Maisonneuve Injury Research Articles

Outcomes of Early Weightbearing Following Open Reduction and Internal Fixation in the Geriatric Population

Category: Ankle; Trauma Introduction/Purpose: Ankle fractures are the third most common extremity fracture, and its incidence is increasing in the elderly [1,2]. While the operative indications in ankle fractures have been established, there is no consensus regarding timing of weightbearing. There has been a growing trend towards early weightbearing due to its advantages in rehabilitation and return to function [3,4,5]. Even so, a survey study revealed that physicians tend to increase the non-weightbearing period for their geriatric population [6]. Expanding on our prior data which advocated for early weightbearing in ankle ORIF patients with syndesmotic injuries, we investigated the effects of early weightbearing after ankle ORIF in the geriatric population [7]. We hypothesized that there would not be an increased complication rate in this study cohort. Methods: A retrospective review was performed of patients over the age of 60 that underwent ankle ORIF at a level 1 trauma center and three neighboring community hospitals from 2015 to 2023. One of three senior surgeons were involved in all cases. Patient demographics, medical comorbidities, concomitant injuries, fixation method and complications were recorded. Maisonneuve injuries, fractures with articular surface involvement greater than 25%, open fractures, and revision cases were excluded. Patients with neuropathy were also excluded. All patients underwent an ORIF with possible syndesmotic fixation depending on intraoperative findings. Postoperatively, patients were 50% partial weightbearing for 2-3 weeks for a period of soft tissue and wound healing. After that, all patients were permitted to bear as much weight as tolerable. Results: 113 patients were identified that met our criteria. The average age was 72.6 years old. 25 were male and 88 were female. The average BMI was 26.8%. 60.2% of patients reported one or more medical comorbidities. The average follow-up time was seven months. We had zero major postoperative complications to report. We considered major complications to include: hardware failure, gross loss of reduction, need for revision ORIF, and accelerated post traumatic arthritis. Four patients were noted to have delayed wound healing. An additional four patients had minor surgical site infections that resolved with oral antibiotics. Six patients underwent hardware removal for various reasons. 65/113 (57%) patients received syndesmotic fixation of some form. Conclusion: This is the largest study to date reporting on effects of early weightbearing in the geriatric ankle ORIF population. In our study of 113 patients, all patients were allowed to weight bear as tolerated after short period of soft tissue rest, indiscriminate of syndesmotic injury or osteoporosis. We report no major complications and a limited number of soft tissues related complications. In a patient population with a known morbidity from prolonged immobility, as evidenced from the hip fracture literature, we hope our data helps to build confidence in early postoperative weightbearing [8].

Detection of fibular rotational changes in cone beam CT: experimental study in a specimen model

BackgroundIn syndesmotic injuries, incorrect reduction leads to early arthrosis of the ankle joint. Being able to analyze the reduction result is therefore crucial for obtaining an anatomical reduction. Several studies that assess fibular rotation in the incisura have already been published. The aim of the study was to validate measurement methods that use cone beam computed tomography imaging to detect rotational malpositions of the fibula in a standardized specimen model.MethodsAn artificial Maisonneuve injury was created on 16 pairs of fresh-frozen lower legs. Using a stable instrument, rotational malpositions of 5, 10, and 15° internal and external rotation were generated. For each malposition of the fibula, a cone beam computed tomography scan was performed. Subsequently, the malpositions were measured and statistically evaluated with t-tests using two measuring methods: angle (γ) at 10 mm proximal to the tibial joint line and the angle (δ) at 6 mm distal to the talar joint line.ResultsRotational malpositions of ≥ 10° could be reliably displayed in the 3D images using the measuring method with angle δ. For angle γ significant results could only be displayed for an external rotation malposition of 15°.ConclusionsClinically relevant rotational malpositions of the fibula in comparison with an uninjured contralateral side can be reliably detected using intraoperative 3D imaging with a C-arm cone beam computed tomography. This may allow surgeons to achieve better reduction of fibular malpositions in the incisura tibiofibularis.

