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Research Type: Level 4 – Case series Introduction/Purpose: Weber B fractures often show unstable gravity stress tests but stable weightbearing radiographs (classified SER4a), suggesting partial deltoid ligament injury with an intact deep posterior tibiotalar ligament (dPTTL). Conversely, a dPTTL rupture is assumed if both radiographs are unstable (classified SER4b). However, the state of the dPTTL in SER4a vs. SER4b has not been well studied. This study assessed the prevalence of dPTTL injury using direct visualization during arthroscopy of SER4a and SER4b fractures. Methods: We conducted a prospective study on 20 patients with Weber B/SER4a-b ankle fractures having unstable gravity stress tests or unstable weightbearing radiographs (medial clear space ≥ 4.0 millimeters). Blinded assessors evaluated the dPTTL using minimally invasive arthroscopy under local anesthesia. Intact dPTTL was defined by normal ligament visualization with tensioning and medial joint space closing with dorsiflexion. Results: Based on radiographic criteria, 15 patients were classified as SER4a and five as SER4b. Arthroscopy showed an intact dPTTL in 14 SER4a injuries. One patient with a 3.9 mm medial clear space had a torn dPTTL. All SER4b injuries revealed dPTTL disruptions with arthroscopic assessment. Conclusion: In Weber B fractures evaluated arthroscopically, the dPTTL is typically intact in cases where weightbearing radiographs are stable despite unstable gravity stress tests. Conversely, complete dPTTL disruption was consistently observed in cases where both tests were unstable. These findings support the hypothesis that a stable weightbearing radiograph indicates an intact dPTTL.

Background: Plantar fasciitis is a prevalent foot condition, often resolving without surgery. However, a subset of patients experiences persistent symptoms beyond 12 months, necessitating interventions like proximal medial gastrocnemius recession (PMGR). PMGR is hypothesized to alleviate plantar fasciitis by increasing ankle dorsiflexion. The procedure’s effects on gait remain unclear. Methods: A subgroup of 29 patients with chronic plantar fasciitis, treated with PMGR and stretching as part of the Plantar Fasciitis Cohort Study, was selected for this preoperative and 3-month postoperative 3-dimensional gait analysis (3DGA) study. Eligibility criteria included symptoms persisting for more than 12 months, failure of conservative treatments, and confirmed gastrocnemius tightness. Gait analysis was performed using a 3D motion capture system. The primary outcome was maximal ankle dorsiflexion during stance. Secondary outcomes included other kinematic, kinetic, and tempo-spatial gait variables potentially influenced by PMGR, the Gait Deviation Index (GDI), and passive ankle dorsiflexion. Results: Maximal ankle dorsiflexion during stance showed no significant change postoperatively (13.5 degrees [12.2, 14.9] vs 14.3 degrees [13.2, 15.3], P = .21). Secondary outcomes, including gait parameters and extremity-specific GDI scores, remained within normal ranges and showed no clinically significant changes. Passive ankle dorsiflexion increased significantly postoperatively, yet this did not translate to detectable changes in gait patterns. Patients demonstrated no notable gait deviations compared with a normative population pre- or postsurgery. Conclusion: Findings suggest that gait patterns are relatively robust and that increased joint range of motion does not appear to affect gait mechanics 3 months postoperative based on a single-segment foot model. Further studies are needed to investigate these findings and to explore the biomechanical mechanisms underlying symptom improvement. Level of Evidence: Level IV, exploratory prospective cohort study. Graphical Abstract This is a visual representation of the abstract.

