The sporting ankle: an update

The ankle is one of the most commonly injured joints during sport, accounting for almost 30% of all musculoskeletal injuries. These result in a spectrum of pathology varying in severity and involving a number of structures around the hind foot. The most common pathologies include lateral ligament and syndesmosis injuries, impingement and osteochondral lesions of the talus. Most of these injuries will resolve with non-operative management, however, more severe injuries may never fully settle and will require surgical intervention. There have been recent developments in the surgical management of these conditions and this review article will focus on the recent advances in the understanding of these injuries and aim to discuss the up-to-date management options.     

The rationale behind surgical approaches to ankle fractures

Ankle fractures and fracture dislocations are one of the commonest injuries seen by orthopaedic surgeons. Decisions around the surgical fixation of ankle fractures require an understanding of the bony and ligamentous anatomy of the joint as well as an appreciation of the normal ankle joint biomechanics. The operative treatment of these injuries aims to hold the joint securely in an anatomically reduced position throughout the period of healing, and allow initiation of joint motion as soon as possible. If these treatment goals are met, a good outcome is a reasonable expectation, given the proviso that disruption of any articular surface can result in permanent damage. However the functional outcome of fractures involving a posterior malleolar fragment is often not satisfactory and recent debate has surrounded ankle fracture fixation, with the posterior malleolus in particular being subject to increased scrutiny for its contribution towards long-term ankle stability. With the advent of excellent results from the use of open reduction and rigid internal fixation, the gold standard of treatment for displaced ankle fractures has become surgical fixation. This article explores the evidence behind commonly used surgical approaches to ankle fracture fixation and the rationale behind their use.     

(iii) Arthroscopy of the foot and ankle

The role of arthroscopy in the management of articular pathology is now well established. Its use in the management of foot and ankle pathology is relatively new, but with innovative techniques and modern equipment, the indications are expanding. Procedures that were previously performed through an open approach can now be done using a pure arthroscopic, or arthroscopically assisted, method with the aim of earlier rehabilitation, reducing complications and scarring, and improving outcome. We describe the history, current role and potential future uses of arthroscopy in the treatment of foot and ankle conditions.     

Osteoarthritis of the ankle

Ankle arthritis is a debilitating condition. Primary ankle joint osteoarthritis is much rarer than hip or knee arthritis. The majority of cases are post-traumatic secondary to previous articular trauma or ligamentous instability. Treatment methods available are guided by disease severity and the patient's functional demands. Weight loss, activity modification, the wearing of an ankle brace or high-topped lace-up boots and orthoses should be the first line of treatment. Joint-sparing procedures such as arthroscopic debridement, supramalleolar osteotomy and distraction arthroplasty have been trialled with low levels of supporting evidence. The demand for joint preservation has led to the development of total ankle allografting procedures, but these have fallen out of favour. Despite advancements, the gold standard for end-stage arthritis remains arthrodesis, although evidence for total ankle arthroplasty in certain groups of patients is increasing. The current third-generation implants have improved survivorship although their results remain inferior to arthroplasty of the hip and knee. There is currently a UK randomized control trial of ankle replacement versus arthrodesis under way as well as several national joint registries, which will hopefully better define those patients who will gain most benefit from replacement as opposed to fusion.     

Management strategies in the treatment of osteochondral lesions of the talus

Osteochondral defects of the talus are a common occurrence and remain a challenge to the orthopaedic surgeon. Commonly found on the medial talar dome, they are usually the sequelae from traumatic injuries and often are delayed in their presentation to the outpatient setting. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Management of these full-thickness cartilage injuries is usually guided by the size, as well as position on the talar dome surface. Arthroscopic microfracture has been the mainstay of first-line surgical treatment as well as for smaller lesions. Larger lesions may need more novel procedures which include scaffold-based therapies or osteochondral transplantation.     

