BACKGROUND: Arthroscopy-assisted closed reduction and percutaneous internal fixation is a minimally invasive technique for medial malleolus fracture treatment. The purpose of the study was to assess the quality and functional outcomes of this technique.
METHODS: Seventy-eight patients with combined medial malleolus fractures were treated with arthroscopy-assisted closed reduction and percutaneous screw fixation technique. The surgical procedure was described in detail; the clinical efficacy of this method was evaluated in terms of time of operation, postoperative complications, and fracture healing time; and functional outcomes were analyzed.
RESULTS: All of the patients were followed up for a minimum of 12 months without complications of the medial malleolus wound, and all of the medial malleolus fractures healed within 6 to 8 weeks. At the last follow-up, the visual analog scale scores ranged from 0 to 3 and the American Orthopaedic Foot and Ankle Society ankle and hindfoot function scores ranged from 75 to 95.
CONCLUSIONS: Arthroscopy-assisted closed reduction and percutaneous internal fixation makes the treatment of medial malleolus fractures less invasive compared with traditional surgical methods and allows simultaneous exploration and management of the articular surface.

BACKGROUND: Logsplitter Injury is a type of high-energy ankle fracture dislocation. The mechanism of injury has not been described in detail. A detailed understanding of the radiological features and pathological changes can further guide treatment.
METHODS: Between April 2009 and December 2018, a retrospective analysis was conducted on 62 patients with Logsplitter injury. The study analysed the characteristics of fibular injury, tibial injury, syndesmosis injury, medial injury and lateral ligament injury on preoperative X-ray and CT scans. The incidence of the different injury types was summarised. The correlation between Logsplitter injuries and the mechanisms causing them were analysed using the Lauge-Hansen classification of ankle fractures.
RESULTS: The study provides data on the types of fractures observed. Of the total fractures, 98.4% were open fractures. The fibula injuries were classified as no fracture (1.6%), transverse or short oblique fractures (61.3%), butterfly fragments (25.8%), and comminuted fractures (11.3%). The tibial injuries included compression of lateral articular surfaces (38.7%) and posterior compressions (6.5%). Medial injuries, including medial malleolar fractures, accounted for 87.1%, and deltoid ligament rupture accounted for 12.9%. The study found that injuries to the syndesmosis consisted of simple ligament ruptures (11.3%), Tillaux fractures (8.1%), Volkmann fractures (43.5%), and Tillaux and Volkmann fractures (37.1%). In 12.9% of cases, there was a complete rupture of the lateral collateral ligament. Based on the Lauge-Hansen classification, 87.1% of injuries were pronation-abduction injuries, while 8.1% were pronation and external rotation injuries, and 1.6% were supination external rotation injuries. Furthermore, 3.2% of cases could not be classified.
CONCLUSIONS: The pathoanatomic characteristics of Logsplitter injury are diverse, with some cases accompanied by collateral ligament injury. It is important to note that these evaluations are objective and based on current results. The most common injury mechanism is vertical violence combined with abduction, although in some cases, it may be a vertical combined external-rotation injury.
METHODS: (4) case series.
BACKGROUND: This study has been approved by the ethical research committee of the Honghui Hospital of Xi\'an Jiaotong University, under the code: 202,003,002.

BACKGROUND: The purpose of this study was to perform a biomechanical analysis to compare different medial column fixation patterns for valgus pilon fractures in a case-based model.
METHODS: Based on the fracture mapping, 48 valgus pilon fracture models were produced and assigned into four groups with different medial column fixation patterns: no fixation (NF), K-wires (KW), intramedullary screws (IS), and locking compression plate (LCP). Each group contained wedge-in and wedge-out subgroups. After fixing each specimen on the machine, gradually increased axial compressive loads were applied with a load speed of one millimeter per minute. The maximum peak force was set at 1500 N. Load-displacement curves were generated and the axial stiffness was calculated. Five different loads of 200 N, 400 N, 600 N, 800 N, 1000 N were selected for analysis. The specimen failure was defined as resultant loading displacement over 3 mm.
RESULTS: For the wedge-out models, Group-IS showed less displacement (p < 0.001), higher axial stiffness (p < 0.01), and higher load to failure (p < 0.001) than Group-NF. Group-KW showed comparable displacement under loads of 200 N, 400 N and 600 N with both Group-IS and Group-LCP. For the wedge-in models, no statistical differences in displacement, axial stiffness, or load to failure were observed among the four groups. Overall, wedge-out models exhibited less axial stiffness than wedge-in models (all p < 0.01).
CONCLUSIONS: Functional reduction with stable fixation of the medial column is essential for the biomechanical stability of valgus pilon fractures and medial column fixation provides the enough biomechanical stability for this kind of fracture in the combination of anterolateral fixation. In detail, the K-wires can provide a provisional stability at an early stage. Intramedullary screws are strong enough to provide the medial column stability as a definitive fixation. In future, this technique can be recommended for medial column fixation as a complement for holistic stability in high-energy valgus pilon fractures.

