Maisonneuve fracture treated with short leg cast: A case report with 41-month follow-up.

RATIONALE: Maisonneuve fracture is a specific type of severe ankle injury. To our current knowledge, once a Maisonneuve fracture is diagnosed, the surgery is always recommended for fear of sequelae from inaccurate joint reconstruction. However, in this case, we treated a Maisonneuve fracture with a short leg cast, and the 41-month follow-up showed a favorable outcome with no post-traumatic osteoarthritis, chronic pain, and instability. Therefore, this case provides evidence for the feasibility of conservative treatment of Maisonneuve fracture. PATIENT CONCERNS: A female patient in her early twenties sprained her left ankle while running, suffering regional pain, swelling, and limited mobility. DIAGNOSES: We diagnosed a Maisonneuve fracture with superior fibular fracture and Volkmann tuberosity fracture, a slight separation of inferior tibiofibular syndesmosis (ITS). INTERVENTIONS: The patient rejected our surgical recommendations in favor of nonsurgical treatment, in addition to refusing immobilization of the knee. Consequently, we had to treat her with a short leg cast for 8 weeks and asked her to return for regular follow-up visits. OUTCOMES: At the final follow-up, the radiography showed complete healing of proximal fibula fracture. The patient reported no discernible subjective differences between her bilateral ankles. The range of motion of the left ankle was measured at 22° of dorsiflexion and 40° of plantarflexion. Functional assessments using Olerud-Molander ankle scale and American Orthopedic Foot and Ankle Society Ankle-Hindfoot scale both scored 100 points. Additionally, the radiographic assessment classified arthritis as stage 0 according to Morrey-Wiedeman classification. LESSONS: To avoid missing and misdiagnosing, the physical examination should always extend to 2 neighboring joints. Secondly, if a Maisonneuve fracture is suspected, further computed tomography scans, radiography, and magnetic resonance imaging can help to determine the stability of the ITS and the integrity of the lateral collateral ligaments before making therapeutic decisions. Finally, considering the lateral collateral ligaments may remain intact, we recommend stabilizing ITS by repairing the medial ligaments, which can be conducted arthroscopically and be more minimally invasive, providing an elastic fixation that aligns better with the biomechanics of the ITS which is characterized as a micro-mobile rather than fully fixed joint.

Preoperative and Postoperative Imaging and Outcome Scores for Osteochondral Lesion Repair of the Ankle.

Cartilage lesions to the ankle joint are common and can result in pain and functional limitations. Surgical treatment aims to restore the damaged cartilage's integrity and quality. However, the current evidence for establishing best practices in ankle cartilage repair is characterized by limited quality and a low level of evidence. One of the contributing factors is the lack of standardized preoperative and postoperative assessment methods to evaluate treatment effectiveness and visualize repaired cartilage. This review article seeks to examine the importance of preoperative imaging, classification systems, patient-reported outcome measures, and radiological evaluation techniques for cartilage repair surgeries.

Management of Pediatric Supination-inversion Ankle Injuries Involving Distal Tibia and Intraepiphyseal Distal Fibula Fractures.

Pediatric ankle fractures are prevalent injuries that make up a notable portion of all periphyseal injuries. The Salter-Harris classification is the most popular classification about physeal and periepiphyseal injuries. Ogden expanded on this and described type 7 fractures which are completely intraepiphyseal and include propagation of the fracture from the articular surface through the epiphyseal cartilage and do not involve the physis. These injuries are common about the distal fibula in pediatric patients with supination-inversion type injuries. There are no specific guidelines or recommendations on treatment of these injuries in the literature. We present three cases of this injury pattern and describe our chosen management that leads each patient to full, painless ankle range of motion and return to all prior activities and sports without complication. Supination-inversion type pediatric ankle fractures are common injuries that all orthopaedic surgeons will encounter at some point throughout their practice or training. Recognizing fracture variants and understanding treatment options of pediatric ankle fractures are important for the orthopaedic community as a whole.

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.

Risk Factors for Revision of External Fixation of Unstable Ankle Injuries.

