Several challenges exist for the foot and ankle surgeon when addressing the complications associated with ankle fracture repair. The risk of joint destruction, debilitation, and even limb loss may be amplified by the noncompliant patient. There is an abundance of literature documenting the management of fracture nonunions in the setting of infection with a variety of techniques proven successful in managing large osseous defects and eradicating infection. We present a particularly challenging case in which we modified an existing method of treatment to preserve the ankle joint of a failed reduction complicated by septic nonunion following placement of a fibular intramedullary nail.

OBJECTIVE: The effectiveness and safety of fibular intramedullary nail fixation (FINF) compared to plate fixation (PF) in treating ankle fractures among adults remains unclear. Therefore, we conducted a meta-analysis to assess the efficacy and safety of FINF versus PF, aiming to provide orthopedic surgeons with valuable insights when choosing between the two internal fixation methods for patient treatment.
METHODS: PubMed, EMBASE, and SCOPUS were systematically searched for articles comparing FINF and PF in ankle fractures among adults. Functional outcomes, complications, and bony union were compared between the implants.
RESULTS: A total of seven studies were included in the study, involving 586 patients. The results revealed no statistically significant differences in functional outcomes between two groups at 3, 6, and 12 months postoperatively. The outcomes favoring FINF comprised a lower infection rate (RR = 0.23, 95%CI, 0.11 to 0.47, P < 0.0001). Conversely, the PF group exhibited a superior performance in terms of hardware failure rate (RR = 2.05, 95%CI, 1.16 to 3.60, P = 0.01). A statistically significant difference was observed in the results of hardware failure rate in the subgroup of studies conducted in Europe (RR = 2.74, 95%CI, 1.45 to 5.18, P = 0.002). Comparable findings were also noted in a subgroup of older adults (RR = 4.25, 95%CI, 1.57 to 11.50, P = 0.004).
CONCLUSIONS: This systematic review suggests that FINF exhibits comparable effectiveness in the management of ankle fractures among adults, as compared to PF. Consequently, it is imperative to further delineate the surgical indications for both FINF and PF with precision to mitigate the risk of complications. Nevertheless, larger sample sizes and multi-center RCTs are imperative to corroborate this conclusion in the future.

UNASSIGNED: The purpose of this study was to analyse the clinical and radiographic data of a consecutive series of patients treated surgically for AO/OTA 44B ankle fracture at Ferrara University Hospital, Italy, with a view to identifying risk factors contributing to worse clinical and radiographic outcomes with a minium follow up of 6 years.
UNASSIGNED: For each patient the following data were recorded: gender, age, Body Mass Index (BMI), follow up (months), previous ankle sprains, type of work, Kellgren-Lawrence (K&L) score, AO/OTA classification for ankle fracture, Foot and Ankle Disability Index (FADI score), ankle dislocation, syndesmotic transfixation, quality of reduction.
UNASSIGNED: FADI score in patients with AO/OTA 44B1 fracture was 95.5±7.5, in 44B2 it was 90.0±8.4 and in 44B3 it was 84.0±13.0 (p25 it was 88.6±11.4 (p=0.047 95%I.C. 0.01-8.10). In case of fracture-dislocation there was a statistically significant difference in the FADI (94.4±6.0 vs 85.8±11.98)(P=0.002 95% I.C. 0.01-8.9). In the former group, there was a statistically significant difference in the ​the K&L (1.97±0.65 vs 2.63±0.85) (P=0.006 95% I.C 0.01-1.00).Finally, the quality of the reduction was a statistically significant parameter in both the FADI and K&L (P=0.012 95% I.C. 0.90-10.60 and P=0.012 95%I.C. 0.01-1.00 respectively).
UNASSIGNED: The most influential risk factors for worse outcome in AO/OTA 44B ankle fractures were found to be BMI, injury severity, fracture-dislocation and reduction quality.

UNASSIGNED: Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques.
UNASSIGNED: Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification.
UNASSIGNED: Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures.
UNASSIGNED: The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended.

