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UNASSIGNED: Talar displacement is considered the main predictive factor for poor outcomes and the development of post-traumatic osteoarthritis after ankle fractures. Isolated lateral talar translation, as previously studied by Ramsey and Hamilton using carbon powder imprinting, does not fully replicate the multidirectional joint subluxations seen in ankle fractures. The purpose of this study was to analyze the influence of multiple uniplanar talar displacements on tibiotalar contact mechanics utilizing weightbearing computed tomography (WBCT) and finite element analysis (FEA).
UNASSIGNED: Nineteen subjects (mean age = 37.6 years) with no history of ankle surgery or injury having undergone WBCT arthrogram (n = 1) and WBCT without arthrogram (n = 18) were included. Segmentation of the WBCT images into 3D simulated models of bone and cartilage was performed. Three-dimensional (3D) multiple uniplanar talar displacements were simulated to investigate the respective influence of various uniaxial displacements (including lateral translation, anteroposterior translation, varus-valgus angulation, and external rotation) on the tibiotalar contact mechanics using FEA. Tibiotalar peak contact stress and contact area were modeled for each displacement and its gradations.
UNASSIGNED: Our modeling demonstrated that peak contact stress of the talus and tibia increased, whereas contact area decreased, with incremental displacement in all tested directions. Contact stress maps of the talus and tibia were computed for each displacement demonstrating unique patterns of pressure derangement. One millimeter of lateral translation resulted in 14% increase of peak talar contact pressure and a 3% decrease in contact area.
UNASSIGNED: Our model predicted that with lateral talar translation, there is less noticeable change in tibiotalar contact area compared with prior studies whereas external rotation greater than 12 degrees had the largest effect on peak contact stress predictions.
UNASSIGNED: Level V, computational simulation study.

BACKGROUND: Over the past decade, there has been a growing interest in the identification and treatment of posterior malleolus fragments, driven by a better understanding of their significance. The Mason & Molloy (M&M) classification system has emerged as a valuable tool for systematically categorizing these fractures and assisting clinicians in formulating treatment. We aim to assess the interobserver reliability of the M&M classification for posterior malleolus fracture by using 20 raters.
METHODS: The study was conducted at a major foot and ankle referral center in Wythenshawe, Manchester, UK. Thirty-eight Computed Tomography (CT) scans were evaluated by 20 independent raters: 15 general orthopedic and trauma surgeons plus five foot and ankle surgeons. Each rater classified the posterior malleolus fracture according to M&M classification into type 1, 2A, 2B, 3, or not classifiable. Statistical analysis was done with the R software package and SPSS (v26; IBM Corp., Armonk, NY). Fleiss kappa (κ) coefficient with a 95% confidence interval (CI) was applied.
RESULTS: The interobserver agreement was moderate with a global κ value of 0.531 (95% CI: 0.518, 0.544). There were good agreements for identifying type 3 M&M (κ=0.785) and those that are not applicable for M&M classification (κ=0.785). There was a strong correlation between all raters in using M&M classification (Tb=0.53-0.59) except for Rater 12.
CONCLUSIONS: M&M classification remains a valuable tool to guide the management of patients with these subsets of ankle fractures.

Successful outcomes in the surgical treatment of the fractured ankle require methods that respect the soft tissue envelope and establish a stable mortise for functional rehabilitation. Ankle fractures in patients with osteopenia and in diabetic patients with deranged bone remodeling constitute high-risk injuries that may result in catastrophic complications. These patients present unique care challenges and should not be approached in the same manner as their healthy counterparts. We present the principles of treatment in high-risk ankle fractures, operative treatment philosophy illustrating techniques frequently used at our institution, and a review of current literature.

This study offers a thorough analysis of tibial pilon fractures, accounting for patient compliance, diverse treatment options, and soft tissue implications. The article discusses varied treatment pathways, ranging from single-stage interventions to two-stage methods for open fractures by presenting seven clinical cases. The emphasis is on the intricate interplay of trauma intensity, bone damage, and adjacent soft tissue in dictating treatment plans and patient outcomes. The challenges posed by non-compliant patients rejecting advised treatments are underscored, illuminating the inherent risks. Drawing from varied patient demographics, comorbidities, and fracture types, a comprehensive guide for clinicians emerges. The findings underscore the importance of a tailored, patient-centric approach, considering the multifaceted nature of ankle fractures, local soft tissue health, patient\'s overall well-being, and their adherence to the proposed treatment regimen.