INTRODUCTION: External fixation of unstable ankle injuries is commonly done by orthopaedic surgeons. An improper technique can negate the benefits of the procedure and necessitate revision. This study sought to determine the risk factors for revision of external fixation of unstable ankle injuries. METHODS: Retrospective cohort at a level I academic trauma center of 120 consecutive patients underwent external fixation of an unstable ankle injury. Exclusion criteria included external fixation for reason other than fracture, inadequate intraoperative imaging, skeletal immaturity, and follow-up less than 30 days. Primary outcome measurement was revision of external fixation within 30 days. RESULTS: Ninety-seven patients met inclusion criteria. Eighteen (18.6%) underwent revision within 30 days of whom 5 (28%, P < 0.001) had a poor reduction intraoperatively. No patients with a good reduction required revision. Revised patients had a significantly higher talar tilt (P < 0.001) and were more likely to lack a first metatarsal pin (P = 0.018). Multivariate analysis revealed talar tilt >0.5° (odds ratio, 22.62; 95% confidence interval, 6.52 to 50.63) as an independent risk factor for revision. DISCUSSION: For external fixation of unstable ankle injuries, poor reduction quality is a risk factor for need for revision surgery. Orthopaedic surgeons should be critical of their final intraoperative assessment to prevent revision.

Bilateral Os Trigonum Fracture Treated With Simultaneous Posterior Ankle Arthroscopy.

This is a case report of a 21-year-old female undergraduate student who sustained bilateral ankle injuries while jumping from a moving van wearing 3-inch high heel shoes. Upon initial presentation, her injury was treated conservatively as an acute bilateral ankle sprain for 6 weeks. However, the patient reported no improvement of pain and remained unable to self-ambulate. Bilateral MRI and CT scans of both ankles demonstrated bilateral os trigonum fractures. She underwent bilateral posterior ankle arthroscopic débridement of both os trigonum. At the postoperative 36-month follow-up, the patient reported notable improvement of all functional outcomes (36-item Short Form survey and Foot and Ankle Ability Measure), reported return to the same level of sports activities, and experienced no pain (visual analog scale) on either ankle. This is the first report in the literature of bilateral os trigonum fracture treated with simultaneous posterior ankle arthroscopic débridement.

Measuring External Rotation of the Fibula and Fibular Length in Bilateral Computed Tomography Scans: How Reliable Is This Method?

OBJECTIVES: During ankle fracture surgery, goals include accurate reduction and fixation of the fibula regarding rotation and fibular length. Bilateral postoperative computed tomography (CT) can be performed to assess fibular rotation using the talar dome angle, and fibular length. The aim of this study was to compare side-to-side differences of the fibular rotation and fibular length using bilateral CT scans of uninjured ankles. DESIGN: Retrospective. SETTING: Single center, Level I Academic Trauma Center. PATIENT SELECTION CRITERIA: Patients with bilateral CT scans of uninjured ankles. OUTCOME MEASURES AND COMPARISONS: External rotation using the Nault talar dome method and fibular length using the coronal method of Prior et al. The average, difference, and ratio (injured side/healthy side) and interobserver variability were calculated. RESULTS: There were 83 patients included (166 ankles, mean age 47 years, 77.1% male). A random set of 66 ankles (33 CT scans) were used to measure interobserver variability. The mean degrees of external rotation ranged from 6.6 to 7.7, mean difference ranged from 1.4 to 3.4 degrees, mean ratio ranged from 1.1 to 1.5, and interobserver variability ranged from 0.27 to 0.65. For fibular length, the mean ranged from 24.6 to 25.8 mm, mean difference in fibular length ranged from 0.5 to 2.1 mm, mean ratio ranged from 1.0 to 1.1 mm, and interobserver variability ranged from 0.45 to 0.73. CONCLUSIONS: Using bilateral ankle CT scans, mean differences in fibular rotation using the Nault talar dome method were 1.4-3.4 degrees. The distal fibular length had a mean difference between both sides of 0.5-2.1 mm. Although the intraclass correlation's were low, the interleg differences between patients were small, making them useful for clinical practice. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

MRI findings of peroneal tendon tears do not necessarily correlate to clinical findings in paediatric and adolescent patients.

