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.

[Comparative study of minimally invasive titanium elastic nail and steel plate on the treatment of fracture of tibiofibular fracture in adults].

OBJECTIVE: To compare the clinical outcomes of using elastic intramedullary nail and plate to fix fibular fracture. METHODS: The 60 patients with tibiofibular fractures admitted from January 2015 to December 2022 were divided into two groups:intramedullary nail group and plate group, 30 cases each, intramedullary nail group was treated with elastic intramedullary nail fixation group, plate group was treated with steel plate and screw fixation group. Intramedullary nail group, there were 18 males and 12 females, aged from 22 to 75 years old with an average of (39.4±9.8) years old, including 24 cases of traffic accidents injury, 6 cases of falling injury, 23 cases of closed fractures, 7 cases of open fractures. Steel plate group, there were 15 males and 15 females, aged from 24 to 78 years old with an average of (38.6±10.2) years old. The 22 cases were injured by traffic accident, 8 cases were injured by falling. The 24 cases were closed fractures and 6 cases were open fractures. The operation time, intraoperative bleeding, American Orthopedic Foot and Ankle Society (AOFAS) ankle and hind foot scores, clinical healing time of fibula and the incidence of wound complications were compared between the two groups. RESULTS: The patients in both groups were followed up for 6 to 21 months, with an average of (14.0±2.8) months. Compared with plate group, intramedullary nail group had shorter operative time, less bleeding, shorter clinical healing time of fibula, and lower infection rate of incision, and the difference was statistically significant (P<0.05). There were 2 cases of delayed healing in intramedullary nail group, 1 case of nonunion in plate group, and 2 cases of delayed healing in plate group, and there was no statistically significant difference between the two groups (P>0.05). In the last follow-up, according to the AOFAS scoring standard, the ankle function in intramedullary nail group was excellent in 17 cases, good in 12 cases, fair in 1 case, with an average of (88.33±4.57) points, while in plate group, excellent in 16 cases, good in 10 cases, fair in 4 cases, with an average of (87.00±4.14) points;There was no statistical difference between the two groups (P>0.05). CONCLUSION: Elastic intramedullary nail has the advantages of short operation time, less intraoperative bleeding, short fracture healing time and less incision complications in the treatment of fibular fracture, which is worthy of clinical application.

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.

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.

The additional value of weight-bearing radiographs in assessing stability of isolated type B fibular fractures.

INTRODUCTION: In isolated type B fibular fractures, the decision whether to operate or treat conservatively is principally based on congruency and stability of the ankle joint. The purpose of the current study is to examine the additional diagnostic value of the weight-bearing radiograph (WBR) in assessing stability of potentially unstable type B fibular fractures. MATERIALS AND METHODS: In this retrospective cohort study, patients were selected based on who presented an isolated type B fracture of the fibula. Unstable fractures were directly planned for surgery. Other patients underwent additional weight-bearing imaging 4-7 days after initial trauma, on which definitive treatment was based. The medial clear space (MCS) was compared between the WBR and the conventional radiograph. RESULTS: A total of 70 patients were included in the period January 2018-December 2021. The average MCS on conventional mortise radiograph was 3.56 mm compared to 3.02 mm on the WBR(p<0.05). The superior clear space (SCS) was equal between both groups (respectively 3.12 mm and 3.08 mm, p = 0.44). All 70 patients were initially treated conservatively with immediate weight-bearing in a brace or soft cast. One patient had the need for open repair and internal fixation due to non-union. DISCUSSION: Different techniques for the assessment of deep deltoid ligament integrity exist, such as the MRI, the ultrasonography and different kinds of stress test radiographs. As fractured ankles don't need direct fixation and operative treatment can be postponed, a stepped approach for the assessment of deep deltoid ligament (DDL) integrity can be of assistance in assessing ankle stability. In isolated type B fibular fractures a stepped approach, using the weight-bearing radiograph can be of additional value in assessing the stability. It is a low cost, prevents unnecessary surgery and contributes to a quick weight-bearing non-operative treatment.

