Hans Polzer

Aims: Little is known about the distal tibiofibular joint (DTFJ) malreduction rate following ventral anterior inferior tibiofibular ligament (AiTFL) augmentation in two-ligament syndesmotic injuries in ankle fracture cases. The aims of the current study were to assess the DTFJ malreduction rate following ventral AiTFL augmentation, and compare these to suture button stabilization in two-ligament (AiTFL, interosseous ligament (IOL)) injuries in fracture cases. Methods: This retrospective radiological study assessed the quality of DTFJ reduction in ankle fractures with a two-ligament syndesmotic injury (AiTFL and IOL rupture). Patients with a syndesmotic stabilization by a single suture button system (January 2010 to October 2020) were compared with those with a ventral augmentation (October 2020 to November 2023). The quality of DTFJ reduction was assessed on postoperative bilateral CT images. The overall cohort was analyzed as well as a propensity score-matched cohort. Results: Overall, 45 patients were eligible for the single suture button group and 78 patients for the ventral augmentation group. There were no significant group differences per the demographic and injury characteristics between the two groups. Neither the malreduction rate (7 (16%) vs 16 (21%); p = 0.497) nor the predominant direction of malreduction (p = 0.063) differed significantly between the two cohorts. These results stayed true for the propensity score-matched analysis (n = 41 per group). Conclusion: Ventral augmentation in two-ligament, syndesmotic injuries results in similar good DTFJ reduction rates as suture button systems, with the ventral augmentation biomechanically more closely resembling the native syndesmosis. Future studies should assess patient-rated outcomes as well as more rapid rehabilitation protocols in patients treated with ventral augmentation for two-ligament, syndesmotic injuries. Cite this article: Bone Joint J 2026;108-B(3):346–354.

Introduction: Ankle fractures often involve intra-articular pathologies, which can only be addressed by additional arthroscopy. This systematic review aims to compare the outcomes of arthroscopically assisted open reduction and internal fixation (AORIF) with traditional open reduction and internal fixation (ORIF) for ankle fractures. Materials and methods: A systematic literature search adhering to PICOS and PRISMA guidelines was conducted across the following databases: MEDLINE (PubMed), Scopus, Central and EMBASE. Studies that compared AORIF and ORIF of ankle fractures and focused on patient-reported outcome measures (PROMs) as the primary outcome were included. Excluded were studies on non-acute or non-isolated fractures, pilon fractures, concomitant injuries outside the ankle, biomechanical or computational studies, and those lacking objective outcome data. Results: A total of 7089 studies were screened, 12 of which met the inclusion criteria for qualitative synthesis. The level of evidence was I-III with a mean MINORS Tool score of 19.17. Among the included studies, six studies focused on unimalleolar fractures, with four demonstrating significantly better PROMs for the AORIF group. Five studies addressed bimalleolar and/or trimalleolar fractures, with one showing significantly better PROMs for AORIF. Seven studies reported on intra-articular pathologies, with a detection rate of up to 88.89%. Two out of three studies on posttraumatic arthritis indicated lower grades of osteoarthritis in the AORIF group. Conclusion: The review suggests that AORIF may lead to improved scores as obtained through various PROMs compared to ORIF, particularly for unimalleolar fractures. However, the heterogeneity among the underlying studies indicates the need for further research to identify specific patient populations and fracture types that would benefit the most from AORIF.