UNASSIGNED: This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.
UNASSIGNED: A total of 157 patients aged 18 years or older who underwent successful open reduction and internal fixation (ORIF) of Weber B (AO44B) ankle fractures were recruited to this randomized controlled trial. At two weeks post-surgical fixation, participants were randomized to either light-weight cast-immobilization or the EMADE programme, consisting of progressive home exercises and weekly advice and education. Both groups were restricted to non-weightbearing until six weeks post-surgery. The primary outcome was assessed using the Olerud-Molander Ankle Score (OMAS) questionnaire at 12 weeks post-surgery, with secondary measures at two, six, 24, and 52 weeks. Exploratory cost-effectiveness analyses were also performed.
UNASSIGNED: Overall, 130 participants returned their 12-week OMAS questionnaires. The mean OMAS was significantly higher in the EMADE group compared with the immobilized group (62.0 (SD 20.9) vs 48.8 (SD 22.5)), with a clinically meaningful mean difference of 13.2 (95% CI 5.66 to 20.73; p < 0.001). These differences were maintained at week 24, with convergence by week 52. No intervention-related adverse events, including instability, were reported.
UNASSIGNED: The EMADE programme demonstrated an accelerated recovery compared to traditional six-week cast immobilization for those who have undergone ORIF surgery to stabilize Weber B (AO44B) ankle fractures. The study found the EMADE intervention to be safe.

UNASSIGNED: Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.
UNASSIGNED: This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling.
UNASSIGNED: A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17).
UNASSIGNED: We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets.

Introduction The purpose of the current study is to present the outcome of closed reduction and stabilization using an Illizarov ring fixator in severe pilon fractures and to investigate the correlation between reduction quality and clinical and functional outcomes. Materials and methods Thirty-three type III tibial plafond fractures, which had been treated with this method, were retrospectively analysed. Quality of reduction was classified according to the Teeny & Wiss (TW) criteria. Clinical and functional assessment was carried out using the Ovadia & Beals (OB) and Olerud & Molander (OM) scores. Results All fractures were successfully united. The mean time in the fixator was 6.3 months, and the mean follow-up was 50 months after frame removal. There were no major infections. There was no significant relationship between TW and OM (r=-0.34, p=0.13), TW and OB (r=0.35, p=0.23), neither Delay (from injury until surgery) and OM (r=-0.03, p=0.28), and Delay and OB (r=0.30, p=0.31). Conclusions The present study demonstrates that the major problems of open reduction and internal fixation of pilon type III fractures can be avoided by a non-invasive approach to the treatment of these fractures. The articular surface can be reconstituted with olive-tip wires and small fragment washers, early ligamentotaxis and fracture stabilization with the Ilizarov ring fixator. These simple steps could lead safely to union and a good clinical and functional outcome.

BACKGROUND: There are many options for the surgical treatment of pronation external rotation (PER) type IV ankle fractures, including the use of fibular plates and screws, the aim of this study was to investigate the biomechanical stability and safety of different internal fixation methods for PER type IV ankle fractures via finite element analysis.
METHODS: A three-dimensional finite element model of the ankle joint and the whole foot of a healthy 26-years-old adult male was established and validated based on computed tomography images of his lower limb, and a computer-aided design was used to produce a PER type IV ankle fracture and plate and screw model. Four different internal fixation modes were simulated, including a (all ankle fixation-utilizing a fibular plate and screws for comprehensive stabilization of the ankle), b (inferior tibiofibular joint fixation + all ankle fixation), c (inferior tibiofibular joint fixation + unfixed anterior ankle), and d (inferior tibiofibular joint fixation + unfixed anterior and posterior ankles). The results of the four different fixation methods were compared via finite element analysis, and the von Mises stresses. The displacements of the four different fixation methods were analyzed as the output indices.
RESULTS: There were no significant differences between the results of using fibular plates and screws and the displacement of fracture breaks among the four internal fixation modalities. The von Mises stress in the tibiotalar joint, median ankle, posterior ankle, and anterior ankle was minimized in the working condition of d, d, b, and d respectively. The von Mises stress in the fibular plate and screws was minimized in the working condition of a. The von Mises stress in the distal fibula was minimized in the working condition of a. However, the stress was mainly concentrated at the attachment point of the inferior tibiofibular anterior ligament, and in the working condition with inferior tibiofibular joint fixation, the stress was significantly concentrated in the inferior tibiofibular joint screw in all the fibular plates and screws.
CONCLUSIONS: The results of this study demonstrate the feasibility of using finite element analysis to compare the biomechanical stability and safety of four configurations of fibular plates and screws for treating PER type IV ankle fractures. All four modalities provided comparable biomechanical stability and safety, showing no significant differences. However, the current limitations of the finite element analysis methodology preclude specific clinical inferences. Further refinement of the methodology in future studies is necessary to enable reliable clinical applications.