Cost analysis and clinical outcomes of anatomic pre-contoured locking versus conventional plates for distal fibula ankle fractures.

PURPOSE: To analyze differences in union, complication rates and cost from surgical fixation of distal fibula fractures with fibular plating implants. METHODS: In total, 380 adult patients from 2012 to 2015 treated with 12 fibular plates from 4 different manufacturers utilized by 9 surgeons were retrospectively reviewed. They were stratified into a conventional one-third tubular fibular plate group, pre-contoured anatomic locking plate group, or a heterogeneous group including 3.5-mm reconstruction, one-third tubular locking, composite, and limited compression plates. The outcomes included failure of fixation, deep infection requiring debridement, time to union, anatomic reduction, superficial infection, hardware removal, and post-traumatic arthritis. Plate and screw costs were calculated from hospital billing records. RESULTS: Pre-contoured locking plates were used in older, female patients with a greater number of comorbidities. Open injuries and OTA 44B fractures were more likely to be an indication for pre-contoured plates. There was no difference noted in time to union between the different plating groups. Risk factors for deep infection requiring debridement included a history of tobacco use, open fractures, and pre-contoured locking plates relative to the conventional plating group. The pre-contoured plating group was on average $586 more expensive compared to the conventional group. CONCLUSION: Pre-contoured locking plates achieved similar radiographic outcomes compared to conventional plates with an increased risk of complications and higher cost. Surgeons should consider their choice of implant based on the patient's fracture pattern, underlying comorbidities, and risk for infection.

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.

Healed ORIF in a fibula fracture - Hardware removal or hardware retention for the fibula in a patient with minor symptoms?

HISTORY: - A 31yo female is involved in a fall while climbing on some wet rocks. She was brought into the emergency department and was found to have suffered a closed fracture of the right fibula with a deltoid ligament injury. Distal neurovascular exam was normal. She is otherwise unhurt. She had ORIF of her ankle injury and it has gone onto heal with good results. She comes back at 6 months and complains of vague pain over her lateral ankle and hardware with a normal physical exam. She wonders about hardware removal, (Figs. 1 and 2). PAST MEDICAL HISTORY: - previous history of breast reduction surgery and she has delivered one child vaginally. No chronic diseases and she takes no pills except the birth control pill. SOCIAL HISTORY: - married with one child and works as an administrative assistant for a manufacturing company; she is a social drinker and nonsmoker. Has a history of using some recreational drugs but none for 10 years. She is moderately active.

Should We Fix the Fibula in Tibial Plafond Fractures? A Meta-analysis Reviewing the Evidence Base for Fibula Open Reduction and Internal Fixation in Tibial Plafond Fractures.

Open reduction and internal fixation are the standard of care to stabilize tibial plafond fractures. However, it remains uncertain as to whether fixation of the fibula affects the outcome. This study aimed to review the evidence base for comparable outcomes in tibial plafond fractures when undergoing open reduction and internal fixation of ipsilateral fibula fractures compared with open reduction and internal fixation of the tibia alone. A systematic review and meta-analysis of the literature was completed; 4 studies were included for analysis. This study demonstrated no statistically significant differences in the incidence of nonunion (p = .784) or mal-union (p = .416). There was a greater rate of removal of metalwork in the fibula operative group compared to the tibia alone group (p < .001). The current evidence demonstrates that open reduction and internal fixation of ipsilateral fibula fractures in tibial plafond fractures is not necessarily routinely indicated for all fractures.

Successful Outcomes With Nonoperative Treatment and Immediate Weightbearing Despite Stress-Positive Radiographs in Isolated Distal Fibula (OTA/AO 44B) Fractures.