Surgical Fixation of Maisonneuve Fractures with a Screw Suture Fixation Device: Results of 10 Cases

Category: Trauma; Ankle; Sports Introduction/Purpose: Maisonneuve fractures consist of a fracture of the fibula in the proximal third with associated syndesmotic injury. Surgical management generally involves restoration of fibula length, reduction of the syndesmosis, and stabilization of the syndesmosis. Flexible fixation devices have gained popularity for syndesmotic fixation over the last several years. Current flexible fixation devices are not reliable for fixation of length unstable patterns of injury, like the Maisonneuve fracture. The purpose of the study was to evaluate the results of a new screw- suture syndesmotic device providing aperture fixation of the syndesmosis for fixation of Maisonneuve fractures. Methods: 10 consecutive patients with Maisonneuve injuries were treated with indirect restoration of fibula length, open reduction of the syndesmosis, and stabilization of the syndesmosis with the screw suture device. Talocrural angle and medial clear space was measured and recorded at time of injury, post operatively and 6 months. Rate of hardware removal was recorded.***2 patients are 2 months short of 6 months. both have healed their proximal fibula fractures so no changes to data are anticipated *** Results: There were 5 males and 5 females. 5 patients slipped on ice, 4 patients fell on uneven walking surfaces, 1 patient was in a motorcycle accident. 2 patients had associated posterior malleolus fractures, 1 was fixed with a posterior plate. 1 patient had a medial malleolus fracture repaired with 2 screws. 9 devices were placed independently. 1 device was inserted through a 4 hole 1/3 tubular plate. Average time to surgery was 12.3 days (range 5-24 days). Talocrural angles averaged 8.92 (4.8-14.5mm) on injury films, 13.8mm (10.6-17mm) post operatively and 13.5mm (10.6-16.6) at 6 months. Medial clear space measurement averaged 5.68mm (2-10mm) on injury films, 2.06mm (1.9-2.3mm) post operatively and 2.1mm (2-2.3mm) at 6 months. No devices required removal during the study period. Conclusion: The screw-suture device provided length stable fixation for treatment of Maisonneuve fracture patterns.

EP.FRI.849 Quality Improvement Project for Management of Unstable Ankle Fracture in Scunthorpe General Hospital

Abstract Introduction In SGH, little emphasis is placed on ankle fracture as compared to hip fracture. Hence, an audit was done to compare management of unstable ankle fracture in adherence to BOAST guidelines. It was found out that few aspects of management in A&E were inadequate. Analyzing the root cause of non-adherence to guideline can lead to better care for these patients. Aim Primary aim is to ensure that ankle fractures are treated effectively in line with BOAST guidelines. Secondary aim is to ensure that ankle fractures are treated in a timely manner. Change in practice Discussion was held between Orthopaedic consultant and A&E consultant. Firstly, poster displaying algorithm for ankle fracture management displayed in A&E. Secondly, Orthopaedics doctor would come to A&E to reduce fracture after first failed attempt. Methods Prospective data is collected. Patients with unstable ankle fracture who are admitted in SGH are assessed in regards to BOAST guidelines via WebV, PACS and clinical notes. Results Major improvement is seen in different aspects. The documentation of neurovascular assessment and skin integrity in A&E department is improved by 57%. Additional radiographs of the whole leg when clinical examination suggests a more proximal fracture of the fibula (Maisonneuve injury) was performed in 60% more patients as compared to previously. Adequacy of reduction done in A&E is improved by 25%. Conclusion Small changes can make a big difference. Good communication and teamwork between different departments is the best way to provide better care for patients.

Immediate Weight Bearing and Range of Motion After Internal Fixation of Unstable Ankle Fractures: A Retrospective Controlled Study