Background: Despite considerable improvements in surgical treatment strategies for unstable ankle fractures, long-term follow-up studies on conventional treatment strategies are missing. The aim of the study was to assess the patient-reported long-term outcome (≥15 years) following surgically treated ankle fractures. Methods: Retrospective, single-center, outcome study with a current follow-up. Identified were all patients treated surgically for an unstable ankle fracture between January 2003 and October 2009. Treatment was performed according to the AO principles. General demographics, injury-, fracture- and treatment details, as well as the current patient-reported outcome (Olerud-Molander Ankle Score [OMAS], the Foot and Ankle Ability Measure [FAAM], the European Foot & Ankle Society Score [EFAS], and the EuroQoL–5 dimensions, 5 levels [EQ-5D-5L]) were assessed. Results: Of 398 eligible patients, 125 patients (31.4%; 54% female, 48% left side) were included. The average age at trauma was 43.1 ± 11.8 years, and the mean follow-up 17.8 ± 2.0 years. Overall, 43%, 22%, and 34% sustained a unimalleolar, bimalleolar, and trimalleolar fracture, respectively. In addition, 53% had a fracture to the posterior malleolus. The overall median outcome for the OMAS, FAAM daily, and EFAS daily were 100 (interquartile range [IQR] 15), 99 (IQR 7), and 96 (IQR 16), respectively. The EQ-5D-5L scored at a median of 1.00 (IQR 0.09). The number of malleoli fractured was the only factor affecting all outcome scores. A moderate or poor outcome was reported for 5% of unimalleolar, 18% of bimalleolar, and 30% of trimalleolar fractures. Conclusion: Although the overall functional outcome was good, about 15% of patients had considerable impairment. The only factor associated with the patient-reported outcomes was the number of malleoli fractured, with 30% of patients with a trimalleolar ankle fracture presenting inferior outcomes.

Zusammenfassung Operationsziel Identifizierung und Behandlung von intraartikulären Begleitpathologien, Verifizierung der Syndesmoseninstabilität, bei chronischen Verletzungen Anfrischen der syndesmalen Strukturen, Reposition und Retention der Fibula im distalen Tibiofibulargelenk. Indikationen Akute und chronische Zwei- oder Dreibandrupturen der Syndesmose bei Patient:innen mit funktionellem Anspruch. Kontraindikationen Weichteilschäden, allgemeine Risikofaktoren, z. B. Durchblutungsstörungen, diabetisches Fußsyndrom, komplexes regionales Schmerzsyndrom. Operationstechnik Durchführung einer diagnostischen Arthroskopie (ASK) des Sprunggelenkes über anterolaterales und -mediales Portal; Identifikation und Behandlung von intraartikulären Begleitpathologien; Verifizierung der syndesmalen Instabilität durch Einführen eine Instrumentes > 4 mm in die Incisura fibularis; bei chronischen Syndesmosenverletzungen Anfrischen der syndesmalen Strukturen und Inspektion ggf. Débridement Deltabandkomplex; Reposition der Fibula in die Incisura fibularis; Retention der Fibula mittels Stellschraube oder Seilzugsystem. Weiterbehandlung Teilbelastung mit 20 kg für 6 Wochen, keine Immobilisation, forcierte Beübung der Beweglichkeit des Sprunggelenkes, Röntgenkontrolle nach 6 Wochen, dann ggf. Belastungssteigerung. Ergebnisse Akute Syndesmosenverletzungen: 19 Patient:innen (37 ± 13 Jahre) wurden 38 ± 17 Monate nach arthroskopisch assistierter Versorgung einer akuten Syndesmosenverletzung nachuntersucht. In 53 % lag eine Zweiband-, in 16 % eine Dreiband-, in 32 % eine knöcherne Syndesmosenverletzung vor. Ein Knorpelschaden Grad II lag bei 35 %, ein Grad-IV-Schaden bei 20 % vor, bei 16 % wurden freie Gelenkkörper entfernt; 94 % der Patient:innen erreichten ein Behandlungsergebnis entsprechend der gesunden Referenzpopulation für den Olerud and Molander Ankle Score (OMAS; primärer Zielparameter) und Foot and Ankle Ability Measure (FAAM). Art der Syndesmosenverletzung und Schwere des Knorpelschadens hatten keinen signifikanten Einfluss auf die Behandlungsergebnisse. Chronische Syndesmosenverletzungen: Im Rahmen einer systematischen Literaturrecherche wurden 17 Arbeiten mit 196 Patient:innen identifiziert nach operativ versorgten, chronischen Syndesmoseninsuffizienzen, 16 davon waren retrospektive Fallserien und eine prospektive Fallserie. Die Operation erfolgte in 13 Studien arthroskopisch assistiert. Unabhängig von der Operationstechnik resultierte die Operation in einer Verbesserung des AOFAS Score in 10 Studien. Insgesamt war die Studienqualität niedrig, und die Angaben zu Komplikationen, sekundärer Diastase, Behandlungsergebnisse etc. waren eingeschränkt.