OBJECTIVES: To determine whether a nonoperative management protocol results in equivalent outcomes in isolated OTA/AO 44B (Weber B) fractures without initial medial clear space (MCS) widening regardless of stress radiography findings. DESIGN: Prospective cohort. SETTING: Level 1 academic trauma center. PATIENT SELECTION CRITERIA: Nonoperatively managed patients with isolated OTA/AO 44B fractures and MCS ≤4 mm on initial non-weightbearing injury radiographs between from January 2018 and January 2022 were included. All patients underwent emergency department gravity stress radiographs and those with widening were considered the widening cohort and those without the non-widening cohort. OUTCOME MEASURE AND COMPARISONS: MCS measurements on weightbearing radiographs were obtained at first follow-up, 6 weeks, 12 weeks, and 6 months postinjury, were considered indicative of instability if >4 mm and were compared between cohorts.; American Orthopaedic Foot and Ankle Society ankle-hindfoot scores were also compared between cohorts. RESULTS: Sixty-nine patients were studied. None of the 38 patients (55%) with widening on gravity stress radiographs demonstrated widening with weightbearing radiographs at any time point. Mean MCS measurement differences between the 2 cohorts were statistically significant for all time points ( P = 0.012); however, with a model adjusted mean MCS value of 2.7 mm for the nonwidening cohort and 2.9 mm for the widening cohort, these are not clinically significant. There was no statistically significant difference in overall final American Orthopaedic Foot and Ankle Society scores between the 2 groups ( P = 0.451). In addition, statistical equivalence using Schuirmann 2 one-sided tests was achieved between the 2 groups. Both cohorts had mean American Orthopaedic Foot and Ankle Society scores representing excellent outcomes at the final follow-up. CONCLUSIONS: Patients with isolated OTA/AO 44B fractures without MCS widening on initial injury radiographs did not demonstrate instability on subsequent weightbearing radiographs and had equivalent outcomes regardless of gravity stress radiography findings when treated nonoperatively. Weightbearing radiographs at the initial follow-up appear to be a reliable assessment of ankle stability in these injuries and are an appropriate alternative to painful and time-consuming stress radiography. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous Free Fibula and Anterolateral Thigh Flap in Lower Extremity Reconstruction Following Osteomyelitis in a Trauma Patient: A Case Report.

This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient's return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.

Treatment and Outcome of a "Floating Fibula" Injury: A Case Report.

CASE: We report a case of a rare "floating fibula" ankle injury characterized by dislocation of the proximal tibiofibular joint (PTFJ), syndesmosis disruption, complete deltoid disruption, and tibiotalar dislocation without fibula fracture in a 44-year-old man. Imaging includes preoperative and postoperative radiographs and CT scans. Treatment involved reduction and screw fixation of the syndesmosis and PTFJ with planned screw removal. A successful clinical and radiographic outcome was achieved at the 15-month follow-up. CONCLUSION: This case highlights the unique features of the "floating fibula" injury and shows that reduction and intraoperative assessment may be more challenging than a typical Maisonneuve injury.

Differences in Pilon Fractures According to Ipsilateral Fibular Injury Patterns: A Clinical Computed Tomography-Based Mapping Study.

Background: Preoperative verification of fracture morphology is essential for determining the definitive fixation strategy in the management of a pilon fracture. This study aimed to determine the correlation between fibular injury patterns and fracture morphologies and introduce clinical implications. Methods: Computed tomography scans of 96 pilon fractures were retrospectively analyzed and divided into three types: intact fibula, simple fracture, and multifragment fracture. The principal fracture line and comminution zones were illustrated on a plafond template and diagrammatized on a 6 × 6 grid using PowerPoint software as fracture mapping. Correlations between fibular injury patterns and fracture morphologies, including comminution zones and principal fracture lines, were analyzed. Results: The thickest comminution zone was most often located in the anterolateral quadrant. According to fibular injury patterns, the comminution zone of the multifragment group was placed two grids more lateral than that of other groups. Lateral exits of the principal fracture line in the multifragment group were much more concentrated within the fibular incisura. Conclusions: In pilon fractures, a more complex fibular fracture pattern was related to the valgus position. Moreover, the articular fracture pattern of pilon fractures differed according to coronal angulation and fibular fracture pattern. These differences should influence the operative approach and placement of the plate.

