Journal of Foot and Ankle Surgery (Asia Pacific)

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2021 | October-December | Volume 8 | Issue 4

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Guest Editorial

Alexandre L Godoy-Santos, German M Joannas

Symposium on Complex Ankle Fractures

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:1] [Pages No:157 - 157]

   DOI: 10.5005/jp-journals-10040-1198  |  Open Access |  How to cite  | 


Symposium: Complex Injuries Around The Ankle

Sriskandarasa Senthilkumaran, Andrew Oppy, Harvinder Bedi

Management of Weber B Ankle Fractures: What have We Learnt since the CROSSBAT Trial?

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:4] [Pages No:158 - 161]

Keywords: Ankle stability, Combined randomized and observational study of surgery for type B ankle fracture treatment, Nonoperative management, Post-traumatic arthrosis, Weber B ankle fracture, Weight-bearing radiograph

   DOI: 10.5005/jp-journals-10040-1168  |  Open Access |  How to cite  | 


Weber B fractures account for about 50% of all fractures at the ankle joint. Despite being a common injury, there is clinical equipoise in the management of an isolated lateral malleolar fracture with presumed medial ligamentous injury. The Combined Randomized and Observational Study of Surgery for type B Ankle fracture Treatment (CROSSBAT) study was a multicenter randomized control trial that also had an observational cohort arm. It showed that nonoperative management of Weber B fractures produced equivalent functional results at 1 year and avoided risks and complications that are associated with operative treatment. Other studies have shown similar results in short to mid-term follow-ups. The key to decision-making in ankle fracture is evaluating the stability of the ankle mortice. Weight-bearing radiographs are gaining popularity in this assessment as we understand the important role of the deep deltoid ligament. A lateral malleolar fracture with a medial ligamentous injury that is deemed to be stable by weight-bearing X-rays can be safely managed nonoperatively. Long-term studies are needed to calculate the relative risk of developing post-traumatic arthrosis in these patients compared to those who underwent fixation.


Symposium: Complex Injuries Around The Ankle

Pilar Martínez de Albornoz, Manuel Monteagudo

Pathomechanics of Syndesmotic Injuries

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:6] [Pages No:162 - 167]

Keywords: Ankle fractures, Biomechanics, Foot and ankle, Syndesmosis

   DOI: 10.5005/jp-journals-10040-1194  |  Open Access |  How to cite  | 


Syndesmotic injuries have gained interest in recent years since they are present in 13% of ankle fractures and up to 20% of ankle sprains. The clinical suspicion of these injuries should lead the surgeon to ask for 3D-computed tomography images to avoid misdiagnosed injuries that may change management planning. The concept of dynamic joint stabilization is important, and overall knowledge of anatomy, biomechanics of a healthy and pathological syndesmosis will provide an objective starting point to improve diagnosis, mechanical repair, and rehabilitation. This review highlights basic and advanced biomechanical concepts, an update of the scientific evidence, and laboratory results with clinical outcomes for a better comprehension of treatment options.


Symposium: Complex Injuries Around The Ankle

Diederick Penning, Merel FN Birnie, Fay RK Sanders, Kristian J de Ruiter, Tim Schepers

Syndesmotic Screw: Where does It Break?

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:4] [Pages No:168 - 171]

Keywords: Ankle, Implant removal, Syndesmosis, Syndesmotic screw

   DOI: 10.5005/jp-journals-10040-1184  |  Open Access |  How to cite  | 


Aim and objective: There is an increasing body of evidence that syndesmotic screws following stabilization of acute syndesmotic disruption in ankle fractures can be retained if not symptomatic. Some broken screws may remain symptomatic (pain, cortical erosion) and can be difficult to remove. This study aimed to evaluate at what level the syndesmotic screw breaks and how often this occurs at a level that may lead to potential refractory complaints needing further surgical intervention. Materials and methods: All consecutive cases with a surgically treated ankle fracture and subsequent placement of one or more syndesmotic screws were included. The level of syndesmotic screw breakage was divided into six potential different patterns. Intraosseous breakage was considered as a location with possible refractory complaints. The need for subsequent removal of the complete broken syndesmotic screw was recorded. Results: A total of 51 broken syndesmotic screws remained for analysis. The largest amount of screws (22 screws, 43.1%) broke at the level of the lateral tibial cortex. One of the screws broke in-between the fibula and tibia. The need for complete removal of a broken screw (including the medial part) was seen in six screws (11.8% of all broken screws). Conclusion: Albeit broken syndesmotic screws are encountered frequently, the number of locations with possible clinical consequences was low. The need for the complete removal of a broken screw was low. Clinical significance: Retaining the syndesmotic screw should be the new gold standard.