Pediatric ankle injuries are common; ankle epiphyseal fractures are also common in children. But isolated distal epiphyseal fibular fractures of the distal fibula are clinically rare. We describe one unusual case of an adolescent with a completely displaced Salter-Harris type II distal fibular epiphyseal fracture. The attempt of closed reduction failed, and the patient required open reduction and internal fixation. The localized periosteum and the superior peroneal retinaculum were avulsed from the distal fibular metaphysis, with the peroneal tendons underneath exposed but no obvious subluxation. To the best of our knowledge, this combination of injuries has not been previously reported.

OBJECTIVE: To assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures.
METHODS: A retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18-65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American orthopedic foot and ankle society score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test.
RESULTS: During the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, preoperative complications with diabetes, smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American orthopedic foot and ankle society score revealed no significant difference between dislocation and no-dislocation patients.
CONCLUSIONS: Dislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.

UNASSIGNED: To evaluate the influence of lateral hinge fracture (LHF) on the early effectiveness of supramalleolar osteotomy (SMO) and to explore the related risk factors for LHF.
UNASSIGNED: A total of 39 patients (39 feet) with varus-type ankle osteoarthritis treated with SMO between January 2016 and December 2022 were analyzed retrospectively. There were 10 males and 29 females, aged from 41 to 71 years (mean, 57.7 years). According to Takakura stage, there were 6 feet in stage Ⅱ, 19 feet in stage Ⅲa, and 14 feet in stage Ⅲb. The LHF was recognized by the immediate postoperative X-ray film. The osteotomy healing time and the changes of pain visual analogue scale (VAS) score, American Orthopaedic Foot and Ankle Society (AOFAS) score, tibial anterior surface angle (TAS), tibial lateral surface angle (TLS), and tibiotalar angle (TT) before and after operation were compared between patients with and without LHF. The age, gender, affected side, body mass index, Takakura stage, preoperative VAS score, preoperative AOFAS score, preoperative TAS, preoperative TLS, preoperative TT, SMO correction angle, osteotomy distraction, distance from medial osteotomy to ankle joint line (MD), and distance from lateral osteotomy to ankle joint line (LD) were compared between with and without LHF patients, and further logistic regression analysis was used to screen the risk factors of LHF during SMO.
UNASSIGNED: All patients were followed up 12-54 months (mean, 27.1 months). During operation, 13 feet developed LHF (group A) and 26 feet did not develop LHF (group B). X-ray film reexamination showed that 1 patient in group A complicated with tibial articular surface cleft fracture had delayed osteotomy and healed successfully after plaster fixation; the osteotomy of other patients healed, and there was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, there were significant differences in VAS score, AOFAS score, TAS, TLS, and TT of the two groups when compared with preoperative ones ( P<0.05), but there was no significant difference in the changes of above indicators before and after operation between the two groups ( P>0.05). The differences in SMO correction angle, osteotomy distraction, and LD between with and without LHF patients were significant ( P<0.05), and further logistic regression analysis showed that excessive LD was the risk factor of LHF during SMO ( P<0.05).
UNASSIGNED: Too high or too low lateral hinge position during SMO may lead to LHF, but as long as appropriate treatment and rehabilitation measurements are taken, the early effectiveness is similar to that of patients without LHF.
UNASSIGNED: 评估外侧合页骨折（lateral hinge fracture，LHF）对踝上截骨术（supramalleolar osteotomy，SMO）早期疗效的影响，并探究导致其产生的相关危险因素。.
UNASSIGNED: 回顾分析2016年1月—2022年12月收治且符合选择标准的 39 例（39足）采用SMO治疗的踝内翻性骨关节炎患者。其中男10例，女 29 例；年龄41～71岁，平均57.7岁。Takakura分期：Ⅱ期6足，Ⅲa期19足，Ⅲb期14足。依据术后即刻 X 线片判断外侧合页位置是否并发LHF，比较发生与未发生LHF患者的截骨愈合时间及疼痛视觉模拟评分（VAS）、美国矫形足踝协会（AOFAS）评分、胫骨关节面角（tibial anterior surface angle，TAS）、胫骨外侧面角（tibial lateral surface angle，TLS）和距骨倾斜角（tibiotalar angle，TT）手术前后变化值。对发生与未发生LHF患者的年龄、性别、侧别、身体质量指数、Takakura分期、术前VAS评分、术前AOFAS评分、术前TAS、术前TLS、术前TT、SMO矫正角、截骨撑开量、截骨处内侧至踝关节线距离（distance from medial osteotomy to ankle joint line，MD）、截骨处外侧至踝关节线距离（distance from lateral osteotomy to ankle joint line，LD）等变量进行单因素分析，并进一步采用logistic回归分析筛选SMO术中发生LHF的危险因素。.
UNASSIGNED: 患者均获随访，随访时间 12～54个月，平均27.1个月。术中13足发生LHF（A组），26足未发生LHF（B组）。X线片复查示A组1例合并胫骨关节面劈裂骨折患者出现截骨延迟愈合，予以石膏固定后成功愈合；其余患者截骨均愈合，两组患者愈合时间比较差异无统计学意义（ P>0.05）。末次随访时，两组患者VAS评分、AOFAS评分及TAS、TLS、TT与术前比较差异均有统计学意义（ P<0.05），上述指标手术前后变化值两组间比较差异均无统计学意义（ P>0.05）。单因素分析示，发生与未发生LHF患者的SMO矫正角、截骨撑开量和LD比较差异有统计学意义（ P<0.05）；进一步logistic回归分析示，LD过大是SMO术中发生LHF的危险因素（ P<0.05）。.
UNASSIGNED: SMO术中外侧合页位置过高或过低都可能导致LHF发生，采取合适治疗和康复方案，术后可获得与未发生LHF患者相似的早期疗效。.