PURPOSE: Pathologic abnormality of the peroneal tendons are thought to be an under-appreciated source of vague ankle and hindfoot pain in paediatric patients, partly because they can be difficult to diagnose and differentiate from lateral ankle ligament injuries. While magnetic resonance imaging (MRI) is the primary imaging modality used to detect peroneal tendon pathology, previous studies in adults have found that positive MRIs demonstrate a positive predictive value (PPV) of associated clinical findings around 48%. There are no similar known published studies in the paediatric population. Our objective was to determine the positive predictive value of peroneal tendon pathology as diagnosed by MRI as related to positive clinical exam findings in the paediatric and adolescent population. METHODS: This IRB approved retrospective study was conducted at a tertiary children's hospital. Inclusion criteria included patients under 18 years from our tertiary care institution with (a) ankle MRI findings indicating pathology of the peroneus brevis/longus tendons confirmed by a board certified paediatric musculoskeletal radiologist and (b) formal review of the clinical examination by a fellowship trained paediatric orthopaedic surgeon. Patients with congenital deformities or previous surgical intervention of the lateral ankle were excluded. RESULTS: Forty-seven patients (with 48 MRIs) met inclusion criteria over a ten year period. The majority of the positive MRI scans (70%) demonstrated a peroneus brevis split tear. Of the patients with positive findings on MRI, 17 patients had an associated positive clinical exam. The positive predictive value of MRI for peroneal tendon tears with positive clinical findings was 35.41% (95% confidence interval = 31.1% to 41.6%). There were 31 patients with MRI positive findings with a negative clinical exam. CONCLUSION: Despite having a negative clinical exam, a high percentage of patients had positive MRI findings suggestive of peroneal tendon pathology which confirms findings of adult populations demonstrating a high rate of incidental finding of peroneal tendon pathology on MRI in paediatric patients.

Differences and relationships between weightbearing and non-weightbearing dorsiflexion range of motion in foot and ankle injuries.

BACKGROUND: This study aimed to: (1) identify assessment methods that can detect greater ankle dorsiflexion range of motion (DROM) limitation in the injured limb; (2) determine whether differences in weightbearing measurements exist even in the absence of DROM limitations in the injured limb according to non-weightbearing measurements; and (3) examine associations between DROM in the weightbearing and non-weightbearing positions and compare those between a patient group with foot and ankle injuries and a healthy group. METHODS: Eighty-two patients with foot and ankle injuries (e.g., fractures, ligament and tendon injuries) and 49 healthy individuals participated in this study. Non-weightbearing DROM was measured under two different conditions: prone position with knee extended and prone position with knee flexed. Weightbearing DROM was measured as the tibia inclination angle (weightbearing angle) and distance between the big toe and wall (weightbearing distance) at maximum dorsiflexion. The effects of side (injured, uninjured) and measurement method on DROM in the patient groups were assessed using two-way repeated-measures ANOVA and t-tests. Pearson correlations between measurements were assessed. In addition, we analyzed whether patients without non-weightbearing DROM limitation (≤ 3 degrees) showed limitations in weightbearing DROM using t-tests with Bonferroni correction. RESULTS: DROM in patient groups differed significantly between legs with all measurement methods (all: P < 0.001), with the largest effect size for weightbearing angle (d = 0.95). Patients without non-weightbearing DROM limitation (n = 37) displayed significantly smaller weightbearing angle and weightbearing distance on the injured side than on the uninjured side (P < 0.001 each), with large effect sizes (d = 0.97-1.06). Correlation coefficients between DROM in non-weightbearing and weightbearing positions were very weak (R = 0.17, P = 0.123) to moderate (R = 0.26-0.49, P < 0.05) for the patient group, and moderate to strong for the healthy group (R = 0.51-0.69, P < 0.05). CONCLUSIONS: DROM limitations due to foot and ankle injuries may be overlooked if measurements are only taken in the non-weightbearing position and should also be measured in the weightbearing position. Furthermore, DROM measurements in non-weightbearing and weightbearing positions may assess different characteristics, particularly in patient group. LEVEL OF EVIDENCE: Level IV, cross-sectional study.

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.

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.

Could medial malleolus fracture be combined with deltoid ligament injury?: A rare case report.

RATIONALE: Medial malleolus injuries mainly comprise of fractures and deltoid ligament ruptures. Medial malleolus fractures, as a kind of common ankle fractures, could occur separately or be accompanied by lateral and posterior malleolus fractures. It is generally agreed that medial malleolus fracture and deltoid ligament rupture could not occur simultaneously. PATIENT CONCERNS: In our study, we report a case of 36 year-old man diagnosed with trimalleolar fracture accompanying ankle dislocation initially. The patient was admitted to our hospital due to traffic accident. DIAGNOSIS: The patient was diagnosed with trimalleolar fracture accompanying ankle dislocation initially. We missed the diagnosis of accompanied deltoid ligament due to the arthralgia of medial ankle and the widened medial articular space in X-ray after operation. INTERVENTION: As we missed the diagnosis of accompanied deltoid ligament, we only selected open reduction and internal fixation for trimalleolar fracture at first. After we realized the existence of deltoid ligament rupture, the patient refuse further diagnosis and treatment in our hospital. OUTCOMES: During the rehabilitation exercise, the patient had medial arthralgia in his right ankle. He complained it and refuse further diagnosis and treatment in our hospital. LESSONS: The newfound injury pattern, medial malleolus fracture accompanying deltoid ligament rupture, has not been reported in previous studies. The injury pattern needs further researches to explore the mechanism and it should be taken seriously in clinical practice.

