BACKGROUND: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound.
METHODS: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle.
CONCLUSIONS: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy.

Background Applying topical vancomycin has shown a decrease in the likelihood of surgical site infections (SSIs) in surgeries linked to a heightened risk of severe and resistant infections. Nevertheless, the effectiveness of this prophylactic approach has not been assessed in open ankle surgeries with internal fixation. Objective This study aimed to assess whether topical vancomycin diminishes the risk of SSI in patients with ankle fractures undergoing open reduction with internal fixation. Methods A randomized, controlled, double-blind clinical trial was carried out. Patients were divided into two groups in a 1:1 ratio. The control group received the standard prophylactic treatment with IV cephalothin 1 g, while the intervention group was administered topical vancomycin (1 g) in addition to the standard prophylactic treatment. The main outcomes were the SSI rates at 14 days, 28 days, and three months post-surgery, based on relevant clinical signs and laboratory tests. Results One hundred thirty-two patients were randomized (51.2% female), with 66 subjects included in each intervention arm. A total of 97.7% of them completed the study. Both groups were homogeneous in baseline characteristics. There were two SSIs in both the vancomycin group (3.3%) and the control group (3.5%), with no statistical differences (p = 0.945). The microorganisms isolated as causal agents were Staphylococcus aureus and Acinetobacter baumannii. By the three-month follow-up, no infections were noted in both intervention groups. Conclusion These results indicate that the topical administration of vancomycin may not represent an advantage in preventing SSI in ankle fractures requiring open reduction with internal fixation at the three-month postoperative stage.

UNASSIGNED: Extensor retinaculum syndrome (ERS) is a relatively rarely diagnosed compartment syndrome-like entity caused by elevated pressures in the tissues deep to the superior extensor retinaculum (SER). ERS is identified as out-of-proportion anterior ankle pain, pain with passive toe plantarflexion, elevated SER pressures (>40 mm Hg), and ultimately toe extension weakness and first web space numbness. Although previously described in a pediatric population, this case series is the first to our knowledge in an adult population.
UNASSIGNED: Seven nonconsecutive cases over 18 years from 2 surgeons are reported who underwent complete SER release for ERS either through the direct lateral approach to the fibula or the anterolateral approach to the distal tibia. All were associated with traumatic injuries including 3 bimalleolar ankle fractures, 3 tibial pilon fractures, and 1 distal tibial/fibular shaft fracture. All patients developed writhing anterior ankle pain worsened with passive toe plantarflexion. SER compartment pressures ranged from 50 to >135 mm Hg. Five cases displayed decreased first web space sensation.
UNASSIGNED: The diminished or absent first web space sensation uniformly improved post-release. Complications included 1 patient with complex regional pain syndrome type 1, 1 patient required hardware removal, and 2 had persistent but improved first web space sensation changes.
UNASSIGNED: Clinical suspicion for possible ERS should arise after distal tibial/fibular fractures when the excruciating pain localizes to the ankle instead of the classic anterior leg muscle bellies. If pain is worsened with passive toe plantarflexion, this diagnosis should be considered. Recommended treatment involves complete release of the SER anywhere on the anterior surface between the tibia and fibula depending on the approach needed for fixation of the associated fracture.
UNASSIGNED: Level IV, case series.

BACKGROUND: Fracture of the lateral tubercle of the posterior process of the talus (Shepherd fracture) is an uncommon injury seen in sport. It is secondary either to indirect trauma on the plantarflexed foot or to high-impact direct trauma. The fracture can be missed with conventional X-rays and therefore advanced imaging methods such as CT scans are usually warranted for management planning. There is a low threshold towards surgical management in the displaced or comminuted case as the delayed functional outcome with conservative treatment is frequently sub-optimal with long-term pain, degenerative changes and non-union. In this regard, recent years saw an increasing interest in the role of minimally invasive approaches for Shepherd´s fracture treatment, such as arthroscopic reduction and internal fixation (ARIF).
METHODS: We present a case of a 27-year-old white male professional football player from Serbia who had Shepard fracture and successfully managed with arthroscopic osteosynthesis. The technical approach is detailed with posterior ankle arthroscopy offering the advantages of a minimally invasive approach with low morbidity and a rapid return to regular sporting activities.
CONCLUSIONS: The utilization of the 2-port arthroscopic approach this method enables the direct observation of the articular surface along with the corresponding fracture lines, thereby affording the surgeon the chance to achieve accurate reduction via a minimally invasive soft tissue aperture. We advocate that Arthroscopic reduction and internal fixation (ARIF) is a reliable method for the fixation of Shepherd\'s fracture in the hands of experienced ankle arthroscopists.