Category:Ankle; TraumaIntroduction/Purpose:Ankle fractures are the third most common adult fractures. Further, they are the second most common fracture type to require inpatient admission, behind only hip fractures, despite occurring in a population on average nearly 30 years younger. There is evidence that early or immediate weight bearing and range of motion may be safe following ankle fracture fixation, but existing studies are small and largely exclude patients with syndesmotic or posterior malleolar fixation. We therefore studied the safety of immediate weight bearing as tolerated (IWBAT) and immediate range of motion (IROM) following open reduction internal fixation (ORIF) of unstable ankle fractures in a diverse cohort and attempted to identify risk factors for complications.Methods:We performed a retrospective case-control study. Out of 268 patients who underwent primary ORIF of an unstable ankle fracture from 2013-18, we identified 133 (49.6%) who were IWBAT and IROM. The treating surgeon excluded patients from IWBAT if they had an ipsilateral leg injury requiring non-weight bearing, a large displaced posterior malleolus fragment, or Maisonneuve injury with fracture of the proximal fibula. We used propensity-score matching to identify 172 controls who were non-weight bearing (NWB) and no range of motion for 6 weeks post-op. We reviewed medical records and radiographs for demographic, injury and treatment characteristics. Our primary outcome was complications. We compared demographics, injury characteristics, treatment episode, and complications between the IWBAT and NWB groups and performed within group analysis to identify risk factors for complications. A p-value <0.05 was considered significant.Results:The groups did not differ significantly in age, BMI, Charleston Comorbidity Index (CCI), smoking status, diabetes status, malleoli involved, percentages undergoing medial malleolus (60.9% IWBAT vs. 51.7% NWB, p=0.11), posterior malleolus (24.1% IWBAT, 26.7% NWB, p=0.59), or syndesmosis fixation (41.4% IWBAT, 42.4% NWB, p=0.85). There was no significant difference in total complications (9.8% IWBAT vs. 12.8% NWB, p=0.41), nonoperative complications (6.8% IWBAT vs. 8.7% NWB, p=0.53), or operative complications (3.8% IWBAT vs. 4.1% NWB, p=0.89). We did not identify any factors associated with increased complication risk, including posterior malleolus or syndesmosis fixation, diabetes, age, CCI or pre-injury assisted ambulation.Conclusion:IWBAT and IROM may be safe following ankle fracture ORIF in a broader patient population than previously believed. We did not identify specific risk factors for post-operative complications. Further study on patient selection may allow for more extensive use of this protocol to reduce the morbidity associated with unstable ankle fractures.

Outcomes of Suture-Button Fixation for Treatment of Maisonneuve Injuries

Category:Ankle; TraumaIntroduction/Purpose:The purpose of this study was to evaluate the radiographic and functional outcomes of suture-button devices for treatment of Maisonneuve injuries, which present unique considerations due to the proximal one-third fibular fracture, through which the distal fibular segment can potentially shorten.Methods:Patients undergoing operative management of Maisonneuve injuries from 2014-2018 utilizing suture-button devices with 2 fellowship-trained foot and ankle orthopedic surgeons were included. Exclusion criteria included use of a transosseous syndesmotic screw, fixation of the proximal fibular fracture, or less than 12 months follow-up. Medial clear space, tibiofibular clear space, tibiofibular overlap, talocrural angle, and distal fibular congruency on the injured and non-injured ankles were measured.Patients also completed the Foot & Ankle Ability Measure (FAAM)-Activities of Daily Living (ADL) and -Sports subscales and Visual Analog Scale (VAS) for pain (n/100). Thirty-three patients were included.Results:Three (9.1%) patients experienced a postoperative complication, including 1 wound dehiscence and 2 requiring hardware removal. No significant differences were demonstrated in radiographic parameters measured between 6-week and final radiographs on the injured ankle, as well between final radiographs taken of the injured and uninjured ankles (Table 1). At mean follow-up of 34.7 (range, 12-58) months, patients had a mean FAAM-ADL of 91.1, FAAM-Sports of 81.7, and VAS pain of 14.3.Conclusion:This study demonstrates that isolated use of suture-button devices for syndesmotic fixation in Maisonneuve injury patterns is effective at maintaining fibular length and reduction of the syndesmosis, as well as achieving satisfactory patient outcomes.

Leg Injury - Football

HISTORY: A 12-year old male quarterback sustained a right leg injury while cutting back across the field. He was running across the field and made a lateral cut to change directions, as this happened he tripped over himself and fell without a twisting motion. He landed on his right lateral leg with immediate pain to the fibular head. There was no numbness, tingling, weakness or radiation of pain however he had a noticeable limp. He presented to clinic 2 days later and denied any prior injuries or trauma to the area. PHYSICAL EXAMINATION:2 days post injury (PCP office) — No deformity, normal knee and ankle exams, no bony tenderness, moderate postero-lateral edema of proximal right lower leg, painful/antalgic gait, TTP lateral gastrocnemius and soleus, negative Thompson's.4 days post injury (Sports Medicine Clinic) — Consistent with prior exam, new findings: point TTP just distal to fibular head, decreased edema, negative squeeze test, negative ER test. DIFFERENTIAL DIAGNOSIS: 1. R fibular contusion 2. R knee apophysitis 3. LCL sprain 4. Gastrocnemius contusion/strain 5. Distal Bicep Femoris strain TEST AND RESULTS: XR: R Tib/Fib AP and Lateral radiographs 2 days after injury — Bones/joints/soft tissue appear unremarkable. Repeat XR 13 days post injury — subtle irregularity along the lateral aspect of the proximal fibula physis with associated periostitis. Final XR 20 days post injury — Noted irregularity along the lateral aspect of the proximal fibula physis with increased benign periostitis. FINAL WORKING DIAGNOSIS: Salter-Harris II fracture of R proximal fibula physis TREATMENT AND OUTCOMES: 1. Cam walker boot 3 weeks with weekly exams/XRs 2. 20 days out from injury completely normal RLE exam, no pain, full ROM, XRs suggestive for healing SH2 fracture; patient was able to return to football as tolerated. DISCUSSION: In isolation this is a very rare injury. There was one reported case of a SH-3 fracture that presented with initial knee injury and ROM deficits that was treated non-operatively. Most injuries to the proximal physis of the fibula occur in combination with an interosseous membrane/syndesmotic and distal tibiofibular injury - must rule out a Maisonneuve injury. The presenting complaint was pain and edema in the region of the soleus this may have been a soleus traction injury to the apophysis vs direct trauma from the fall.