Research Type: Level 4 – Case series Introduction/Purpose: Plantar fasciitis is a prevalent foot condition, often resolving without surgery. However, a subset of patients experiences persistent symptoms beyond 12 months, necessitating interventions like Proximal Medial Gastrocnemius Recession (PMGR). PMGR is hypothesized to alleviate plantar fasciitis by increasing ankle dorsiflexion and decreasing tension in the plantar fascia. The procedures potential effects on gait remain unclear. Methods: A subgroup of 29 patients with chronic plantar fasciitis, treated with Proximal Medial Gastrocnemius Recession (PMGR) and stretching as part of the Plantar Fasciitis Cohort Study, was selected for this pre- and 3-month postoperative three-dimensional gait analysis (3DGA) study. Eligibility criteria included symptoms persisting for over 12 months, failure of conservative treatments, and confirmed gastrocnemius tightness. Gait analysis was performed using a 3D motion capture system. The primary outcome was maximal ankle dorsiflexion during stance. Secondary outcomes included other kinematic, kinetic, and tempo-spatial gait variables potentially influenced by PMGR, the Gait Deviation Index (GDI), and passive ankle dorsiflexion. Results: Maximal ankle dorsiflexion during stance showed no significant change postoperatively (13.5°(12.2,14.9) vs. 14.3°(13.2,15.3), p = 0.21). Secondary outcomes, including ankle dorsiflexion at maximal knee extension, ankle dorsiflexion at foot strike, foot progression angle, knee extension at maximal ankle dorsiflexion, maximal knee extension during stance, ankle power and GDI scores, remained within normal ranges and showed no clinically significant changes. Passive ankle dorsiflexion increased significantly postoperatively, yet this did not translate to detectable changes in gait patterns. Patients demonstrated no notable gait deviations compared to a normative population pre- or post-surgery. Conclusion: Findings suggest that gait patterns are robust, and that increased joint range of motion does not necessarily affect gait mechanics. Patients and healthcare professionals can be reassured that PMGR is a safe and effective treatment option for chronic plantar fasciitis, with no significant impact on gait patterns. Further studies are needed to explore the biomechanical mechanisms underlying symptom improvement. 3DGA parameters Recorded in the Stance Phase

Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Deltoid ligament injuries occur in predefined sequences during rotational ankle fractures, but current knowledge about these sequences may be inaccurate. Computer modeling provides a novel approach to evaluate ligament behavior under rotational injury mechanisms. Methods: A biomechanical computer simulation model was developed using the AnyBody Modeling Software to evaluate ligament strain in rotational ankle injuries. Experimental data from a cadaveric study involving 18 human ankle specimens subjected to various loading conditions were used to optimize the computer model. Having optimized the computer model with uninjured cadaveric data, we simulated Supination-External Rotation (SER) stage 2-4b injuries by removing corresponding ligaments. Validation was done by comparing computer model predictions against the biomechanical experimental data. Results: The computer model replicated experimental findings, with correlation coefficients ranging from 0.81 to 0.99 across all injury stages and loading conditions. Furthermore, tension in the deep posterior tibiotalar ligament (DPTTL) increased progressively from SER2 to SER4a but remained unchanged in the SER2 phase. The model successfully captured progressive ligament strain and medial clear space changes during injury progression. Conclusion: This study introduces and validates a biomechanical simulation model for rotational ankle injuries. It offers a novel tool for exploring ligament biomechanics and injury mechanisms. The medial sagittal view of the computer model with the ligaments specified. The medial sagittal view of the computer model with the ligaments specified. Deltoid ligament sections are shown with black arrows, while other ligaments are shown with blue arrows. The deep deltoid sections are also shown with solid arrows and depicted as red. Note that the tibiofibular syndesmosis ligaments were hidden for the sake of visibility.

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results Introduction/Purpose: According to Lauge-Hanse, suprasyndesmotic ankle fractures occur in pronation type injuries to the ankle. Because of the expected instability of these fractures, operative stabilization is advised. Recent studies on Weber B fractures have shown that varying degrees of medial injury exist, influencing stability and treatment approach. The deep posterior part of the deltoid complex has been found to play a crucial role in maintaining talocrural stability. A congruent ankle joint on stress radiographs may indicate intact medial stability, suggesting that operative stabilization may not be warranted. However, studies on the ligamentous injuries of suprasyndesmotic ankle fractures that show congruency on weightbearing radiographs are lacking. This study aims to utilize MRI to examine the ligamentous injuries in suprasyndesmotic ankle fractures that appear stable on stress radiographs. Methods: Twenty patients with suprasyndesmotic ankle fractures (Weber C/Maisonneuve) and talocrural congruency on weightbearing radiographs were recruited from Oslo University Hospital and Østfold Hospital, Kalnes. MRI was performed within two weeks of the injury. Two senior musculoskeletal radiologists from both centres assessed the images and scored the ligamentous injuries to the deltoid ligaments and syndesmotic ligaments based on the degree of damage (intact, partial, or complete rupture). In cases of disagreement between radiologists on the degree of damage, a consensus would be reached. Results: We included twenty patients during a period of one year (2023-2024). Mean age was 55 years (22-75). High fibular fractures (Maisonneuve) accounted for 55% of the included injuries. The anterior inferior tibiofibular ligament (AITFL) and intraosseous ligament (IOL) was completely ruptured in 90% (18/20). The posterior inferior tibiofibular ligament (PITFL) and the deep posterior tibiotalar ligament (dPTTL) was completely ruptured in only 10% (2/20). Conclusion: Suprasyndesmotic ankle fractures that show talocrural congruency on weightbearing radiographs tend to have an intact deep posterior tibiotalar ligament and posterior inferior tibiofibular ligament when assessed by MRI. These fractures may retain sufficient stability to be managed conservatively in line with the current approach to stable Weber B fractures, but further clinical studies are needed.