Symposium: Complex Injuries Around The Ankle

Camilo A Delgadillo, Eduard J Salavarrieta, Rodrigo F Pesántez

Open Fractures of the Ankle Joint and the Hindfoot

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:8] [Pages No:172 - 179]

Keywords: Amputation, Ankle fracture, Debridement, Flap cover, Hindfoot, Open ankle dislocation

   DOI: 10.5005/jp-journals-10040-1191  |  Open Access |  How to cite  | 


Ankle fractures are common lesions in sportive activities and high-velocity trauma, 17% could be open fractures; obese and older women are more prone. Leading to coverage defects, osteomyelitis, and bone loss. Management of open fracture requires an interdisciplinary team, with extensive knowledge in this complex situation. Treatment in the emergency department includes clear documentation of the wound, including contamination, neurologic and vascular status, radiographic diagnosis and early administration of antibiotics and tetanus prophylaxis, provisional reduction, and splint the extremity. A debridement similar to oncology protocol decreased the probability of infection as a complication. The use of negative pressure wound therapy has a positive impact on wound closure and decreased necrosis of flaps and grafts. Fractures of the hindfoot are least prevalent but may have frequent complications.


Symposium: Complex Injuries Around The Ankle

Alexandre L Godoy-Santos, Mario Herrera-Pérez, Cesar de Cesar Netto, André Wajnsztejn, Vincenzo Giordano

Is Ankle Post-traumatic Osteoarthritis Inevitable after Malleolar Fractures?

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:8] [Pages No:180 - 187]

Keywords: Ankle joint, Arthritis, Malleolar fracture

   DOI: 10.5005/jp-journals-10040-1195  |  Open Access |  How to cite  | 


The tibiotalar joint is one of the most prevalent intra-articular fracture sites in the human body, resulting in high rates of post-traumatic ankle osteoarthritis (PTOA). Studies have shown multifactorial causes for PTOA and highlight the importance of three determining factors for clinical outcomes after malleolar fracture: quality of joint reduction and fracture fixation, residual ligament instability, and initial damage to joint tissues—including chondral tissue, synovial tissue, and synovial fluid. This special article summarizes recent evidence of malleolar fractures treatment, with a main focus on important factors related to improve clinical outcomes in order to avoid post-traumatic ankle osteoarthritis (OA).


Symposium: Complex Injuries Around The Ankle

Nicholas Genovese, Jay Patel, Sheldon S Lin, Joshua Greendyk

Primary Tibiotalocalcaneal Fusion for High-risk Complex Ankle Fractures

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:5] [Pages No:188 - 192]

Keywords: Ankle arthrodesis, Ankle fractures, Diabetic ankle fracture, Fusion, Tibiotalocalcaneal arthrodesis

   DOI: 10.5005/jp-journals-10040-1180  |  Open Access |  How to cite  | 


Successful management of high-risk diabetic patients with unstable ankle fractures remains a difficult task given the high incidence of complications and need for reoperation. Ankle arthrodesis has been primarily described as a salvage procedure for Charcot arthropathy or failed fracture fixation. Primary tibiotalocalcaneal (TTC) fusion is a simple and effective treatment option for dealing with the pathophysiologic factors that diabetic patients encounter when they sustain an unstable ankle fracture.


Symposium: Complex Injuries Around The Ankle

Joannas German, Arrondo Guillermo, Stefan Rammelt, Casola Leandro, Mizdraji Luciano

Quadrimalleolar Fractures of the Ankle: Think 360°—A Step-by-step Guide on Evaluation and Fixation

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:8] [Pages No:193 - 200]

Keywords: Ankle fracture, Anterolateral approach, Complex ankle fractures, Modified posteromedial approach, Posterior malleolus, Posterolateral approach, Quadrimalleolar fractures, Syndesmosis injury

   DOI: 10.5005/jp-journals-10040-1199  |  Open Access |  How to cite  | 


Trimalleolar fractures, which involve the medial malleolus, lateral malleolus, and posterior malleolus, have been traditionally associated with a less favorable prognosis in ankle fractures. Less frequently, the anterolateral tibial rim (“Tillaux-Chaput tubercle”) and anteromedial fibular rim (“Wagstaffe-LeFort fragment”) are fractured. Trimalleolar fractures with anterior fractures are named quadrimalleolar fractures. Only correct planning will lead us to a good result. A 360° view is needed to plan appropriate treatment for fractures including the anterior and posterior tibial rim. CT scanning is essential. The ankle is divided into four areas on the axial CT scan: (A) (posterior malleolus), (B) (medial malleolus), (C) (lateral malleolus), and (D) (anterior malleolus Chaput and/or Wagstaffe fragments). Depending on which malleolus is involved, different approaches and ways of fixing the fractures have been described. At the end of the procedure, after performing open reduction and internal fixation of all four malleoli, syndesmotic stability must be tested intraoperatively. Patients with complex malleolar fractures are kept with a walker boot for 15–21 days after surgery with sole contact (max. 20 kg), to avoid subsequent retraction and forced plantar flexion of the ankle. Early walking as tolerated with two crutches at week 4. In the fifth week, we are authorized to weight bear 50% (one crutch) and in the sixth week full weight-bearing. These periods are prolonged with osteoporosis, plafond impaction, or poor patient compliance.



