OBJECTIVE: To demonstrate how the use of adjunctive Computed Tomography (CT) can modify diagnosis, treatment options, and operative planning of ankle fractures in comparison with conventional radiographs (CR) in isolation.
METHODS: A total of 53 patients diagnosed with an ankle fracture between 2011 and 2016, were assessed with CT and CR. Evaluations of the fractures using CR in isolation and CR combined with CT were compared using different readers. Fractures were assessed in terms of type, displacement, size, associated injuries, treatment, patient position and surgical planning.
RESULTS: The medial malleolus fractures characteristics (posteromedial fragment and anterior colliculus), the presence of posterior malleolus fracture and its characteristics (displacement, size, posteromedial or posterolateral segment) (ps < 0.042), syndesmosis injury (p < 0.001), and the absence of deltoid ligament lesion (p < 0.001), were more evident with the combination of CT and radiographs. There was an increase in operative indication (p = 0.007), prone positioning (p = 0.002), posterior malleolus surgical treatment (p < 0.001), posterolateral approach for the lateral malleolus (p = 0.003), and syndesmosis fixation (p = 0.020) with the association of CT and CR, among all groups of expertise, with a high interobserver reliability (> 0.75).
CONCLUSIONS: The CR may fail to demonstrate subtle lesions, such as posterior malleolus fractures and syndesmotic injuries. The CT evaluation increases the diagnostic precision and improves the quality of information the surgeon receives, what might positively affect patient care.
METHODS: Retrospective Comparative Study.

OBJECTIVE: Ankle joint fractures are often accompanied by medial deltoid ligament rupture. There is controversy over whether or how to treat deltoid ligament rupture. This study was aimed to explore the feasibility of repairing the medial deltoid ligament using Kirschner wire internal fixation of the medial tibiotalar joint combined with external fixation.
METHODS: Forty-six patients with ankle fractures involving deltoid ligament rupture, treated between October 2012 and February 2021, were retrospectively evaluated. Twenty-five patients were treated with a Kirschner wire to fix the tibiotalar joint and indirectly repair the deltoid ligament as the repaired group. Twenty-one patients underwent reduction and fixation of internal and external malleolus fractures, and the deltoid ligament was not repaired in the unrepaired group. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analog scale (VAS), Medical Outcomes Short Form 36-item questionnaire score (SF-36), and Medial clear space perpendicular (preoperative, postoperative, final follow-up) were used for functional evaluations and reduction assessments. Mann-Whitney test were used to compare the differences between the groups.
RESULTS: The follow-up time was 13-112 months with a mean of 59.32 months for the repaired group and 11-94 months with a mean of 53.43 months for the unrepaired group. There was no significant difference in the operative time or intraoperative blood loss between the two groups (p > 0.05). At the last follow-up, the AOFAS ankle-hindfoot and SF-36 scores of the repaired group were significantly higher than those of the non-repaired group (p < 0.05). Moreover, the VAS pain score was significantly lower and the Medial clear space perpendicular was significantly narrower in the repaired group than that in the unrepaired group.
CONCLUSIONS: Tibiotalar joint fixation using Kirschner wires is a simple and effective technique that can indirectly reduce and repair the deltoid ligament and stabilize the ankle.

BACKGROUND: The aim was to provide an update on anatomy and function of the medial ankle ligaments, diagnosis of their injuries and treatment of medial ankle instability.
METHODS: Literature search on PubMed.
RESULTS: Injuries to the deltoid ligament are not uncommon in relation to malleolar fractures and ankle sprains. Chronic instability may lead to ankle osteoarthritis. However, there is no consensus on diagnostic criteria (clinically, by imaging and by arthroscopy), on indications for non-operative and operative treatment, and on standards for repair and reconstruction of the ligament complex. There is no current evidence to support acute repair of deltoid ligament injury. Reports on the effect of isolated deltoid ligament reconstruction are very sparse.
CONCLUSIONS: There is a need for a focused effort to establish evidence for all aspects of deltoid ligament injury.