A reliable method for intraoperative detection of lateral malleolar malrotation using conventional fluoroscopy

ObjectiveTo introduce a new method for intraoperative detection of rotational malreduction of the lateral malleolus using conventional fluoroscopy. Material and methodsFrom January 2014 to December 2017, 56 Weber type C unstable lateral malleolar fractures with syndesmosis injury were identified. The fibular fracture patterns were simple oblique or transverse in 20, comminuted in 25, and Maisonneuve injury with fibular neck fractures in 11 cases. 47 cases were operated with ORIF, and 9 cases of Maisonneuve fractures were operated with CRIF. The mortise view of the contralateral uninjured ankle was used for intraoperative comparison. Two indexes were applied for fluoroscopic detection of distal fibula malrotation, i.e. the contour profile change in lateral malleolar shape, and the intrinsic structure appearance of lateral malleolar fossa cortex. Postoperative talofibular joint congruency was measured on axial CT scan to confirm the reduction quality. ResultsUsing the two radiographic parameters for intraoperative fluoroscopic evaluation, we finally achieved satisfying reduction and fixation of the lateral malleolus in all 56 cases. A more spoon-shaped fibula profile and disappearance of the lateral fossa cortex shadow indicates an internal rotation, while a more pointed blade-shaped fibula profile and disappearance of lateral fossa cortex shadow indicates an external rotation. Postoperative CT scanning identified distal fibular no rotation in 44 cases (78.6%), mild rotation less than 5° in 12 cases (21.4%), with 7 cases internal rotation (mean 3.1°) and 5 cases external rotation (mean 2.8°). ConclusionUsing conventional intraoperative fluoroscopy on mortise view, new radiographic parameters can provide reliable method to detect rotational malreduction of the lateral malleolus.

Rates and Types of Syndesmotic Fixation in Operatively Treated Ankle Fractures

Category: Trauma Introduction/Purpose: Roughly 15% of ankle sprains and 23% of ankle fractures involve disruption of the syndesmotic ligaments. It has been shown that patients who require syndesmotic stabilization have worse subjective outcomes than those who do not require fixation. Recent studies have demonstrated that both Weber B and Weber C distal fibula ankle fractures can have concomitant syndesmotic injury necessitating trans-syndesmotic fixation. Significant controversy exists regarding the proper syndesmotic fixation strategy in regards to size, number and type of screws, and number of engaged cortices. The goal of our study was to establish the current practice in syndesmotic fixation in surgically-treated ankle fractures at our institution, through a retrospective review, based on fracture pattern and surgeon subspecialty training. Methods: A multi-center retrospective cohort study of 219 surgically-treated ankle fractures over a 2 year period was performed. Institutional Review Board (IRB) approval and a waiver of informed consent were obtained prior to data collection. Patient selection criteria was based on CPT codes, while exclusion criteria included open trauma, pilon fracture, history of prior ankle fracture and pediatric patients. All preoperative radiographs were reviewed for Danis-Weber classification. All intra- operative fluoroscopy, operative reports and postoperative radiographs were reviewed to confirm surgeon detection of syndesmotic injury and type of syndesmotic fixation utilized. This search included number of screws, screw size (mm) and number of engaged cortices. Surgeons were divided into three groups according to fellowship training: foot and ankle, trauma, and general. There were two foot and ankle fellowship-trained orthopaedists, five trauma fellowship-trained orthopaedists, and eight generalists whose fellowships included sports, hand, and spine. Patient demographics and medical risk factors were also recorded. Results: There were 153 Weber B and 64 Weber C cases. Of those overall, 32.4% required trans-syndesmotic fixation, with 33.8% being Weber B, and 66.2% being Weber C fractures. 15.6% of the Weber B and 73.4% of the Weber C cases required syndesmotic fixation. There was a statistically significant difference in the use of two screws versus one screw overall and for Weber C (P &lt; 0.0009 and 0.0003 respectively). The fixation of four cortices was more common overall (59.6% of 71 cases) and for Weber C (63.8% of 47 cases). 3.5 mm screws were used in 73.2% (52/71) of cases, 4.0 mm screws in 19.7% (14/71) of cases and 4.5 mm screws in 7% (5/71) of cases. Of the 4.5 mm screws used, 80% were used in Maisonneuve injuries. Conclusion: There is variability in the literature regarding fracture pattern and the presence of syndesmotic injury. Detection and repair of the syndesmosis is critical in maximizing post-operative outcomes. While many investigators have debated the practicality of fracture classifications and pre-operative imaging in diagnosing syndesmotic injury, a high clinical and intraoperative suspicion must remain, especially when accompanying a low level fibular fracture. When diagnosed, multiple acceptable fixation options exist; however, our study shows that surgeons prefer two screws over one screw for Weber C fractures, as well as screws with a diameter of 3.5 mm with no preference in engaged cortices.