Background: Rotational malalignment of the first metatarsal is increasingly recognized as a key feature of hallux valgus deformity, but the reliability of radiographic rotation markers remains uncertain. This study assessed the inter- and intraobserver reliability of 4 commonly used radiographic parameters: metatarsal pronation angle (MPA), tibial sesamoid position (TSP), lateral head shape (LHS), and round head sign (RH). Methods: In this prospective reliability study, 3 senior clinicians independently evaluated weightbearing anteroposterior and axial sesamoid radiographs of 75 hallux valgus cases on 2 occasions. Metatarsal pronation angle (MPA) was measured as a continuous variable and analyzed using intraclass correlation coefficients (ICCs). Tibial sesamoid position (TSP), lateral head shape (LHS), and round head sign (RH) were graded using ordinal scales and assessed with weighted kappa statistics (κ). Subgroup analyses evaluated whether reliability varied by deformity severity (hallux valgus angle) or increased distal metatarsal articular angle (DMAA > 10 degrees). Results: MPA showed excellent agreement (ICC = 0.81-0.94). TSP also demonstrated high reliability (κ = 0.88-0.98), although its value as a rotation marker is limited. LHS showed moderate to substantial agreement (κ = 0.59-0.85), whereas RH had fair to moderate reliability (κ = 0.35-0.66). RH was least reliable in mild deformities, whereas other parameters remained stable across subgroups, with slightly lower values in cases with elevated DMAA. Conclusions: Conventional radiographs offer reliable assessment of MPA and TSP. LHS provides acceptable reproducibility, whereas RH is less consistent. These findings support the use of selected radiographic markers and suggest that further validation against 3-dimensional imaging and standardized grading frameworks may improve consistency and clinical applicability. Level of Evidence: Level IV, case series. Graphical Abstract

Background: Suturing the deep posterior deltoid ligament in unstable ankle fractures is novel to established treatment. Some cadaveric and clinical trials support that adding deltoid ligament repair to plating of the lateral fracture will improve stability restoration. Objectives: We will investigate the effects of deep deltoid ligament repair on patient-reported function, radiologic stability parameters, and the incidence of ankle osteoarthritis and the possible side effects from this additional procedure. The medial ankle injury patterns found will be described. Study design: A randomised controlled nonblinded multicentre trial. Methods: A total of 120 patients with Lauge Hansen SER 4B ankle fractures will be randomised (1:1 ratio) to conventional plating of the lateral malleolus only or additional suture of the deep deltoid ligament. The primary end point was patient-reported function measured in Olerud-Molander Ankle Score (OMAS) at 1 and 2 years. The secondary end points included Self-Reported Foot and Ankle Score (SEFAS), Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), VAS pain, and EuroQol-5D-5L scores; rates of treatment-related adverse events, reoperations, and incidence of posttraumatic arthritis; and comparison of side-to-side differences in tibiotalar medial clear space from bilateral weightbearing ankle radiographs and gravity stress on group level. Graphical Abstract