Fractures of the distal tibial physis

Injuries around the ankle in children can result in fractures that primarily involve the growth plate: the weakest area of the developing distal tibia. The morphology of the fracture varies depending on age and mechanism of injury. Unique fracture patterns occur due to the complex interplay of anatomy and physiology, and asymmetric closure of this physis near skeletal maturity produces a unique subset of injuries called transitional fractures. The method of treatment can be controversial and depends upon the fracture type and age of the patient. Detailed imaging is essential for decision making, particularly when surgical intervention is required. Operative strategies must be mindful of the need to preserve remaining growth and prevent deformity. Growth disturbance and deformity are common and must be monitored. Several strategies for dealing with premature physeal closure are available but decisions are based on careful planning and individualized to the patient and their carers.     

Ankle instability and intra-articular injuries in children

Ankle instability is a common problem in children and adolescents. What may seem like an initial, relatively benign ankle injury for a child may lead to chronic pain, chronic instability and gradual loss of the ability to participate in certain activities. The complications of an ankle injury can include osteochondral defects, which may require urgent surgical attention and may be associated with an increased long-term risk of osteoarthritis. This article aims to provide trainees and general orthopaedic surgeons with a systematic approach to the assessment, diagnosis and management of ankle instability in the paediatric population. We explore the mechanisms of the initial injury together with factors that may increase the risk of injury to the child. Guidance on clinical examination and of the ankle joint is provided. Though short periods of immobilization and proprioceptive activities are the mainstay of treatment, there is a small subset of these patients who will benefit from further imaging and surgical intervention to prevent the chronic sequelae of ankle instability.     

(iii) Lateral ankle instability

Ankle sprains are the most common sports-related injury and are caused by forced plantar flexion and inversion. Most involve the lateral ligamentous complex and recover with conservative management, but 20% go on to develop biomechanical or functional instability. This article focuses on clinical symptoms, signs, conservative and surgical management of acute lateral ankle sprains and lateral ankle instability.     

Malleolar ankle fractures. A guide to evaluation and treatment

Malleolar ankle fractures are commonly encountered in orthopaedic trauma practice. The goal for treatment of these injuries is to maximize function and minimize complications. The treatment programme is based on the nature of osseoligamentous and soft tissue injury, the functional requirements of the patient and the overall medical condition of the patient. Non-operative treatment is usually reserved for stable fractures of the lateral malleolus; unstable bimalleolar and trimalleolar injuries are usually treated operatively. Staged treatment with initial external fixation and delayed definitive internal fixation is utilized to avoid soft tissue complications in high energy injuries. The Danis–Weber and Lauge-Hansen classification systems are useful for systematic diagnosis and formulation of a treatment plan of specific fracture patterns and ligamentous injuries. Definitive operative treatment is focused on the restoration of the anatomy of the ankle mortise. Injury to the medial malleolus and medial ligaments, the fibula, the syndesmosis and the posterior malleolus are addressed sequentially. The postoperative rehabilitation programme is designed based on the severity of the injury and the patient profile.     

Maxillofacial Injuries due to Bear Mauling

Bear bite injuries have become a common occurrence as the forest covers and natural habitats are diminishing. Patients injured in bear attack present with different patterns of injuries. A common protocol may not be suitable for the management of injuries inflicted by these large wild animals. These animals usually attack in remote areas where composite trauma centres do not exist and urgent referrals of these patients will have significant effect on the final outcome. Limited literature is available describing bear bite management in maxillofacial practice. The goal of the present case reports is to document the injuries suffered in bear mauling and to add to the literature on the conservative management with minimal complications.     

Intra-articular osteotomy for ankle arthritis

Ankle arthritis is a condition affecting a wide age range of patients. There are a variety of surgical treatment options available when non-operative treatments are not providing adequate symptom control. These are broadly classified into joint-preserving or joint-sacrificing surgery with arthroplasty or arthrodesis. The joint-preserving operations include soft tissue and bone debridement, osteochondral defect surgery, distraction arthroplasty and realignment osteotomies. For the younger patients with high activity and work demands the development of realignment osteotomies as a measure to delay joint sacrificing procedures is appealing. The realignment surgery aims to alter the mechanical axis and alter the joint contact pressures. Depending on the arthritis pattern, the osteotomy can be intra-articular or extra-articular or a combination of osteotomies. The focus of this article is an in-depth review of the biomechanics, surgical techniques and results of intra-articular osteotomies performed for ankle arthritis.     

