Drs. Clements, Motley, Garrett, and Carpenter reply to Drs. Öztürk, Özkan, and Yalçin:

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We appreciate the interest and perspective from our international colleagues (J Foot Ankle Surg 47(4): 372) and will do our best to address their points of interest. First, it is true that a large number of patients were excluded from our study. A total of 214 charts were reviewed and 51 were included from our study. Most of the excluded patients received operative treatment. Our focus was on patients who met traditional operative criteria but were treated nonoperatively. If we discovered during our data collection that the patient's injury was treated surgically, then that patient was excluded. Second, the authors acknowledge there is a selection bias, which is a limitation of a retrospective (nonrandomized) design. In an attempt to minimize chart review discrepancies, it was necessary that “medial ecchymosis” and “medial tenderness” be clearly documented in order to proceed with radiographic analysis of medial clear space. In fact, our inclusion/exclusion criteria most likely excluded subjects who could have been enrolled in the study; however, if the aforementioned language was not documented the patients were excluded. Third, to clarify, the three measurements of a patient's medial clear space were made by a single surgeon. One surgeon did not measure all radiographs, but the same surgeon measured the same medial clear space three times. We did not determine intraobserver reliability in this study. However, we feel this measurement, our data, and our conclusions are clinically useful and serve as valid references when evaluating bimalleolar equivalent ankle fractures. Dear EditorThe Journal of Foot and Ankle SurgeryVol. 47Issue 4PreviewWe read the article “Nonoperative Treatment of Bimalleolar Equivalent Ankle Fractures: A Retrospective Analysis of 51 Patients” (J Foot Ankle Surg 47(1):40–45, 2008) in the January/February issue. It gave relevant data about Weber type B fracture of fibula, which is at the level of tibiofibular syndesmosis. The authors suggested valuable information about operative criteria of these fractures and they evaluated the relation of medial clear space measurements with the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Functional Survey Scores, perfectly. Full-Text PDF