Proximal fibular stress fracture in adolecent soccer player. A case report.

Fibular fractures are the third most common stress fractures in children and adolescents. Proximal fibular location is a very rare finding, with few reports in the literature and, frequently, careful investigations before a definitive diagnosis could be necessary. The authors report a case of an adolescent 13 years old soccer player with a proximal fibular fracture that was initially underestimated and misdiagnosed and ultimately confirmed as a stress lesion by MRI.

Maisonneuve ankle fracture.

Maisonneuve fracture (MF) is defined as an ankle fracture-dislocation associated always with a fracture of the proximal quarter of the fibula and rupture of the anterior and interosseous tibiofibular ligaments. Other injuries are variable. Recent CT studies have demonstrated that MF is a far more complex injury than initially supposed. Therefore it is necessary to change substantially the current concepts related to this issue. MF is combined in about 80% of cases with a fracture of the posterior malleolus and also with malposition of the distal fibula in the fibular notch. An exact assessment of these injuries requires post-injury CT examination which should be used as a standard in MFs. The main goal of treatment is anatomical reduction of the distal fibula into the fibular notch. In case of avulsion of a larger fragment of the posterior malleolus, it is necessary to perform as the first step its reduction and fixation from the posterolateral approach and thus restore integrity of the notch. Closed reduction of the distal fibula is associated with malposition in up to 50% of cases and therefore open reduction from a short anterolateral approach is preferred. Accuracy of reduction should be always checked by postoperative CT scan.

A Young Skier with Leg Pain.

BACKGROUND: Proximal tibiofibular joint (PTFJ) dislocation is a rare injury that can disrupt the proximal tibia-fibula joint. The abnormalities in knee x-ray imaging can be subtle and difficult to detect, requiring careful assessment. This rare cause of lateral knee pain requires a high level of suspicion for diagnosis. Treatment is closed reduction; unstable PTFJ dislocations often require surgical intervention. CASE REPORT: A 17-year-old young man presented to the emergency department (ED) with right lateral knee pain and difficulty walking after colliding with another skier 2 days prior. The examination showed right lateral ecchymosis and tenderness over the lateral proximal fibula. He remained neurovascularly intact with a full passive and active range of motion. X-ray studies were obtained. The patient was referred by his outpatient orthopedic surgeon after the initial knee x-ray study was concerning for PTFJ dislocation and unsuccessful reduction. In the ED, the patient underwent moderate sedation and successful orthopedic-guided reduction via medial force on the lateral fibular head, while hyper-flexing the knee and holding the foot dorsiflexed and everted. Post-reduction radiographs showed improved proximal tibiofibular alignment without fracture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PTFJ dislocation is a rare injury that can be missed easily and requires a high level of suspicion when presented with an acute traumatic knee pain. Closed reduction of PTFJ dislocation can be achieved in the ED and early identification can prevent long-term sequelae.

Geometric variation of the human tibia-fibula: a public dataset of tibia-fibula surface meshes and statistical shape model.

