Background: Posterior malleolar (PM) fractures are present in 10-44% of all ankle fractures. Cadaveric studies have shown the posterior-inferior-tibiofibular-ligament remains attached to this fragment. Biomechanical studies have demonstrated that the posterior inferior tibiofibular ligament forms the main resistance against diastasis contributing up to 42%. Studies have also demonstrated that the size of the PM fragment is much less significant than displacement and articular step off in determining outcomes. As a result, controversy persists on how to address these injuries surgically to ensure long term syndesmotic stability.
Methods: A pilot retrospective review of our medical records was undertaken to identify skeletally mature patients that underwent surgical fixation of trimalleolar ankle fractures between January 2019 and January 2022. We categorized our patients into two groups: group PM – those who had direct fixation of the posterior malleolus only and S – those who had syndesmotic stabilization in addition to direct fixation of the posterior malleolar fracture. Our primary aim was to determine if there are any significant differences in the radiographic measures of syndesmotic stability and patient reported outcomes measures (PROMS) between the two groups.
Results: The search revealed 29 ankle injuries in total in the 3-year period with 71% females and 29% male followed up for an average of 25 months. Syndesmotic reduction was maintained in both groups on follow up x-rays and PROMS were equivalent between the two.
Conclusion: The indications for syndesmotic stabilization remain unsettled. With the completion of our research, we aim to better define the indications and expected outcomes in trimalleolar ankle fractures that undergo direct posterior malleolar fixation.

Charcot neuroarthropathy (CN) of the foot and ankle is a progressive debilitating condition affecting the bones, joints and soft tissue. The main aim of the treatment in CN is to restore stable and plantigrade foot. We hypothesize, in patients with midfoot and hindfoot CN stabilisation of hindfoot alone is adequate to restore stable and plantigrade foot.
Material: It was a prospective study conducted at tertiary care center between March 2014 to March 2021. Institutional ethical committee approval was obtained. All patients were operated for hindfoot stabilization by a single surgeon. The PROMIS, FFI and FADI score were done pre operatively and at final follow up for all the patients.
Result: Fourteen patients were included in the study. There were 6 males (42.85%) and 8 females (57.14%) with mean follow up of 4.8 ± 1.17 years (range 2 - 6.3 years). The mean duration of symptoms was 14.85 ± 5.85 months. The osseous union of the hindfoot was seen at 16.4 ± 1.7 weeks in eleven patients and three patients had aseptic fibrous union with stable joint and no implant loosening at final follow up. All the patients were able to walk independently with customized footwear with a stable plantigrade foot at final follow up. Reulceration was not seen in any patient. Statistically significant improvement was seen in PROMIS, FADI and FFI scoring.
Conclusion: Hindfoot stabilisation is adequate in patients with hindfoot - midfoot CN. The micro mobility at the midfoot region helps with hindfoot stability and the better functional outcomes.

Introduction: Calcaneal fractures are one of the most difficult fractures to surgically manage and often require a steep learning curve to achieve consistent results.Management of intra-articular calcaneal fractures has ranged from the nihilistic approach of no active treatment to open reduction and internal fixation or even to early subtalar arthrodesis.We describe a technique of open reduction and internal fixation through an extended-lateral approach utilizing a temporary external fixator intra-operatively.The fixator allows ample access and easy reduction of the articular fragments.
Objectives: The goal of treatment for displaced fractures of the calcaneum is the restoration of the three dimensional structure, with emphasis on correct alignment in the coronal and axial planes and the height of calcaneal body
Results: We have had no instance of bone failure at pin insertion site or soft tissue injury. Although pin sites represent stress risers, no stress fractures have been observed.
Conclusions: We propose this operative strategy as an option for the treatment of calcaneal fractures. The controlled distractive force provides numerous benefits. These include improved exposure of the subtalar joint, correction of angulation and maintenance of temporary stability prior to definitive fixation. We have found this technique applicable and easily reproducible.

The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw.

After IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT). The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital.

Seventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001).

We introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery with a higher rate of hardware removal than traditional plate osteosynthesis.

Introduction : The optimal treatment of distal tibial fractures remains controversial . Plentiful treatment modalities have been described. Soft tissue Complications result either from the injury itself or surgery or both. Approaching the fracture via the lateral window might avoid the soft tissue hazards if the surgery is done thru the medial side of the tibia. The aim of this study is to evaluate the results of surgical treatment of distal tibial fractures by fibula-pro-tibia procedure. Methods: The study included 30 patients with distal tibial fractures presented to El-Hadara University Hospital. All patients completed the study. The mean age was 35.9.11 Patients were females and 19 were males . 50% of patients were manual workers.70% of injuries were due to fall from height while 30% was after road traffic collision. According to AO classification , 7 fractures were extra articular , 23 were partial articular . Regarding the soft tissue condition as described by Tscherne and Goetzen (T&G) classification 8 were type 0,16 were type 1 & 6 were type 2. 40% had associated fractures elsewhere. Results : There was no correlation between the final outcome & the age, sex, mechanism of trauma & associated injury. There was a statistically significant negative correlation between the final outcome & soft tissue condition . superficial infection occurred in 2 cases and they were T&G 2. None of the patients had metal failure . Conclusion: Fibula pro tibia technique could be safely used in treating extra & partial articular distal tibial fractures.