UNASSIGNED: Ankle fracture combined with deltoid ligament (DL) injury results in decreased stability of ankle mortise, reduced contact surface between tibial and talus, increased local stress, and increased postoperative complications. The purpose of this meta-analysis was to evaluate the postoperative effects of repairing ligaments in ankle fractures with DL rupture.
UNASSIGNED: According to the steps of the Cochrane systematic review, the related literatures from PubMed, Embase and the Cochrane Library Databases were retrieved as of September 1, 2021, and all relevant randomized controlled trials and retrospective studies were collected. The evaluation indicators include medial clear space (MCS), visual analogue scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS), complications rate. Meta-analysis was conducted by RevMan® 5.3 provided by the Cochrane collaboration.
UNASSIGNED: A total of 388 patients (195 patients in the ligament repair group and 193 patients in the non-repair group) were included in 7 clinical trials. Meta-analysis data showed there were no statistically significant differences between the ligament repair group and non-repair group in final follow-up VAS, final AOFAS and postoperative MCS (P = 0.50, P = 0.04, P = 0.14, P = 0.14, respectively). Final follow-up MCS and complications rate in ligament repair group were smaller than those in the non-repair group and were statistically significant (P < 0.00001, P = 0.006, respectively).
UNASSIGNED: Although there was no difference in in final follow-up VAS, final follow-up AOFAS and postoperative MCS between experimental group and control group, It\'s statistically significant in final follow-up MCS and complications rate. Ligament repair could reduce the width of MCS, restore ankle stability, reduce the incidence of complications and lead to a better prognosis.

UNASSIGNED: To compare clinical outcomes of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption.
UNASSIGNED: Patients diagnosed with lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption who received open reduction and internal fixation (ORIF) were retrospectively reviewed. Seventy-eight patients were enrolled into the study, including 40 patients treated with lateral malleolus fracture ORIF and trans-syndesmotic fixation, and 38 patients treated with lateral malleolus fracture ORIF and deltoid ligament repair. Basic information and pre- and postoperative radiological materials were reviewed. Visual analog pain scale (VAS) score, Olerud-Molander score, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale were used for evaluating pain control and functional recovery postoperatively at different time points.
UNASSIGNED: No complication was reported in both groups. In the trans-syndesmotic fixation group, all patients received syndesmotic screw removal 6-8 weeks postoperatively. The Olerud-Molander score and AOFAS Ankle-Hindfoot Scale in the deltoid ligament repair group were higher than the trans-syndesmotic fixation group 3 months after operation. No statistical difference was found between the two groups in VAS score from 1 to 12 months postoperatively.
UNASSIGNED: Lateral malleolus fracture ORIF and deltoid ligament repair is an effective method for lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Compared with trans-syndesmotic fixation, deltoid ligament repair holds the advantage of not needing surgical removal of inferior tibiofibular screws postoperatively.