Introduction: Evidence for the diagnostic yield of noninvasive diagnostic assessment for the diagnosis of peripheral arterial disease (PAD) in diabetic foot syndrome (DFS) is poor. Pulse volume recordings (PVRs) at the forefoot level could be a valuable diagnostic tool in the presence of medial arterial calcification. Patients and methods: Patients with DFS who underwent invasive angiography between 01/2020 and 11/2024 and had corresponding PVRs performed within 30 days prior to the procedure were included. DFS was classified according to the Wagner–Armstrong classification. Clinical characteristics and hemodynamic parameters, including systolic ankle pressures and ankle–brachial index were recorded. PVRs were analyzed semiquantitatively by investigators blinded to the clinical information and quantitatively with determination of upstroke time (UST), upstroke ratio (USR), and maximum systolic amplitude (MSA). Angiographic PAD severity was graded according to the GLASS classification. Statistical analysis included univariate significance tests, 2 × 2 contingency tables, receiver–operator characteristic (ROC) analysis and determination of interobserver agreement. Results: In this study, 90 extremities of 70 patients were analyzed, 47 of whom had an ABI ≥ 1.3. Critical limb-threatening ischemia with non-pulsatile PVRs was evident in 6.7%. An abnormal PVR curve morphology (mildly or severely abnormal) yielded a sensitivity and specificity of 63.3% and 85.7% for detection of severe PAD (GLASS stages 2 and 3). Interobserver agreement of semiquantitative PVR rating was substantial (Cohen’s kappa 0.8) in 51 evaluated cases. For detection of any PAD (GLASS ≥ 1) or severe PAD (GLASS ≥ 2), we found the highest diagnostic accuracy for MSA (area under the curve [AUC] 0.89 and 0.82). With a cut-off value of 0.58 mmHg, MSA had a sensitivity of 91.4% and a specificity of 80.8% for detection of any PAD (GLASS ≥ 1). MSA with a cut-off of 0.27 mmHg had a sensitivity of 72.2% and a specificity of 77.1% for detection of severe PAD, whereas the sensitivity and specificity for detection of inframalleolar disease were 62.9% and 69.4%, respectively. Results were consistent in subgroup analyses. Conclusions: PVRs with extraction of quantitative features offer promising diagnostic yield for detection of PAD in the setting of DFS. MSA outperformed UST and USR but showed limited capability of detecting impaired inframalleolar outflow.

Background: Syndesmotic complex injuries are supposedly associated with injuries to the deltoid ligament (DL) complex. Several syndesmosis classifications take DL injuries into account when rating the stability of the syndesmotic injury. Still, no study has yet assessed the frequency and severity of DL injuries in unstable syndesmotic injuries. The aim of this retrospective cohort study was to assess both the severity of the syndesmotic and DL injury in patients undergoing surgery for an unstable syndesmotic injury. Methods: The integrity of the syndesmotic and DL complex of 37 patients were assessed on MRI by 2 musculoskeletal radiologists. Eligible were adult patients with an acute, isolated, unstable syndesmotic injury (ligamentous or bony avulsions) who underwent surgery. The DL complex was classified as having 3 superficial (TNL/TSL/TCL) and 2 deep (aTTL/pTTL) components. Grade 0 indicated an intact ligament; grade I showed a periligamentous edema; grade II a partial tear presenting as laxity, irregular contour, or partial discontinuity with concomitant hyperintense signaling; grade III a complete tear; or grade IV in case of an avulsion fracture. Frequency and severity of DL injuries were assessed, and possible injury combinations analyzed using an h-cluster analysis and Mann-Whitney U test. Results: Mean severity (grade 0-3) was 2.6 ± 0.8 for the syndesmotic complex and 1.6 ± 1.1 for the DL (superficial 1.5 ± 1.1, deep 1.6 ± 1.1). Seven patients (19%) had no (n = 3; 8%) or minor (grade 1: n = 4; 11%) DL injuries. Overall, 2 different patient clusters and 4 separate ligament clusters were identified. Conclusion: Unstable syndesmotic injuries can occur isolated or with an accompanying DL injury. There appears to be a great heterogeneity between the severity of syndesmotic and deltoid ligament injuries.