Introduction
The number of day case forefoot surgical procedures performed in the United Kingdom has grown rapidly in recent years. There remains a good deal of controversy concerning day case forefoot surgery.
Objectives
To assess safety and patient satisfaction with forefoot day surgery
Methods
40 consecutive patient attending Birmingham university hospitals for forefoot day surgery procedure were surveyed. The hospitals governance department approved a data pro forma. Basic demographic data was captured along with patient’s satisfaction with process and overall care.
Results
The mean patient age was 53.8. 34 were females and 6 were males. The mean BMI was 26.4. 26 patients had American Society of Anaesthesiologists Score (ASA) of 1 while 14 were ASA 2. 15 patients underwent Minimally invasive Chevron and Akin’s osteotomy, 10 had SCARF osteotomy,4 had minimally invasive Cheilectomy, 5 had lesser toes corrective surgery, 3 had first metatarsophalangeal joint fusion, and 3 had Morton’s neuroma excision. All the 40 patients filled in a 2 pages A4 pro forma to assess satisfaction after forefoot day surgery. 36 patients had received a clinic letter outlining their procedure prior to surgery written to them by their consultant. 39 of the patients knew that they were having a day surgery procedure. All the 40 patients attended a preoperative consent clinic. The mean satisfaction rate with the preoperative process was 89.1%. The mean satisfaction rate with the postoperative Physiotherapy was 81%..

Conclusions
Forefoot day surgery is not only acceptable and safe it is associated with high patient satisfaction rate.

Displaced intra-articular fractures are generally treated with open reduction and internal fixation in order to restore calcaneal anatomy as well as subtalar and calcaneocuboid joint congruency. Bone loss is common in such fractures due to the impaction of cancellous bone beneath the posterior facet as a result of the axial loading mechanism of injury. Bone loss that results in critical-sized bone defects are commonly addressed with the Masquelet ‘induced membrane technique’ incorporating autogenous or allogenous bone graft. Synthetic bone scaffolds are readily available and customisable through 3-dimensional (3D) printing, and have been well described in the literature surrounding ophthalmic and neurosurgery. This case report describes the novel use of a custom 3D-printed polycaprolactone-tricalcium phosphate scaffold (Osteopore®) in conjunction with the Masquelet ‘induced membrane’ technique incorporating autogenous iliac crest bone graft and bone marrow aspirate concentrate (BMAC) in the management of a critical-sized bone defect for a patient with an open intra-articular calcaneal fracture. The bone defect has been adequately addressed resulting in good restoration of calcaneal anatomy as well as joint congruency. At 7 months post-operation, the patient remains pain and infection-free. Repeat radiographs show maintenance of fracture reduction and early signs of graft incorporation. This case report shows promising early results from the use of a custom PCL-TCP scaffold (Osteopore®) in conjunction with the Masquelet ‘induced membrane’ technique in the management of a critical-sized bone defect for a patient with an open intra-articular calcaneal fracture.

Introduction: The chronic sprain of the ankle, or the lateral ankle instability is a very common entity often misdiagnosed or over diagnosed, and unfortunately undertreated. The only secure way to restore the desired ankle stability is the ligamentoplasty, be it open, percutaneous or arthroscopically assisted. Methods: Between 2018 and 2022, 14 ankles - 11 right and 3 left, 8 in women and 6 in men, patents age between 18 and 32 y.o, were all operated using the p-antiRoll technique and the gracilis Y-shaped autograft, described by Takato, Glasebrook and Guyot, which was retained in proper position either by compression screws or by tenodesis ancres. The recovery period was always initiated immediately post-op by stabilising the ankle in a walking boot, with partial weight bearing for 3 weeks and active mobilisation of the ankle out of the boot, followed by 3 more weeks of protected walking with a full weight bearing. Results: Specific scales for assessment of the ankle and foot were used, all confirming the complete restoration of the stability, lack of pain on rest or exercise and return to desired activities within 6 to 8 weeks post-op. Except for 2 cases with transitory sensorial deficit over the course of the lateral cutaneous nerve, no other complications were recorded.