Background: Deltoid ligament injuries occur in specific sequences during rotational ankle trauma, yet the current understanding of these sequences may be flawed. Computer modeling offers a new method for assessing ligament behavior under rotational injury mechanisms. Methods: A biomechanical computer simulation model was developed using AnyBody Modeling Software to evaluate ligament strain in rotational ankle injuries. Experimental data from a cadaveric study involving 15 human ankle specimens subjected to various loading conditions were used to identify the model parameters. After parameter identification from uninjured cadaveric data, we simulated Supination-External Rotation (SER) stage 2-4b injury model by removing the corresponding ligaments. Validation was performed by comparing the model predictions against the biomechanical experimental data. Results: The computer model replicated experimental findings, with correlation coefficients ranging from 0.81 to 0.99 across all injury stages and loading conditions. Furthermore, tension in the deep posterior tibiotalar ligament (DPTTL) progressively increased from SER2 to SER4a but remained unchanged in the SER2 phase. The model effectively captured progressive ligament strain and changes in medial clear space during injury progression. Conclusion: This study presents and validates an early-stage biomechanical simulation model for rotational ankle injuries, providing a novel tool for examining ligament biomechanics and injury mechanisms. Clinical Relevance: Our model offers insights that were previously unattainable through cadaveric or clinical studies by simulating ligament strain during injuries. This can assist in generating hypotheses, enhance injury detection, refine treatment strategies, and may challenge existing classification systems.

IntroductionSurgery is widely recognised as the treatment of choice for suprasyndesmotic ankle fractures, because of the assumption that these injuries yield instability of the ankle joint. Stability assessment of ankle fractures using weightbearing radiographs is now used regularly to guide the treatment of transsyndesmotic and infrasyndesmotic ankle fractures. Patients with a congruent ankle joint on weightbearing radiographs can be treated non-operatively with excellent results. Weightbearing radiographs are, however, rarely performed on suprasyndesmotic fractures due to the assumed unstable nature of these fractures. If weightbearing radiographs can be used to identify suprasyndesmotic fractures suitable for non-operative treatment, we may save patients from the potential burdens of surgery.Our aim is to compare the efficacy of operative and non-operative treatment of patients with suprasyndesmotic ankle fractures that reduce on weightbearing radiographs.Methods and analysisA non-inferiority randomised controlled trial involving 120 patients will be conducted. A total of 120 patients with suprasyndesmotic ankle fractures with an initial radiographic medial clear space of <7 mm will be subjected to weightbearing radiographs. If the tibio-talar joint is completely reduced, we will randomise in a 1:1 ratio to either operative treatment including reduction and fixation of the syndesmosis or non-operative treatment with an orthosis. The primary study outcome is patient-reported ankle function and symptoms as measured by the Olerud-Molander Ankle Score at 2-year follow-up. Secondary outcomes include the Manchester-Oxford Foot Questionnaire, range of motion, radiographic results and rates of adverse events.Ethics and disseminationThe Regional Committee for Medical and Health Research South East, group A (permission number: 169307), has granted ethics approval. The results of this study will provide valuable insights for developing future diagnostic and treatment strategies for a common fracture type. The findings will be shared through publication in peer-reviewed journals and presentations at conferences.Trial registration numberNCT04615650.

Background: Deltoid ligament injury occurs often with supination-external rotation (SER) ankle trauma. SER fibula fractures with concomitant deltoid ligament injury are considered unstable—requiring operative fixation. Recent studies have questioned this general practice with emphasis on better defining the medial side ankle ligamentous injury. The function of the individual bands of the deltoid ligament, and the interplay between them, are not fully understood. We undertook this study to develop a better understanding of these complex ligamentous structures and ultimately aid assessment and treatment choice of SER ankle fractures with concomitant deltoid ligament injuries. Methods: Ten fresh-frozen cadaveric foot and ankle specimens were studied. We identified the various ligament bands and did a functional analysis by assessment of ligament length and tension at predefined angles of ankle dorsi-plantarflexion combined with valgus/varus and rotation. The results were determined by manual evaluation with calipers and goniometers, manual stress, and direct visualization. Results: We recorded primarily 5 different bands of the deltoid ligament: the tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL; 10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar ligaments were tense in dorsiflexion. The superficial layer ligaments and the deep anterior tibiotalar ligament length and tension were largely affected by changes in varus/valgus and rotation. The deep posterior tibiotalar ligament length and tension was altered predominantly by changes in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this band. Conclusions: We confirmed the finding of previous studies that dorsi-plantarflexion affects the tensile engagement of the separate ligament bands differently. Likewise, combined movements with varus/valgus and rotation seem to affect the separate ligament bands differently. Our results suggest that the TNL, TSL, and dATTL are at risk of injury, whereas the TCL and particularly the dPTTL are protected in the event of an SER-type ankle fracture mechanism of injury. Level of Evidence Level V, cadaveric study.