Variability in sonographic anterior drawer test measurements of the ankle: Experienced versus beginner examiners.

BACKGROUND: This study aimed to clarify the variability in the measurements of stress sonography of the ankle and determine the effects of examiner experience on the measurements. METHODS: Twenty examiners (10 experienced and 10 beginners) were included in the study. Each examiner performed stress ultrasonography on a patient with a chronic anterior talofibular ligament injury and a patient with an intact ligament using the reverse anterior drawer method. Changes in ligament length before versus after stress were determined. The same 20 examiners performed ultrasonography on two other patients with an injured or intact ATFL using the anterior drawer method. The length change values and variance were compared between the groups using t-tests and F-tests. RESULTS: Using the reverse anterior drawer method, the change in the anterior talofibular ligament length was 3.3 mm (range, 2.2-4.8 mm) in the experienced group and 2.7 mm (0.0-4.1 mm) in the beginner group for the ligament injured patient. The length changes for the patient with intact anterior talofibular ligament were 0.5 mm (0.1-0.9 mm) and 0.4 mm (-0.1-1.5 mm) in the experienced and beginner groups, respectively. There were no significant intergroup differences in measurement amount (P = 0.37) or variance (P = 0.72). Similarly, using the anterior drawer method, no significant differences between the groups were found in measurement amount or variance. CONCLUSION: The quantitative evaluation of stress sonography of the ankle was variable regardless of examiner experience or stress method, particularly in patients with an anterior talofibular ligament injury. The amount of variability appeared to be unacceptably large for clinical application. Our study results highlight the need for technical standardization.

All-suture fixation of syndesmotic injuries: a case series.

BACKGROUND: To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS: This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS: In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS: In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

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.

Center-Center Surgical Technique With Dynamic Syndesmosis Fixation: A Cadaveric Pilot Study.

The objective of this cadaveric biomechanical study was to evaluate if the center-center surgical technique is a reliable and repeatable method of achieving proper syndesmotic reduction when using dynamic syndesmotic fixation. Nine fresh frozen above-knee cadaveric lower extremities were used. Computerized tomography (CT) scans were first obtained for each intact specimen as the baseline for comparison. A simulated complete syndesmotic disruption was created by transection of all deltoid and syndesmotic ligaments. Instability of the ankle was confirmed with stress imaging using fluoroscopy. Each unstable specimen was repaired using the center-center surgical technique with dynamic syndesmosis fixation. A series of measurements from the axial CT images of intact and repaired specimens were used to determine the anatomic distal tibiofibular relationships for comparison of changes from intact to postfixation. All radiographic measurements were performed by 4 independent foot and ankle surgeons. The level of inter-rater reliability for all the measurements was found to be "moderate" to "excellent" agreement (ICC value: 0.865-0.983, 95% confidence interval: 0.634-0.996). There was no statistical difference found between rotational alignment of native and postfixation (a/b: p = .843; b-a: p = .125; θ: p = .062). There was a statistical difference detected for lateral alignment at the center of fibularis incisura between native and postfixation (average: -0.6 ± 0.8 mm, range: -2.3 to 1.2 mm, p < .001). There was no statistical difference found for the anteroposterior translation alignment between native and postfixation (d/e: p = .251; f: p = .377). This study demonstrated the use of the center-center surgical technique as a viable and repeatable method for achieving anatomical reduction of the tibiofibular syndesmosis when used with dynamic fixation modalities.

Morphology of Fibular Incisura is a Deciding Factor Between Posterior Malleolus Avulsion Fracture or Syndesmotic Ligament Injury in Ankle Fractures.

The bone anatomy of tibiofibular syndesmosis has been a topic of interest. Fibular incisura morphology has been analyzed on cadaver specimens, plain radiographs, or CT images. The aim of this study is to examine the effects of fibula incisura features and fibula morphology in ankle injuries, especially involving posterior malleolus and posteroinferior tibiofibular ligament injuries. From 2017 through 2022, A total of 59 patients with isolated lateral malleolar fracture, Mason-Malloy type 1 posterior malleolar fracture, syndesmosis injury in those without posterior malleolar fracture, supination external rotation type 3 injuries according to Lauge-Hansen classification, and preoperative bilateral ankle computed tomography images were included in the study. Fibula morphologies and syndesmosis measurements were made from preoperative computed tomography images using axial CT images from 1 cm proximal to the tibial plafond. The diagnosis of posterior malleolar fractures was made using the CT classification system of Mason and Malloy, and the diagnosis of syndesmosis injury was made with a cotton test during surgery. Age, gender, fractured side, incisura type, incisor depth, width, anterior and posterior facet lengths, incisor version (antevert-retrovert), the angle between the anterior and posterior facets, and fibula type were recorded. There was a statistically significant difference between the groups in posterior facet length and incisura width. Morphological features of fibular incisura may be the determinant of PITFL injury or PMA injury in fibular fractures caused by an external rotation mechanism.