Introduction: Treatment of distal tibial fractures by medial tibial plating is usually complicated by wound dehiscence, poor soft tissue healing or infection owing to associated soft tissue injury, subcutaneous nature of bone, fracture usually open and unavailability of ideal implant. Material and methods: 30 patients of distal tibial fracture either open or poor soft tissue medially were treated with fibula pro tibia plating (lateral fibular plate with longer screws fixing both tibia and fibula) and outcome assessment was done for union, alignment and functionally by AOFAS score. Results: The mean was 30.4 years (range 20 to 55 years). Mean blood loss, duration of surgery and exposure was 80ml, 84 min and 110. Mean union time was 9.7 weeks (range 9 to 14 weeks). Mean distal plafond angle was 2.50 and 6.830 in AP and lateral view respectively. Mean AOFAS score was 78.73 with 24 (80%) patients having excellent to good results. Conclusion: Fibula pro tibia plating owing stronger biomechanical construct and intact undisturbed medial soft tissue provides early union, better outcome, alignment and mobility in management of open distal tibial fracture.

Purpose: To evaluate the outcomes of Ilizarov External Fixator (IEF) and minimal invasive surgery (MIS) in correction of neglected club foot (NCF). Methods: Thirty seven feet in 24 child, between five and 15 years old were diagnosed as NCF. All were treated with Achilles tendon lengthening (ATL) and IEF for gradual correction. After its removal, cast was applied for six weeks to maintain correction of the deformity. Results: There were 20 boys and four girls. Seven children had left (Lt), four children had right (Rt) while 13 children had bilateral foot deformity. The mean age at surgery was 10.3 (range 5–15) years with an average follow-up of 32.5 (range 24-96) months. All feet were graded as severe according to Pirani score. All feet were corrected after an average six weeks in IEF. After 2 years follow up, 23 feet (16 patients) showed good results, five feet (3 patients) showed fair results and four feet (2 patients) had Rt side foot fair result while the Lt foot had good result in both patients. Five feet (3 patients) showed poor results. Eight patients had pin site infection. One case had infected skin and subcutaneous tissue and needed debridement. Two cases developed skin sloughing, changes in color and needed close follow up. Conclusion: We recommend combined IEF and MIS as a suitable, efficient and successful salvage procedure in management of severe idiopathic NCF in children especially in developing countries.

Introduction: The aim was to demonstrate that supramalleolar osteotomy (SMO) is a valuable treatment method in eccentric ankle arthritis and it is very much an underutilised procedure. We retrospectively analysed the outcome of SMO performed over a 10 year period. We also compared the results of newly introduced computer-assisted custom-made implant with standard method.
Material and Methods: Data was analysed from 42 patients over 10 years; 25 varus, 17 valgus deformity. The mean age was 57 (26-79 y/o), male:female ratio was 25:17. Mean follow-up was 15.25 months; the computer-assisted only 6 months. TAS, TTS and TT angels were measured pre and post-operatively. Fixation using a plate with/without bone graft or custom-made implant was performed by single surgeon. MOXFQ and AOFAS questionnaires were completed pre and post-operatively. All followed similar rehabilitation programme.
Results: Average radiological healing time was 24.3 weeks. MOXFQ score improved from 55.17 to 25.11 and AOFAS from 20.16 to 56.21. Complications were 2 non-unions, 1 stress fracture. 7 patients require fusion/replacement after 3 years. The computer-assisted case gave similar accuracy to standard method but with a smoother approach for the surgeon.
Conclusion: Our results are comparable to similar studies. Being a joint preserving technique, supra malleolar osteotomy should be considered in addition to fusion and replacement, either as an interim or definitive procedure especially with the development of computer assisted technologies. Patient selection criteria is essential for a good outcome.

Presently the role of CRPP in ankle is limited to certain isolated, un-displaced fractures. Based on our research on CRPP, we had successfully treated all types of ankle fractures including type-C fractures, even with impending soft tissue complications. It was a prospective study of 60 ankle fractures of all types (excluding AO types A1 and B1) from 2014 to 2020. Age group of the cohorts was 13 to 75. Percutaneous pinning was done by creating a hardware framework with multiple K-wires in 3 sets. 1st set is from lateral side of the lateral malleolus to tibia with two or more K-wires under c-arm. 2nd set is from the medial malleolus with 2 or more K-wires from the medial side engaging both cortex. The point of entry of the K-wire may be 0.5 to 2centimeters away from the tip of medial malleolus. 3rd set is used for stabilization of the syndesmotic joint if required with 2 or more K-wires either in diverging or converging manner, parallel to the tibial plafond through subchondral bone to complete a triangular framework. For fixing the diaphyseal fracture fibula is done with a combination of crossed interfragmentary fixation with or without intramedullary K-wires. Posterior malleolus fracture and intra articular fracture in pilon-fracture were fixed with K-wires. Below-knee POP slab without weightbearing for 6 weeks followed by weight bearing and K-wire removal at 16 weeks. Results-The results were evaluated based on AOFAS Ankle-Hindfoot Scale. The mean follow-up was 36 months with 85% of excellent and good results.