Posterolateral approach for Maisonneuve injury associated with posterior malleolus fracture

Objective To investigate the surgical treatment of Maisonneuve injury associated with posterior malleolus fracture under direct visualization via the posterolateral approach. Methods Between January 2008 and June 2015, 27 patients with Maisonneuve injury associated with posterior malleolus fracture were treated at our department. They were 18 men and 9 women, aged from 20 to 60 years (average, 40.1 years). All fractures and syndesmoses received open reduction under direct visualization and internal fixation via the posterolateral approach. The posterior malleolus fractures were fixed with screws or plate and the syndesmoses fixed using cortical bone screws. Functional results were evaluated using the Baird-Jackson ankle scoring system. Results The patients were followed up for 8 to 30 months (average, 18 months). No wound infection, necrosis, dehiscence, lose of reduction or implant failure was found during follow-up visits. All cases got bony union at the last visit. The excellent and good rate was 92.6%. Conclusion Since the posterolateral approach allows good access to the Maisonneuve injury and posterior malleolus fracture under direct visualization, it facilitates accurate direct fracture reduction, stable fixation and early exercise. Key words: Fibula; Hock; Fractures, bone; Fracture fixation, internal; Posterolateral approach

Tibialis Anterior Tendon Entrapment After Ankle Tightrope Insertion for Acute Syndesmosis Injury

Ankle syndesmotic injuries often require anatomic reduction and fixation. Syndesmosis screw fixation is commonly used; however, this prevents physiological motion at the joint, often requires a second operation for screw removal, and may limit postoperative weight bearing. The Ankle Tightrope (Arthrex, Naples, FL) was introduced to allow physiological tibiofibular micromotion, early ankle range of motion, and weight bearing, and did not require a second operation for removal. For Maisonneuve injuries, or more severe syndesmosis instability, a second tightrope is required. This is advised to be placed 1 cm above the first with axial divergence in the coronal plane to increase rotational stability. Initial series have shown the main complications of tightrope fixation to be knot prominence or wound complications. Other documented complications include erosion of the buttons into bone, synostosis, and diastasis. This is the first report of tendon entrapment from the medial button. Reasons for this are discussed with suggestions for surgical technique.

The management of acute distal tibio-fibular syndesmotic injuries: Results of a nationwide survey

IntroductionAnkle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands. Materials and methodsA postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw. ResultsA total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the ‘Hook test’. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1–4.0cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. ConclusionCompared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication.

Maisonneuve Injury: Beware of the ‘Isolated’ Medial Malleolus or Proximal Fibula Fracture

Ankle injuries are a common presentation of patients to the emergency department. When fractures are noted around the ankle, it is mandatory that the entire leg and knee are examined. We present three cases of patients who attended our emergency department with ankle injuries. Each patient was diagnosed with isolated malleolar fractures and discharged to the fracture clinic. On review by the orthopaedic team, they were all found to have associated proximal fibula fractures, the Maisonneuve injury, which required surgical intervention. Maisonneuve type injuries are easily overlooked in busy emergency departments. Full clinical examination of the entire limb is mandatory and suspicion should be raised if there is (a) tenderness on palpation of the proximal fibula; (b) evidence of talar shift within the joint; (c) isolated malleolar or fibula fractures.