BACKGROUND: Despite fractures of Isolated Weber B being prevalent, there is a lack of clarity regarding the relative effectiveness of surgical versus conservative treatment. This systematic review and meta-analysis aimed to investigate the clinical effects and complications of surgical versus conservative treatment of the Isolated Weber B ankle fractures.
METHODS: This study involved thorough searches across multiple electronic databases, including PubMed, Cochrane, Embase, and Web of Science, to identify all relevant publications on Isolated Weber B ankle fractures repaired through surgical versus conservative treatment. Through a comprehensive meta-analysis, several outcomes were evaluated, including post-operative function, complications and reoperation rate.
RESULTS: Six articles involving 818 patients who met the inclusion criteria. Among these participants, 350 were male and 636 were female. 651 patients received conservative treatment, while 396 underwent surgical intervention. The findings indicate no significant differences in OMAS, FAOQ, PCS, MCS scores, and return to work between surgical and non-surgical treatments for isolated Weber B ankle fractures. However, compared with surgical treatment, non-surgical treatment has a higher AOFAS score(MD = -5.31, 95% CI = [-9.06, -1.55], P = 0.20, I2 = 39%), lower VAS score(MD = 0.72, 95% CI = [0.33, 1.10], P = 0.69, I2 = 0%), lower complication rate (RR = 3.06, 95% CI = [1.58, 6.01], P = 0.05, I2 = 54%), and lower reoperation rate(RR = 8.40, 95% CI = [1.57, 45.06], P = 0.05, I2 = 67%).
CONCLUSIONS:

OBJECTIVE: There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs.
METHODS: We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications.
RESULTS: Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P＜0.00001, I2 =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I2 =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees.
CONCLUSIONS: We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs.
UNASSIGNED: Ⅱb.