Background: Variation in tibia geometry is a risk factor for tibial stress fractures. Geometric variability in bones is often quantified using statistical shape modelling. Statistical shape models (SSM) offer a method to assess three-dimensional variation of structures and identify the source of variation. Although SSM have been used widely to assess long bones, there is limited open-source datasets of this kind. Overall, the creation of SSM can be an expensive process, that requires advanced skills. A publicly available tibia shape model would be beneficial as it enables researchers to improve skills. Further, it could benefit health, sport and medicine with the potential to assess geometries suitable for medical equipment, and aid in clinical diagnosis. This study aimed to: (i) quantify tibial geometry using a SSM; and (ii) provide the SSM and associated code as an open-source dataset. Methods: Lower limb computed tomography (CT) scans from the right tibia-fibula of 30 cadavers (male n = 20, female n = 10) were obtained from the New Mexico Decedent Image Database. Tibias were segmented and reconstructed into both cortical and trabecular sections. Fibulas were segmented as a singular surface. The segmented bones were used to develop three SSM of the: (i) tibia; (ii) tibia-fibula; and (iii) cortical-trabecular. Principal component analysis was applied to obtain the three SSM, with the principal components that explained 95% of geometric variation retained. Results: Overall size was the main source of variation in all three models accounting for 90.31%, 84.24% and 85.06%. Other sources of geometric variation in the tibia surface models included overall and midshaft thickness; prominence and size of the condyle plateau, tibial tuberosity, and anterior crest; and axial torsion of the tibial shaft. Further variations in the tibia-fibula model included midshaft thickness of the fibula; fibula head position relative to the tibia; tibia and fibula anterior-posterior curvature; fibula posterior curvature; tibia plateau rotation; and interosseous width. The main sources of variation in the cortical-trabecular model other than general size included variation in the medulla cavity diameter; cortical thickness; anterior-posterior shaft curvature; and the volume of trabecular bone in the proximal and distal ends of the bone. Conclusion: Variations that could increase the risk of tibial stress injury were observed, these included general tibial thickness, midshaft thickness, tibial length and medulla cavity diameter (indicative of cortical thickness). Further research is needed to better understand the effect of these tibial-fibula shape characteristics on tibial stress and injury risk. This SSM, the associated code, and three use examples for the SSM have been provided in an open-source dataset. The developed tibial surface models and statistical shape model will be made available for use at: https://simtk.org/projects/ssm_tibia.

Investigation of the Characteristics and Mechanism of Interosseous Membrane Injuries in Typical Maisonneuve Fracture.

OBJECTIVES: Previous studies on the mechanism and scope of interosseous membrane injury in Maisonneuve fractures have been inconsistent. In order to better guide clinical treatment, the characteristics and mechanism of interosseous membrane injuries and proximal 1/3 fibular fracture in typical Maisonneuve fracture were investigated. METHODS: The study comprised 15 patients between January 2019 and June 2021 with Maisonneuve fracture. All patients received X-ray and MRI examination of the calf and ankle joint, and CT scanning of the ankle joint. The injuries of medial structure, inferior tibiofibular syndesmosis, fibula, posterior malleolus, and interosseous membrane were evaluated. RESULTS: MR images of the calf showed that the injury of interosseous membrane (IOM) was from the syndesmosis to the proximal fibular fracture site in two patients, with a range of 32.3 and 29.8 cm, respectively. In the other 13 patients, the IOM rupture was not only confined to the distal third of the calf, but also close to the fibula fracture, and the IOM was intact between the two fracture sites. The range of distal IOM rupture was 3.7-12.2 cm, with an average of 8.06 ± 2.35 cm. The proximal IOM was completely ruptured from the fibular side at the site of the fibular fracture and the range was 4.1-9.1 (average: 6.75 ± 1.64) cm. The average length of the integrate middle segment of the IOM was 14.55 ± 4.11 (5.6-20.3) cm. MR images of the calf also showed partial rupture of the posterior tibial muscle at the ending point on the fibula in 15 cases, partial rupture of soleus muscle and flexor hallucis longus in seven cases. CONCLUSIONS: The rupture of the IOM was caused by a combination of abduction and external rotation violence. It was manifested in two forms, most of which was not only distal end but also near fibular fracture site ruptures with the middle part intact, and a few were ruptures of the IOM from the ankle to the near fibular fracture site. The tibialis posterior muscle may be related to the location of the fibular fracture.

Retrospective analysis of locked versus non-locked plating of distal fibula fractures.