The reliability of posterior malleolar ankle fracture assessment: a unique perspective.

AIM: This study aims to elucidate the pathology of PMFs in the South African population, establish correlations between fracture patterns and international classification guidelines and evaluate the interobserver reliability of current classifications. METHODS: A retrospective review was conducted in a multicentre analysis over a one-year period from January 2019 to December 2019 at our institution. Computer tomography scans for foot and ankle injuries were reviewed, and posterior malleolus fractures were included. Pathoanatomical data was collected and analysed according to known classification systems and subsequent treatment modalities evaluated. A panel of observers individually reviewed radiographic data to determine interobserver reliability. RESULTS: A total of 71 patients were included with a mean age of 41 ± 13.4 years (range 18-78) and a female predominant population (69%). A greater proportion of injuries were high energy (23.9%), with significant fragment comminution (53.5%), and half (52.1%) of all injuries were subluxated/dislocated at presentation. A total of 93% of injuries were managed operatively, despite theatre access limitations resulting in significant delays to fixation (19.1 days). Despite good pathoanatomical agreement with most international classifications, interobserver reliability was poor (Krippendorff α-coefficient < 0.667). Inconsistent treatment patterns in operative and non-operative strategies are reported. CONCLUSION: A unique patient population of younger, female individuals incurred posterior malleolar fractures due to higher energy mechanisms of injury. Whilst injury patterns were mostly comparable, significant interobserver variability was noted. Resource limitations, diagnostic challenges, poorly defined and inconsistent treatment strategies, inevitably impact outcomes within the South African population. LEVEL OF EVIDENCE: Level III.

Normal Values for Distal Tibiofibular Syndesmotic Space With and Without Subject-Driven External Rotation Stress.

BACKGROUND: The diagnosis and treatment of distal tibiofibular syndesmosis (DTFS) injury can be challenging, especially in cases of subtle instability that may be masked on 2-dimensional conventional radiographs. Weightbearing computed tomography (WBCT) has recently emerged as a useful diagnostic tool allowing direct assessment of distal tibiofibular area widening. The purpose of the current study was to examine and report normal threshold values for DTFS area measurements in a cohort of healthy volunteers, assessing the ankles in natural weightbearing position and under subject-driven external rotation stress. METHODS: In this prospective study, we enrolled 25 healthy volunteers without a history of DTFS injury or high ankle sprain, previous foot and ankle surgery, or current ankle pain. Subjects with any prior ankle injuries were excluded. Study participants underwent bilateral standing nonstress and external rotation stress WBCT scans. The DTFS area (mm2) was semiautomatically quantified on axial-plane WBCT images 1 cm proximal to the apex of the talar dome using validated software. Syndesmosis area values were compared between "unstressed" and "stressed" ankles, as well as left and right ankles. Statistical analysis was performed using independent t tests/Wilcoxon analysis with statistical significance defined as P <.05. RESULTS: The study cohort consisted of 50 ankles in 25 patients (12 males, 48%) with a mean age of 28.7 ± 9.3 years. In the unstressed ankle, the mean pooled DTFS area was determined to be 103.8 + 20.8 mm2. The mean syndesmosis area of unstressed left ankles (104.2 + 19.5 mm2) was similar to unstressed right ankles (109.2 + 17.2 mm2) in the cohort (P = .117). With external rotation stress, the DTFS area of left ankles (mean difference -0.304 mm2, CI -12.1 to 11.5; P = .082), right ankles (mean difference -5.5 mm2, CI 16.7-5.7; P = .132), and all ankles (mean difference -2.9 mm2, CI -10.8 to 5.1; P = .324) remained similar. CONCLUSION: This study presents normal values and range for DTFS area calculation. In uninjured ankles with expected intact ligaments, subject-driven external rotation stress did not result in significant widening of the DTFS space as imaged on with WBCT. LEVEL OF EVIDENCE: Level II, cross-sectional study.