UNASSIGNED: To explore the necessity of repairing the deep layer of deltoid ligament in the treatment of mixed medial injury associated with ankle fractures.
UNASSIGNED: Between January 2016 and December 2018, 12 patients with mixed medial injury associated with ankle fractures were treated with the fixation of the lateral malleolus by bone plates, the fixation of the anterior colliculus of medial malleolus by cannulated screws, and the repair of the deltoid ligament by suture anchors. There were 8 males and 4 females, with an average age of 42 years (range, 18-56 years). According to the Lauge-Hansen classification criteria, there were 11 cases of supination-external rotation type and 1 case of pronation-external rotation type. According to the Weber classification criteria, all cases were type B. The time from injury to operation was 3-6 days, with an average of 4.7 days. In each patient, X-ray films of anteroposterior and lateral views and mortise view of ankle were taken postoperatively. The motion range of ankle joints was observed. The function of the ankle and the outcome of the treatment were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system, Olerud-Molander scoring system, and the visual analogue scale (VAS) score.
UNASSIGNED: All cases were followed up 12-42 months (mean, 28 months). The 12 patients returned to their pre-injury jobs. Five patients with sports injury completely recovered to their pre-injury motor function. No patient experienced persistent medial ankle pain or ankle instability. At last follow-up, the ankle range of motion in dorsiflexion was 9°-25° (mean, 17.96°), which was 0°-11° (mean, 4.02°) less than that in normal side; the range of motion in plantar flexion was 38°-50° (mean, 43.90°), which was 0°-7° (mean, 2.53°) less than that in normal side. The AOFAS score was 88-100 (mean, 96.7); the Olerud-Molander score was 90-100 (mean, 96.5); the VAS score was 0-3 (mean, 1.1).
UNASSIGNED: It is necessary to repair the deep layer of deltoid ligament in the mixed medial injuries associated with ankle fracture, which include anterior colliculus fracture and deep deltoid ligament injury. A better outcome can be achieved by employing the suture anchor repair method.
UNASSIGNED: 探讨在混合型内侧损伤踝关节骨折治疗中修复三角韧带深层的必要性。.
UNASSIGNED: 2016 年 1 月—2018 年 12 月，采用外踝接骨板固定、内踝前丘空心螺钉固定、三角韧带深层缝合锚修复方式治疗 12 例混合型内侧损伤踝关节骨折患者。其中男 8 例，女 4 例；年龄 18～56 岁，平均 42 岁。根据 Lauge-Hansen 分型：旋后外旋型 11 例，旋前外旋型 1 例；根据 Weber 分型，均为 B 型。受伤至手术时间 3～6 d，平均 4.7 d。术后摄踝关节正侧位及踝穴位 X 线片，测量踝关节活动度，并采用美国矫形足踝协会（AOFAS）评分、Olerud-Molander 评分及疼痛视觉模拟评分（VAS）评价疗效。.
UNASSIGNED: 12 例患者均获随访，随访时间 12～42 个月，平均 28 个月。12 例患者均恢复了伤前工作，5 例运动损伤患者全部恢复运动功能。所有患者均未诉踝关节内侧持续性疼痛及踝关节不稳。末次随访时，患侧踝关节背伸活动度为 9°～25°，平均 17.96°，与健侧相差 0°～11°，平均 4.02°；踝关节跖屈活动度为 38°～50°，平均 43.90°，与健侧相差 0°～7°，平均 2.53°。AOFAS 评分为 88～100 分，平均 96.7 分；Olerud-Molander 评分为 90～100 分，平均 96.5 分；VAS 评分为 0～3 分，平均 1.1 分。.
UNASSIGNED: 在同时存在内踝前丘骨折及三角韧带深层断裂的混合型内侧损伤踝关节骨折中，修复三角韧带深层非常必要，缝合锚修复方式可取得较好疗效。.

BACKGROUND: Injuries to the distal tibio-fibular ligaments are common. While pronounced injuries can be reliably diagnosed using conventional radiographs, assessment of subtle syndesmotic injuries is challenging. This cadaver study determines the impact of loading on the assessment of incomplete and more complete syndesmotic injuries when using weightbearing computed tomography (CT) scans.
METHODS: Fourteen paired male cadavers (tibial plateau to toe-tip) were included. A radiolucent frame held specimens in a plantigrade position while both non-weightbearing and weightbearing computed tomography (CT) scans were taken. The following conditions were tested: First, intact ankles (Native) were scanned. Second, one specimen from each pair underwent anterior inferior tibio-fibular ligament (AITFL) transection (Condition 1A), while the contralateral underwent deltoid transection (Condition 1B). Third, the remaining intact deltoid or AITFL was transected from each specimen (Condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (Condition 3). Eight different measurements were performed to assess the integrity of the distal tibio-fibular syndesmosis on axial CT scans.
RESULTS: Load application had no impact on most measurements. While incomplete syndesmotic injuries could not be identified, cadavers with more complete injuries differentiated from native ankles when assessed using axial CT images. No significant difference was evident between discrete AITFL or deltoid ligament transection.
CONCLUSIONS: In a cadaver model, load application had no effect on the assessment of the distal tibio-fibular syndesmosis in incomplete and more complete syndesmotic injuries. Only more complete injuries of the distal tibio-fibular syndesmosis could be identified using axial CT images.