Acute nerve injuries in the hand: common patterns and treatment strategies

Acute nerve injuries in the hand are common. Mechanisms of injury vary and include sharp transection, direct and indirect blunt trauma resulting in contusions and traction injuries respectively, ischaemic and compression injuries and chemical, thermal or electrical injury. Sharp, penetrating injuries are the most common, with patients typically presenting after a laceration with glass or a knife. Both blunt and sharp injuries can be associated with bony injuries as well as injury to the vascular and tendinous structures. The management principles of nerve injuries in the hand follow those of nerve injuries elsewhere, however the distal nature of the injuries often means that some treatment strategies are less applicable. In this article we will discuss the basic structure of nerves as well as the anatomy of the peripheral nerves in the hand, followed by the treatment strategies that can be employed to address acute nerve injuries in the hand.     

Medial collateral ligament of the knee: anatomy,management and surgical techniques for reconstruction

The medial collateral ligament (MCL) is the most commonly injured ligament in the knee. The incidence is reported to be 0.24 per 1000 per year, and twice as high in males. The majority of MCL injuries are isolated, occurring in young sportsmen and women. However, they can occur in association with other injuries of the knee, most commonly the anterior cruciate ligament. Most injuries to the medial supporting structures occur as a result of valgus forces; but in sports, these can be a result of skiing injuries or ‘cutting’ manoeuvres. The majority of MCL injuries heal well with non-operative management and rarely require surgery; but if acute injuries are insufficiently treated or missed, the result can be chronic laxity. This chapter reviews the existing literature on common history and examination findings in MCL injuries. There are a number of classification systems designed to grade the severity of injury, which are based on the amount of laxity and the ability of the assessor to feel an end-point. There has been significant advancement in the understanding of the anatomy and biomechanics of the different components of the MCL. The anatomical landmarks of the superficial and deep MCL as well as the posterior oblique ligament are discussed along with the function of these individual structures. Although most MCL injuries heal well with non-operative management, there are a number of indications for operative intervention. These include open and multi-ligament knee injuries, as well as chronic instability. Broadly these are divide into repair or reconstruction categories. Repair is best performed in acute cases, where surgery is indicated for other reasons such as a meniscal tear; whereas reconstruction is best reserved for chronic instability. The reconstruction techniques including the Lind and LaPrade are described.     

Monteggia injuries and radial neck fractures in children

This paper reviews the means to evaluate these injuries and reviews the evidence for different management strategies. Monteggia injuries and radial neck fractures are not amongst the most common fractures in children. However, the morbidity associated with a missed or underappreciated injury can be significant. Monteggia injuries are classically associated with a fracture of the ulna but radio-capitellar dislocation can also occur with plastic deformation of the ulna alone. Closed reduction of the ulna is the primary method of management. The reduction is stabilized by application of cast or fixation of the ulna; though uncertainty remains about how aggressive surgeons should be with ulnar fixation. Should a patient present late ulnar osteotomy is often required to allow reduction of the radio-capitellar joint. Radial neck fractures are often associated with other injuries around the elbow. The fracture can result in both angulation and translation. Angulation can be better tolerated and has a higher potential for remodelling. If translation of more than 2–3 mm is present this can result in the fracture healing with a significant cam lesion which impinges on rotation of the forearm. There are several means to try and achieve a closed reduction which are described.     

Avascular necrosis of the foot and ankle: aetiology,investigation and management

Avascular necrosis (AVN) of the foot and ankle can pose both a diagnostic challenge, and a management dilemma. This paper seeks to describe the various types of AVN in the foot and ankle and clarify the expected presentation, examination findings, investigations and management strategies available. In addition, discussion of the relevant basic sciences, and the process of bone healing will facilitate a broader understanding of the condition, and the risk factors for its development. AVN can be secondary to trauma, as in most cases of talar AVN, or secondary to factors such as steroid use, alcohol excess, metabolic diseases, repetitive microtrauma, and abnormal biomechanics. Usually, a combination of the above is thought to be responsible. Many of the conditions described are established in childhood, either presenting at the time, or in the third or fourth decade. Management ranges from exercise limitation and offloading footwear, to surgical decompression, osteotomy, fusion or excision. AVN has a high morbidity and affects a young demographic, causing a substantial burden on healthcare. Early recognition of symptoms, and appropriate investigation and management could reduce the number of patients progressing to advanced disease, avoiding the frequently unsatisfactory surgical outcomes associated with options such as fusion and excision.     