INTRODUCTION: Unstable distal fibular fractures have traditionally been treated with open reduction internal fixation using a 1/3 tubular non-locked plate (compression plating). Locked plating is a newer technique that has become more popular despite the lack of clinical data supporting improved outcomes. The cost of locked plating is almost four times that of compression plating. We compared rates of reoperation due to implant failure, infection, and symptomatic device between compression and locked plating in open reduction internal fixation of distal fibular fractures METHODS: A retrospective study was performed at a level one trauma center over a ten-year period (2008-2017). Patients who were 18 and older and treated for unstable ankle fractures with locking or non-locking plate were included in this study. Patient charts were reviewed by orthopedic trauma surgeons to identify whether patients were treated with a 1/3 tubular non-locking or pre-contoured locked plate and to determine the cause of reoperation. RESULTS: In total, 442 patients were identified with 203 in the non-locked 1/3 tubular plate group and 239 in the pre-contoured locked plate group. A total of 38 patients (8.6%) underwent device removal with a higher proportion of patients in the non-locked 1/3 tubular plate cohort (11.3% vs. 6.3%, p = 0.059). Statistically significant differences in reasons for reoperation were found for symptomatic implant (78.3% vs. 46.7%, p = 0.045) and infection (8.7% vs 53.3%., p < 0.01). Of patients who had device removal for symptomatic implant in the compression plating cohort, 13 (72.2%) had lateral positioning and 5 (27.8%) had posterior positioning (p < 0.01) whereas there was no statistical difference in plate positioning in the locked cohort. Of all medical comorbidities identified, only diabetes was associated with a higher rate of infection-related reoperations (83.3% vs. 15.6%, p < 0.01). CONCLUSIONS: Both compression and locked plate techniques demonstrated low reoperation rates. Compression plating with 1/3 tubular plates placed laterally more often resulted in reoperation due to symptomatic implant but had fewer complications of infection. Given that the cost is significantly less, 1/3 tubular plating placed posteriorly may be preferred to decrease the risks of symptomatic implant and infection.

What is the best treatment for syndesmosis fixation? Suture-button or syndesmotic screw ? Bilateral CT-based early postoperative analysis.

BACKGROUND: The aim of this study was to compare the effectiveness of syndesmotic screw (SS) and suture button (SB) on the reduction and fixation of syndesmosis via early postoperative bilateral computed tomography (CT). METHODS: This single-center retrospective study included 76 patients aged ≥ 18 years with a unilateral syndesmosis injury. SS was applied to 40 patients and SB to 36 patients. The differences between the sides stabilized using SB or SS and the intact sides were analyzed using the parameters of tibio-fibular clear space (∆CS) and anterior or posterior sagittal translation (∆ST) depending on the orientation of the fibula. The cases in which the fibula was translocated to the posterior of the tibia after the change of ∆ST and ∆CS> 2 mm were evaluated as malreduction. Axial CT images taken from the level of syndesmosis fixation were divided into 4 zones according to the orientation angle of the implant sent from the fibula to the tibia. RESULTS: No significant difference was found in the analyses performed between total patient group with malreduction and fixation groups in terms of ∆CS and ∆ST values (p = 0.708, p = 0.289). It was observed that the fixation material was in zone 3 in 54 patients and in zone 2 in 22 patients. No significant difference was found in the analyses performed between the SS and SB groups according to the implant zone (p = 0.191). In the SS group sent from Zone 2, the malreduction rate according to the ∆ST value of syndesmosis was found to be significantly higher than in the SB group (p = 0.008, p = 0.003). CONCLUSION: When the implant is applied with the correct technique, there is no difference between SS and SB in terms of early postoperative reduction. When the SS is advanced at an inappropriate angle, it negatively affects the reduction of the fibula, while SB can better tolerate angle errors up to certain degrees due to its flexible structure. Therefore, it can be presumed that the suture button system is a more convenient method in the reduction and fixation of syndesmosis than the syndesmotic screw. LEVEL OF EVIDENCE: Level IV.