Biodex balance system. The participants were matched with a healthy control group according to age, sex and BMI. RESULTS: The results of the AOFAS score showed significantly convincing results in all subscores postoperatively. A bilateral comparison of the postural stability showed that the affected side had become functionally similar to the healthy side. No statistical significant difference was detected concerning both one-legged and two-legged standing with the control group. Pedobarographic results revealed no difference between the affected and contralateral side, as well as between the patients and the healthy control group. CONCLUSION: Open reconstruction of the peroneus brevis tendon leads to significant better postoperative results and can be recommended after unsuccessful conservative treatment as promising option.

Value of arthroscopy in the management of acute lesions of the distal tibiofibular joint.

PURPOSE: Managing the distal tibiofibular (DTF) joint remains a challenge despite recent developments. Ankle arthroscopy is emerging as a diagnostic and therapeutic means. Our study aimed to compare preoperative imaging data and arthroscopic data, with the hypothesis that imaging alone is insufficient to evaluate acute laxity, and with arthroscopy as the reference examination. METHODS: All patients treated in 2023 in our department for an acute isolated DTF lesion were included prospectively. Preoperative radiographic and MRI imaging were compared with arthroscopic data. RESULTS: Ten patients were treated. For five patients, the instability was doubtful after carrying out an appropriate imaging assessment (X-rays of both ankles, MRI). For four of these five patients, instability was confirmed by arthroscopy. Arthroscopy was useful for suturing the anterior bundle of the DTF joint for two patients and allowed for verifying the reduction in the sagittal and coronal planes for two patients. No complications were detected. CONCLUSIONS: Arthroscopy in isolated acute DTF lesions seems to provide a diagnostic and therapeutic advantage. Its use may allow for exhaustive assessment and complete repair of lesions. It must be offered as soon as possible; a delay in specialized imaging may delay therapeutic care.

Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis.

INTRODUCTION: The present meta-analysis evaluated current level I clinical trials which compared the use of a suture button (SB) versus syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. It was hypothesised that SB might achieve better PROMs along with a lower rate of complications. METHODS: This study was conducted according to the 2020 PRISMA statement. In August 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed. All the randomised controlled trials (RCTs) which compared SB versus SS fixation for syndesmosis injuries of the ankle were accessed. Data concerning the American Orthopaedic Foot & Ankle Society (AOFAS), and Olerud-Molander score (OMS) were collected at baseline and at last follow-up. Data on implant failure, implant removal, and joint malreduction were also retrieved. RESULTS: Data from seven RCTs (490 patients) were collected. 33% (161 of 490) were women. The mean length of the follow-up was 30.8 ± 27.4 months. The mean age of the patients was 41.1 ± 4.1 years. Between the two groups (SB and SS), comparability was found in the mean age, and men:women ratio. The SS group evidenced lower OMS (P = 0.0006) and lower AOFAS (P = 0.03). The SS group evidenced a greater rate of implant failure (P = 0.0003), implant removal (P = 0.0005), and malreduction (P = 0.04). CONCLUSION: Suture button fixation might perform better than the syndesmotic screw fixation in syndesmotic injuries of the ankle.

Comparison between screw fixation and plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis.