The Maisonneuve Injury: A Comprehensive Review

As a result of reading this article, physicians should be able to: 1. Describe the pathoanatomy of Maisonneuve injuries. 2. Discuss the various mechanisms of injury that can cause Maisonneuve injuries. 3. Explain the various treatment options available. 4. Identify the common complications of Maisonneuve injuries.

The Maisonneuve Injury: A Comprehensive Review

Educational Objectives As a result of reading this article, physicians should be able to: 1. Describe the pathoanatomy of Maisonneuve injuries. 2. Discuss the various mechanisms of injury that can cause Maisonneuve injuries. 3. Explain the various treatment options available. 4. Identify the common complications of Maisonneuve injuries.

Lateral ankle fracture with missed proximal tibiofibular joint instability (Maisonneuve injury)

We present a case of a soccer player who sustained a lateral ankle fracture and the associated proximal anterolateral tibiofibular joint instability (Maisonneuve injury) was overlooked. After a non-contact injury the (incomplete) diagnosis of a lateral malleolar fracture (type Weber B, AO 44-B1) was made and the patient was surgically treated with open reduction and internal fixation including a distal syndesmosis screw. After removal of the syndesmosis screw (six weeks after surgery) the patient suffered from activity-related pain around the fibular head. After thorough clinical and radiologic examination, temporary screw transfixation of the fibular head and capsular repair under meticulous fluoroscopic control of fibular rotation helped to restore patient's sport activity level. This case report emphasizes the importance of precise clinical examination for detection of a proximal tibiofibular joint instability. Restoration of a well functioning and stable proximal tibiofibular joint may be difficult to achieve in previously operated and missed instabilities.

Evaluation der Stellung der distalen Fibula nach geschlossener Reposition und Stellschraubenplatzierung mit intraoperativer dreidimensionaler Bildgebung (ISO-C-3D)

Purpose An incorrect position of the distal fibula results in an incongruence of the ankle. In this study, the potential benefit of an intraoperative three-dimensional imaging with ISO-C-3D™ for evaluation of the distal fibula position after closed reduction and syndesmotic screw placement was intended. Methods The ISO-C-3D™ was used between June 1, 2003 and May 3, 2005 in all patients, in whom closed reduction and syndesmotic screw placement had been performed. The ISO-C-3D™ was used after reduction and implant position was judged to be correct with conventional fluoroscopy. In cases with incorrect reduction and/or implant position, a correction was performed after ISO-C-3D™ use in the same operative procedure. The percentage of such corrections, time spent with the ISO-C-3D and surgeons' rating of the ISO-C-3D™ (Visual Analogue Scale (VAS), 0–10, feasibility, image quality and clinical benefit) were recorded and analyzed. Result A total of 18 cases were included (Weber-B fracture, n = 3; Weber-C fracture, n = 15, among those Maisonneuve injuries, n = 7). In seven cases (39%), a correction of reduction and/or implant position after ISO-C-3D use was performed. The operative procedure was on average interrupted for ISO-C-3D™ use for 400 s (scan, image processing, image analysis by the surgeon). The ratings of the eight surgeons involved were as follows: feasibility, 9; image quality, 9.1; clinical benefit, 8.5. Conclusions Intraoperative three-dimensional visualization with ISO-C-3D™ can provide important information during the operative treatment of Weber-C fractures which cannot be obtained from plain films or c-arm use alone (ISO-C-3D™ alone recognized that 40% of cases needed correction). The use of ISO-C-3D™ is not considerably time consuming.

Superior tibiofibular joint disruption—as a variant of Maisonneuve injury

Although ankle subluxations have been described without injury to fibula, any injury to the distal tibio fibular joint should raise the suspicion of a fractured proximal fibula, in the absence of which dislocation of superior tibio fibular joint must be ruled out.

Maisonneuve fracture in an adolescent

We present an atypical case with a rare combination of Maisonneuve and triplane fracture A Maisonneuve injury can present with external rotation of foot in the absence of signs and symptoms of a proximal injury. Pre-operative CT scans of the growth plate injury facilitates planning open reduction and internal fixation; it is vital to check the syndesmotic stability by intra-operative imaging. This rare combination of fracture pattern illustrates the need for awareness of the dual pathology and to provide adequate stability to prevent chronic ankle pain.