BACKGROUND: The diagnosis of subtle injuries to the distal tibiofibular syndesmosis remains elusive. Conventional radiographs miss a large subset of injuries that present without frank diastasis. This study evaluated the impact of torque application on the assessment of syndesmotic injuries when using weightbearing computed tomography (CT) scans.
METHODS: Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kg) and with (10 Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during 4 test conditions. First, intact ankles (native) were scanned. Second, 1 specimen from each pair underwent anterior inferior tibiofibular ligament (AITFL) transection (condition 1A), while the contralateral underwent deltoid transection (condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (condition 3). Measurements were performed to assess the integrity of the distal tibiofibular syndesmosis on digitally reconstructed radiographs (DRRs) and on axial CT scans.
RESULTS: Torque impacted DRR and axial CT scan measurements in almost all conditions. The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection.
CONCLUSIONS: Torque application had a notable impact on two-dimensional (2-D) measurements used to diagnose syndesmotic injuries for both DRRs and axial CT scans. Because weightbearing conditions allow for standardized positioning of the foot while radiographs or CT scans are taken, the combination of axial load and torque application may be desirable.
CONCLUSIONS: Application of torque to the tibia impacts 2-D measurements and may be useful when diagnosing syndesmotic injuries by DRRs or axial CT images.

OBJECTIVE: Accurate identification of distal tibio-fibular syndesmotic injuries is essential to limit potential deleterious post-traumatic effects. To date, conventional radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) have shown limited utilization. This cadaver study evaluates the utility of weight-bearing CT scans on the assessment of incomplete and more complete syndesmotic injuries.
METHODS: Ten male cadavers (tibial plateau to toe-tip) were included. Weight-bearing CTs were taken under four test conditions, with and without torque on the tibia (corresponding to external rotation of the foot and ankle). First, intact ankles (native) underwent imaging. Second, the anterior-inferior tibio-fibular ligament (AITFL) was transected (condition 1). Then, the deltoid ligament (condition 2) was transected, followed by the interosseous membrane (IOM, condition 3). Finally, the posterior-inferior tibio-fibular ligament (PITFL) was transected (condition 4). The medial clear space (MCS), the tibio-fibular clear space (TFCS), and the tibio-fibular overlap (TFO) were assessed on digitally reconstructed radiographs (DRRs), and on axial CT images.
RESULTS: The TFO differentiated isolated AITFL transection from native ankles when torque was applied. Also under torque conditions, the MCS was a useful predictor of an additional deltoid ligament transection, whereas the TFCS identified cadavers in which the PITFL was also transected.
CONCLUSIONS: Torque application helps to diagnose incomplete syndesmotic injuries when using weight-bearing CT. The TFO may be useful for identifying incomplete syndesmotic injuries, whereas the MCS and TFCS predict more complete injuries.

BACKGROUND: Although Maisonneuve fracture (MF) is a well-known type of ankle fracture-dislocation, there is still a lack of information about the epidemiology and the extent of all associated injuries. The aim of study is to describe MF pathoanatomy on the basis of radiographs, CT scans and intraoperative findings.
METHODS: The study comprised 54 adult patients. MF was defined as an ankle fracture-dislocation with a fracture of the fibula in its proximal quarter. Ankle radiographs and lower leg radiographs were obtained in all patients. Computed tomography (CT) examination was performed in 43 patients, of these in 34 patients in combination with 3D CT reconstructions. A total of 51 patients were treated operatively, and in 38 of these an open procedure was performed.
RESULTS: The fibular fracture-fibular head was involved in four cases, and the subcapital region of the proximal quarter of the fibula was affected in 50 cases. Fractures of the posterior malleolus were identified in 43 of 54 patients (80%). Injury to the deltoid ligament was recorded in 27 cases (50%), a fracture of the medial malleolus in 20 cases (37%) and medial structures were intact in 7 cases (13%). Position fibula in fibular notch-in 9 cases the position changed only minimally, in 11 cases the space between the tibia and the fibula was larger than 2 mm, in 20 cases widening of the tibiofibular space was associated with external rotation of the fibula, in 2 cases fibula was trapped behind the posterior tibial tubercle and in 1 case it was associated with a complete tibiofibular diastasis.
CONCLUSIONS: MF is a variable injury, always associated with rupture of the anterior and interosseous tibiofibular ligaments. CT examination should be employed widely in MF, and MRI should be considered under special circumstances.