BACKGROUND: Optimal surgical fixation for displaced intra-articular calcaneal fractures (DIACF) remains a subject of debate, particularly regarding the superiority between screw fixation and plate fixation via the sinus tarsi approach (STA). This review aims to determine the preferred treatment for DIACF and compare the outcomes of minimally invasive surgery options. METHODS: Our study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on distal intra-articular fractures of the calcaneus (DIACFs) that were fixed using cannulated screws or plates via STA. Through a comprehensive meta-analysis, we evaluated several outcomes, including post-operative function, radiological measurements, and complications. RESULT: A total of 728 patients from 7 studies met the inclusion criteria. Among them, 435 patients underwent screw fixation via STA, and 373 patients underwent plate fixation via STA. The study found no statistically significant differences between the screw fixation and the plate fixation via sinus tarsi approach (STA) in terms of AOFAS scores, Bohler's angle, Gissane's angle, sural nerve injury, secondary subtalar arthrodesis and reoperation. Compared with screw fixation, plate fixation via STA can reduce reduction loss of Bohler's angle (WMD = - 1.64, 95% CI = [- 2.96, - 0.31], P = 0.06, I2 = 59%), lower the incidence of fixation failure (OR = 0.32, 95% CI = [0.13, 0.81], P = 0.78, I2 = 0%), and decrease intra-articular step-off (WMD = - 0.52, 95% CI = [- 0.87, - 0.17], P = 0.66, I2 = 0%). CONCLUSIONS: Plate fixation demonstrates superior capability in restoring calcaneal width, maintaining Bohler's angle, and minimizing intra-articular step-off, thereby maintaining better reduction of the subtalar articular surface. In addition, plate fixation exhibits the modest complication rate and a low incidence of fixation failure. Therefore, we recommend the use of plate fixation through the STA, especially for complex and comminuted intra-articular calcaneal fractures.

Relationship between pain and intra-articular pathology in patients with chronic lateral ankle instability.

PURPOSE: Repeated ankle sprains can lead to chronic lateral ankle instability (CLAI). It is unclear whether CLAI causes pain unless complicated by intra-articular lesions. This study aimed to analyze the characteristics of pain and the relationship between pain and intra-articular pathology in patients with CLAI. MATERIALS AND METHODS: Fifty-three ankles in 46 patients with CLAI who had undergone surgery were retrospectively reviewed. The self-administered foot evaluation questionnaire (SAFE-Q) was given to patients the day before surgery. Intra-articular lesions were assessed using arthroscopy and magnetic resonance imaging (MRI). In addition, the Hounsfield Unit (HU) on computed tomography (CT) of the medial gutter was measured. The relationship between pain and intra-articular findings was also analyzed. RESULTS: The pain and pain-related scores in the SAFE-Q were significantly correlated with synovitis in 96.3% (rs = - 0.532). HU ratios in the tibia and talus were also significantly correlated with pain (rs = - 0.603, - 0.534, respectively). The arthroscopic synovitis score and HU ratios in patients with high pain scores were significantly higher than those in patients with low pain scores. Forty ankles (75.5%) had synovitis and articular cartilage injuries were observed in 22 ankles (41.5%). Patients with fluid collection or bone marrow lesions (BML) scored significantly lower in pain than those without, but there was no significant difference between patients with and without cartilage injury. Multiple regression analysis revealed that a high synovitis score and HU ratio of the talus were significantly associated with high pain. CONCLUSIONS: Intra-articular lesions such as synovitis and BML were associated with pain in patients with CLAI. Osteosclerotic changes in the medial gutter also induced ankle pain, indicating that osteoarthritic changes had already begun. Therefore, lateral ankle ligament injuries after ankle sprain should be appropriately treated to avoid secondary degenerative changes.

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography.

INTRODUCTION: The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries. MATERIALS AND METHODS: The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant. RESULTS: The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury. CONCLUSION: Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

High Resolution MRI Confirms Torsional Injury as Mechanism for Combined Ankle and Common Fibular (Peroneal) Nerve Injuries.

Common fibular nerve (CFN) injury due to ankle fracture is an underreported complication. The authors have proposed that torsional injury to the ankle can be translated along the interosseous membrane (IOM), producing tension on the CFN at the fibular neck. A 23-year-old woman presented to our clinic for left foot drop. Three months prior, the patient sustained a fall with left ankle inversion injury while running. She was diagnosed with a minor ankle fracture and placed in an orthopaedic boot. Unfortunately, her swelling worsened and one week later the patient was diagnosed with foot drop, which was further corroborated with EMG studies showing severe CFN injury localizing to the fibular neck. Because of the lack of recovery, she underwent decompression of the CFN. She experienced immediate symptomatic relief. High resolution imaging in this case supports our previous mechanism for indirect trauma to the ankle resulting in CFN injury. (Journal of Surgical Orthopaedic Advances 33(1):053-055, 2024).