Haemorrhage control beyond Advanced Trauma Life Support (ATLS) protocol in life threatening maxillofacial trauma – experience from a level Ⅰ trauma centre

Maxillofacial injuries are usually not life-threatening and do not get priority over other associated injuries. However, some maxillofacial injuries with active oral or nasal bleeding need immediate management due to threatened airway and blood loss. In the case of major active vascular bleeding, measures such as local pressure, anterior nasal packing, posterior nasal packing, and balloon tamponade are ineffective. In these cases, angiography and transcatheter arterial embolisation (TAE) are used to treat life-threatening haemorrhage caused by maxillofacial trauma. We analysed the medical records of 39 patients with severe maxillofacial trauma and life-threatening haemorrhage that was a result of intractable oral or nasal bleeding. These patients were considered for TAE from January 2010 to December 2019. A total of 1668 patients was admitted, out of which 39 (2.3%) had severe maxillofacial injuries with life-threatening oral or nasal bleeding and underwent TAE. Out of a total of 39 patients, 38 were male and one female. Ages ranged from 16 to 65 years. Road traffic injury was the most common cause of injury (79.5%), Lefort I and II were the most common facial fractures, and traumatic brain injury was the most common associated injury. Embolisation and bleeding control were done successfully in all 39 patients with no procedure-related complications. A total of 17 deaths during the study period were due to severe traumatic brain injuries or haemorrhagic shock.     

Fractures of the mandible: role of the general dentist.

Mandibular fractures are the second most common facial fracture, the majority being the result of interpersonal violence, road traffic accidents, or sports injuries. Although most of these patients attend a hospital, it is not uncommon for patients with these injuries to present first to the general dentist, perhaps complaining of a loose tooth or abnormal bite. A careful history should be taken from the patient in order to identify the possibility of other injuries. Mandibular fractures are rarely life-threatening, although airway difficulties can arise. A systematic approach to diagnosis is essential if fractures are not to be missed, including radiological assessment in two planes at right angles. The initial treatment consists of airway management, control of fracture segments, and pharmacologic management. Most fractures have been traditionally managed by the use of intermaxillary fixation; however, increasing use is being made of open reduction and internal fixation techniques. Occasionally, general dentists are involved in the post-operative care of the patient following definitive management.     

Paediatric fractures of the tibia

Fractures of the paediatric tibia are common and, as with all paediatric bone injuries, require specific attention based on the anatomical location and degree of displacement. It is paramount that the soft tissues are accurately assessed and managed appropriately. Lack of recognition of these injuries, or inappropriate management, may lead to long-term problems. This paper aims to review the mechanism of injury, management options and potential problems associated with these injuries.     

Soft tissue pediatric facial trauma: a review

Facial soft tissue injuries are common in pediatric trauma patients. Early diagnosis and definitive treatment as well as good postoperative wound care are important when dealing with soft tissue injuries, such as facial nerve and parotid injuries, animal bites, avulsive skin wounds and eyelid and ear lacerations. Children heal quickly, but they also tend to develop hypertrophic scars. Proper wound management during the healing period can help to minimize the risk of adverse scar formation. Dentists may be involved in the initial assessment of these patients. Knowledge of the diagnosis and management of soft tissue trauma is useful when dealing with pediatric patients and their parents postoperatively.     

Consent in foot and ankle surgery

The process of consent for surgical procedures has undergone a fundamental change since the landmark Montgomery vs Lanarkshire Health Board Case. The judge in that case determined that consent should focus on the risks that are material to the patient, and not purely those that a body of expert opinion feels are prudent to mention. This is a change from a paternalistic to a patient-centred approach. Ideally the consenting process should be done by the operating surgeon, or other doctor who has adequate knowledge of the risks and potential complications of the procedure. Taking consent is a process that occurs over several patient contacts, rather than being a singular consenting event. In this article we discuss several of the particular risks of each foot or ankle procedure and their relative incidence, as well as providing guidance regarding optimizing the consent process.