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.

UNASSIGNED: Distal fibula osteoporotic comminuted fractures are challenging to treat and are often treated with periarticular locking plates. This study examined the biomechanical difference between locked plating and dual non-locked one-third tubular plating.
UNASSIGNED: Using an osteoporotic Sawbones fibula model, simulated fracture were fixated with one-third tubular dual plating and locked periarticular plating. The samples were then torqued to failure and peak torque, stiffness, and displacement were recorded.
UNASSIGNED: The peak torque of the dual plating group was found to be statistically higher than the periarticular locked plating group (0.841 Nm and 0.740 Nm respectively; p = 0.024). However overall stiffness calculated at each 10° increment of displacement was noted to have no significant difference between the two constructs.
UNASSIGNED: Dual non-locked plating of distal fibula osteoporotic comminuted fractures is biomechanically equivalent to locked periarticular plating.

Isolated Tillaux fracture is a rare anterolateral distal tibia fracture frequently misdiagnosed in adults. It typically occurs in adolescents nearing skeletal maturity by avulsion of the anterior-inferior tibiofibular ligament. This case-based literature review study aims to elicit the existing information regarding this fracture in adults, and summarize its injury mechanism, diagnosis, and treatment procedures. According to the literature, this is only the eighth case described: a 46-year-old woman that suffered an isolated Tillaux fracture with 4 mm of displacement, and open reduction and fixation with double cannulated screws were performed. After proper rehabilitation, an excellent functional and radiological outcome was reached. It is important to recognize and appropriately treat these distinct injuries to prevent further instability, degenerative changes, and ankle joint function limitation. Early diagnosis and appropriate osteosynthesis play a significant role in a successful recovery prognosis.

Introduction Ankle fractures are commonly encountered fractures in emergency departments worldwide. These fractures often have significant articular involvement that requires anatomic surgical reduction and stabilization. Radiographs can be used in everyday practice to evaluate ankle fractures utilizing various parameters to assess reduction quality intraoperatively and postoperatively. Several factors have been found to influence the reduction quality of fractures across body regions. This retrospective study aimed to evaluate the influence of several factors on the reduction quality of ankle fractures in a tertiary care center in the Kingdom of Bahrain. Materials and methods A total of 462 records were identified during the search, and 68 records were excluded. A total of 394 ankle fractures met the inclusion criteria for the study. Five orthopedic surgeons then evaluated the operative films in accordance with the Delphi consensus parameters for evaluating ankle fractures, and the reductions were graded as good, adequate, or poor. Results The study included 394 ankle fractures that met the inclusion criteria, and four significant associations were noted to affect the quality of reduction. Ankle fractures with posterior malleolus involvement (PMI) were significantly associated (p = 0.001) with fragments smaller than 15% and larger than 20% having decreased outcomes. The number of days from admission to operation was also significant (p = 0.009), with the best reductions observed between zero and one day from admission. Operating surgeon was also a significant factor (p = 0.038), with inferior reductions noted in specialist surgeons compared to trainees. The last significant association was the number of malleoli (p = 0.001), with an inferior reduction with a larger number of malleoli involved. Conclusion Ankle fractures are a common and significant orthopedic injury. Reduction quality is important for optimal outcomes after surgical stabilization. Various factors including the number of malleoli, the grade of the operating surgeon, and the time of surgery were significantly related to the quality reduction in this single-center study. Expedited surgical management of fractures that are amenable to early fixation, careful assessment, and meticulous technique in fixation of fractures with multiple fractured malleoli is indicated to reduce the chance of malreduction particularly in complex injuries. Further assessment of factors related to reduction quality with large-scale prospective studies would provide orthopedic surgeons with insights into the identification and optimal treatment of such fractures.

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.