UNASSIGNED: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal.
UNASSIGNED: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal.
UNASSIGNED: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80).
UNASSIGNED: Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal.
UNASSIGNED: Level III, retrospective cohort study.

Background The tibiofibular line (TFL) technique was initially proposed to assess syndesmosis reduction. Clinical utility was limited by low observer reliability when applied to all fibulas. This study aimed to refine this technique by describing TFL\'s applicability to various fibula morphologies. Methods Three observers reviewed 52 ankle CT scans. Observer consistencies for TFL measurement, anterolateral fibula contact length, and fibula morphology were assessed using intraclass correlation (ICC) and Fleiss\' Kappa. Results TFL measurement and fibula contact length intra-observer and inter-observer consistencies were excellent (minimum ICC, 0.87). Fibula shape categorization intra-observer consistency was substantial to almost perfect (Fleiss\' Kappa, 0.73 to 0.97). Six to 10 mm of fibula contact length corresponded to excellent TFL distance consistency (ICC, 0.80 to 0.98). Conclusion The TFL technique appears best for patients with 6 mm to 10 mm of straight anterolateral fibula. Sixty-one percent (61%) of fibulas featured this morphology, indicating most patients may be amenable to this technique.

Osteochondral damage to the ankle joint can be a difficult problem to manage in a young active patient. There are several described surgical treatments ranging from cartilage repair techniques to arthrodesis and ankle replacement. In this case, we present a 28-year-old male who sustained a right type IIIA open medial malleolus fracture following an all-terrain vehicle crash. After sharp debridement, the clinical decision was made to treat the patient with an osteochondral allograft. At one- and two-year post-allograft reconstruction, radiographs demonstrated good incorporation of the graft. The patient was ambulating with no pain or assistive devices. Our case report specifically describes the successful treatment of a traumatic medial malleolus ankle fracture with bone loss using an osteochondral allograft in a young active patient.

Introduction Order Communication Systems (Ordercomms) are computer applications used to enter diagnostic and therapeutic patient care orders and view test results. These electronic systems allow the integration of Clinical Decision Support Systems (CDSS). CDSS are computer applications designed to aid clinicians in making diagnostic and therapeutic decisions in patient care (e.g. can notify clinicians of best practice guidelines when requesting investigations or prescribing medications). The aims of this study were to determine whether electronic notifications (via Ordercomms) are effective in improving clinician compliance with the Ottawa Rules in plain radiographs requesting for ankle trauma, and the efficacy of electronic notifications in reducing inappropriate imaging requests. Methods The Ottawa Rules are a globally validated clinical decision tool with a sensitivity of 99%-100% for ankle fractures. When used, they can reduce the number of unnecessary radiographs by 30%-40%. Importantly, the Royal College of Radiologists stipulates that a patient must fulfill the Ottawa Rules in order to proceed with a plain radiograph of the ankle in trauma. A retrospective analysis of 366 plain ankle radiographs was performed to exclude bony injury in the emergency department between February and March 2018. Information gathered included patient demographics, the request form completed by the emergency department clinician, and radiology report. A pop-up reminder was then implemented on the electronic requesting system to prompt clinicians to apply the Ottawa Ankle Rules and document their plain radiograph request accordingly. Following the intervention, a further 473 plain radiographs were analysed in the same way over a three-month period (April-June 2018). Results In the two months prior to the intervention, 366 plain radiographs were performed for ankle trauma. Of these, 45.1% fulfilled the Ottawa Rules. In the three months following our intervention, 473 plain radiographs were carried out. There was no significant increase in the percentage of requests fulfilling the Ottawa Rules (45.7%). Unnecessary radiographs (those which did not fulfill the Ottawa Rules and consequently showed no fracture) also showed no change. The data demonstrates that the electronic reminder asking individuals to apply and document the Ottawa Rules appropriately had no impact on the imaging requesting behaviour, and subsequently on the number of unnecessary plain radiographs. Conclusion Electronic notifications in Order Communication Systems did not change clinicians\' behaviour in this specific circumstance. This study has implications for electronic notifications in prescribing systems and pathology requesting systems. Further research is needed to determine if the findings are replicated with other imaging types.

Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.