BACKGROUND: The present study aimed to analyze and compare the efficacy of the anterolateral and posterolateral approaches for surgical treatment of supination-external rotation type IV ankle fractures.
METHODS: This retrospective study enrolled 60 patients (60 feet) with supination-external rotation type IV ankle fractures, including 30 patients (30 feet) treated by means of the anterolateral approach and 30 patients (30 feet) treated by means of the posterolateral approach. Postoperative clinical efficacy was compared between the groups based on operation time, intraoperative blood loss, postoperative complications, fracture healing time, visual analog scale scores, Short Form-36 Health Survey scores, and American Orthopedic Foot and Ankle Society scores. Comparisons between the two groups were performed using independent-samples t tests and analyses of variance. Intragroup differences were compared using paired t tests, and the χ2 test was used to compare categorical variables.
RESULTS: All 60 included patients completed follow-up ranging from 12 to 18 months (mean duration, 14.8 ± 3.5 months). Although baseline characteristics were similar in the two groups, there were significant differences in operation time (86.73 ± 17.44 min versus 111.23 ± 10.05 min; P < .001) and intraoperative blood loss (112.60 ± 25.05 mL versus 149.47 ± 44.30 mL; P < .001). Although fracture healing time (10.90 ± 0.66 weeks versus 11.27 ± 0.94 weeks; P = .087) was shorter in the anterolateral group than in the posterolateral group, the difference was not significant. Postoperative complications occurred in one and three patients in the anterolateral and posterolateral approach groups, respectively. Visual analog scale scores were significantly lower in the anterolateral group than in the posterolateral group (1.43 ± 0.50 versus 1.83 ± 0.75; P = .019), although there was no significant difference in Short Form-36 Health Survey scores between the groups (73.63 ± 4.07 versus 72.70 ± 4.04; P = .377). However, American Orthopedic Foot and Ankle Society scores were higher in the anterolateral group than in the posterolateral group (80.43 ± 4.32 versus 75.43 ± 11.32; P = .030).
CONCLUSIONS: Both the anterolateral and posterolateral approaches can achieve good results in the treatment of supination-external rotation type IV ankle fractures. Compared with the posterolateral approach, the anterolateral approach is advantageous for the treatment of supination-external rotation type IV ankle fractures given its safety and ability to reduce trauma, clear field of view revealed, and allow for exploration and repair of the inferior tibiofibular anterior syndesmosis within the same incision.

BACKGROUND: Talar fractures often require osteotomy during surgery to achieve reduction and screw fixation of the fractured fragments due to limited visualization and operating space of the talar articular surface. The objective of this study was to evaluate the horizontal approach to the medial malleolus facet by maximizing exposure through dorsiflexion and plantarflexion positions.
METHODS: In dorsiflexion, plantarflexion, and functional foot positions, we respectively obtained the anterior and posterior edge lines of the projection of the medial malleolus on the medial malleolar facet. The talar model from Mimics was imported into Geomagic software for image refinement. Then Solidworks software was used to segment the medial surface of the talus and extend the edge lines from the three positions to project them onto the \"semicircular\" base for 2D projection. The exposed area in different positions, the percentage of total area it represents, and the anatomic location of the insertion point at the groove between the anteroposternal protrusions of the medial malleolus were calculated.
RESULTS: The mean total area of the \"semicircular\" region on the medial malleolus surface of the talus was 542.10 ± 80.05 mm2. In the functional position, the exposed mean area of the medial malleolar facet around the medial malleolus both anteriorly and posteriorly was 141.22 ± 24.34 mm2, 167.58 ± 22.36mm2, respectively. In dorsiflexion, the mean area of the posterior aspect of the medial malleolar facet was 366.28 ± 48.12 mm2. In plantarflexion, the mean of the anterior aspect of the medial malleolar facet was 222.70 ± 35.32 mm2. The mean overlap area of unexposed area in both dorsiflexion and plantarflexion was 23.32 ± 5.94 mm2. The mean percentage of the increased exposure area in dorsiflexion and plantarflexion were 36.71 ± 3.25% and 15.13 ± 2.83%. The mean distance from the insertion point to the top of the talar dome was 10.69 ± 1.24 mm, to the medial malleolus facet border of the talar trochlea was 5.61 ± 0.96 mm, and to the tuberosity of the posterior tibiotalar portion of the deltoid ligament complex was 4.53 ± 0.64 mm.
CONCLUSIONS: Within the 3D model, we measured the exposed area of the medial malleolus facet in different positions and the anatomic location of the insertion point at the medial malleolus groove. When the foot is in plantarflexion or dorsiflexion, a sufficiently large area and operating space can be exposed during surgery. The data regarding the exposed visualization area and virtual screws need to be combined with clinical experience for safer reduction and fixation of fracture fragments. Further validation of its intraoperative feasibility will require additional clinical research.