YeokPin Chua, WengKong Low, Rukmanikanthan Shanmugam, Aik Saw, Mark C Blackney

Mechanical Analysis of Five Methods of Tibiotalar Arthrodesis Using Screw Fixation Technique: A Cadaveric Study

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:5] [Pages No:201 - 205]

Keywords: Ankle arthrodesis, Anterior plate, AO screw, Arthroscopic ankle fusion, Headless screw

   DOI: 10.5005/jp-journals-10040-1179  |  Open Access |  How to cite  | 


Background: Many different techniques for ankle arthrodesis have been described. Compression screws require the least dissection and can be done percutaneously, hence leading to faster healing. It was conventionally carried out by using half-threaded cancellous AO screws to achieve the compressive effect across the arthrodesis site. Even with the introduction of newer implants and screw systems, there is a lack of standardization in the surgical technique used in ankle arthrodesis surgery; and there is no recent study comparing the mechanical strength of these newer implants. Hence, we performed the study to determine the biomechanical properties of the five surgical techniques for ankle fusion as mentioned above. Materials and methods: Fifteen fresh frozen cadaveric ankles were obtained and the specimens were then divided into five groups: three samples for each group; group I (two cross standard AO screw technique), group II (two cross headless compression screw technique), group III (two cross headless compression screws with anterior locking plate), group IV (three cross headless compression screws), and group V (IO Fix System). Arthrodesis fixation was then performed according to the groups divided. Each of the specimens was then tested following a standard loading protocol for its stiffness in plantar flexion, dorsiflexion, inversion, and eversion using Instron machine in NOCERAL PPUM. Results collected were analyzed using SPSS Ver 22. Results: The results showed that group II has higher stiffness in all aspects when compared with group I. We also found that group III is the stiffest construct in the aspect of plantar flexion and dorsiflexion, and it is statistically significant when comparing plantar flexion stiffness with the group I (p = 0.042) and group II (p = 0.039). On the other hand, group IV is the stiffest construct inversion and eversion comparing to other groups. Group I is the weakest construct in all-loading aspects. Conclusion: From the results of our study, we concluded that the newer generation of screws does have a biomechanical advantage over the conventional standard half-threaded AO screws. We recommend the use of headless compression screws in replacement of the standard AO half-threaded cancellous screws, and to use two cross screws with an anterior plate for open technique, or three screws fixation technique for arthroscopic ankle fusion.



Jean P Filler Leung, Bernardino Alpuerto II, Ilian Eusebio

Open Total Talar Dislocation with Extrusion: Tips and Tricks in Management

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:3] [Pages No:206 - 208]

Keywords: Early surgery, External fixation, Talar extrusion

   DOI: 10.5005/jp-journals-10040-1175  |  Open Access |  How to cite  | 


Open total talar dislocations are rare but potentially catastrophic injuries of the hindfoot. Successful management involves following the principles of open fracture management—thorough debridement, reduction, stabilization, and wound management. We detail our surgical technique in managing such a case, with specific tips on each step that may help others in the management of such cases.


Radiology Corner

Sandeep Patel, Manjunath Nishani

Intraoperative C-arm CT for Assessment of Syndesmotic Reduction

[Year:2021] [Month:October-December] [Volume:8] [Number:4] [Pages:2] [Pages No:209 - 210]

Keywords: Ankle fracture, Intraoperative CT, Syndesmosis injury

   DOI: 10.5005/jp-journals-10040-1183  |  Open Access |  How to cite  | 


Anatomic syndesmotic reduction is an important predictor of successful outcomes after ankle fracture fixation with associated syndesmotic injury. Various methods to check syndesmotic reduction range from mini-open technique and visualization to various radiographic parameters on standard C-arm to postoperative CT scans. Intraoperative CT scan will definitely be the best imaging modality and can avoid re-surgeries. With the advent of C-arm CT scans, the whole process of intraoperative CT scans can be cost-effective, compact, and easy portability between operation theaters.


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