This study aimed to evaluate the occurrence of partial bridging and synostosis in the distal tibiofibular joint after surgically treated ankle fractures and determine possible risk factors. In this retrospective study, patients admitted to our hospital with ankle trauma between January 1, 2016, and December 31, 2020, who were operated on for an ankle fracture and had a follow-up period of at least one year, were included. Patients underwent anteroposterior, lateral, and mortise radiographs of the ankle and low-dose computed tomography postoperatively. The presence of partial bridging and synostosis in the distal tibiofibular joint was evaluated. The study included 75 patients (50 males, 25 females). There were 40 patients with the right fracture side and 35 patients with the left fracture side. The mean age of the patients included in the study was 43.96±15.07 years. The total follow-up period was 40±13 months. Nineteen patients had partial bridging (13 males, 6 females), and 9 had synostosis (7 males, 2 females). The incidence of partial bridging was 25.3%, and synostosis was 12%. We determined that high-energy trauma is a risk factor for synostosis, but we found that syndesmosis injury is not a risk factor for developing distal tibiofibular synostosis. Additionally, we found that distal tibiofibular synostosis and partial bridging do not affect ankle joint movements. Level of clinical evidence: 4.

Three computed tomography (CT)-based classifications, including Haraguchi, Bartoníček-Rammelt, and Mason-Molloy systems, have been developed to better determine the characteristics of posterior malleolus fractures (PMFs). The aims of this study were (1) to determine the intra- and inter-observer reliability of the computed tomography-based classification systems and (2) to investigate the clinical experience and expertise on their reliabilities. Sixty-seven preoperative ankle CT scans of 67 adult patients with \"ankle fracture with the involvement of the posterior malleolus\"\'\' were retrospectively identified. CT images were assessed by 10 observers with different levels of clinical experience from 2 different specialties, including orthopedics and radiology. The observers were asked to classify PMFs according to 3 CT-based classifications on 2 separate occasions with a 4-week interval. Cohen\'s κ values were measured for 2 raters and Fleiss\' κ values were measured for 3 raters and more. Overall, each classification had moderate to very good intraobserver reliability (κ=0.41 to 0.95, P < .01) as well as moderate interobserver reliability for each of the 2 separate assessments (κ=0.41 to 0.60, P < .01 for the first occasion; κ=0.44 to 0.59, P < .01 for the second occasion). Interobserver agreement among the foot and ankle surgeons regarding the Haraguchi and Bartoníček classifications was substantial for both assessment periods, whereas there was a moderate agreement for the Mason classification. Orthopedic residents showed moderate interobserver agreement in each period for both Bartoníček and Mason classifications. Radiology experts illustrated slight and fair agreements in the 2 assessments for Mason classification, moderate agreement in both assessments for Haraguchi classification, and substantial to moderate agreement in the first and second assessments for Bartoníček classification, respectively. Computed tomography-based classification system for PMFs demonstrated moderate interobserver reliability as well as moderate to very good intraobserver reliability. Moreover, foot and ankle specialists exhibit enhanced K values for both inter and intraobserver reliability for each classification system, consistency seems to increase as the interest in the field condenses.