Introduction: Hallux valgus deformity severity is one determent for the surgical procedure for hallux valgus (HV) correction. HV deformities are usually classified into mild/moderate/severe. The aim was to investigate the cut-off criteria used to classify HV deformity. Materials and Methods: The study was based on a previous living systematic review. Four common databases were searched for the last decade. All review-steps were conducted by two reviewers. Data assessed were the individual cut-off values used to classify HV deformity into mild/moderate/severe, and the referenced classification systems. Results: 46 studies were included. 21/18 studies grade deformity based on the intermetatarsal angle (IMA)/ hallux valgus angle (HVA) with great heterogeneity throughout the different cut-off values. The most referenced classification systems were the Coughlin and Mann’s and the Robinson classification. Conclusions: The currently used classification systems are heterogenic, and no standard could be defined. The community should define a uniform classification system. Level of Evidence. Level I, systematic review of randomized controlled trials and prospective comparative studies.

Introduction: In recent years, there has been an increasing demand for patient-reported outcome measures (PROMs) to assess the outcome following orthopedic surgery. But, we are lacking a standard set of PROMs to assess the outcome of hallux valgus surgery. The aim of this study was to analyze the chosen patient rated outcome scores used in studies reporting on hallux valgus surgery. Materials and methods: The study was based on a previously published living systematic review. Included were prospective, comparative studies of different surgical procedures or the same procedure for different degrees of deformity. Four common databases were searched for the last decade. Study selection, data extraction, and risk of bias assessment were made by two independent reviewers. Data assessed were the individual PROMs used to assess the outcome of hallux valgus surgery. Results: 46 studies (30 RCTs and 16 non-randomized prospective studies) met the inclusion criteria. The most commonly used clinical outcome measures were the AOFAS (55%) and the VAS (30%). No differences were found between frequency of the individual scores per the level of evidence or the type of osteotomy. Conclusion: Based on a systematic literature review, the AOFAS and VAS are the most frequently used outcome tools in studies assessing the outcome following hallux valgus surgery. Based on the literature available, the MOXFQ is a more valid alternative. Level of evidence: Level I; systematic review of prospective comparative (level II) and randomized controlled trials (level I).

Introduction: More than 100 surgical techniques are described for hallux valgus (HV) correction, but the most appropriate technique remains debatable. The aim of this study was to develop and conduct a “living systematic review” for the outcome of surgically treated HV. Materials and methods: The “living systematic review” was conducted per the PRISMA-P and PICOS guidelines and is the basis for the German AWMF S2e guideline “Hallux valgus” (033-018). Four common databases and the grey-literature were searched. Eligible were studies on adult patients comparing either two different primary surgical interventions or the same primary surgical intervention for different hallux valgus severities. The main outcome parameters were the osseous correction potential and the patient rated outcome. Results: Out of 3022 studies, 46 studies (100 arms) were included. The meta-analysis included 31 studies (53 arms). The IMA (1933 procedures) improved on average by 7.3°, without significant group differences. The HVA (1883 procedures) improved on average by 18.9°, with significantly better results for third generation MIS (21.2°). The AOFAS (1338 procedures) improved on average by 33.8 points without significant group differences. The meta-regression revealed constant AOFAS scores over time. 69%/39% of the correction potential for the IMA/HVA could be explained by the preoperative values and 82% of the AOFAS improvement by the preoperative AOFAS scores. Conclusion: Open and minimally invasive techniques are powerful tools to correct hallux valgus deformity. Third generation MIS procedures revealed a possible superiority for the correction of the HVA. The AOFAS improvement appeared to be constant over time. Level of evidence: Level I; living systematic review and meta-analysis of prospective comparative studies (level II) and randomized controlled trials (level I).

Background: Syndesmotic malreduction is common and has been associated to an impaired outcome. Various risk factors for DTFJ malreduction have been postulated. The aims of this study were to assess the DTFJ malreduction rate based on (1) the severity of the syndesmotic injury, (2) the anatomy of the tibial incisura, and (3) the fixation device used in patients treated with suture-button systems. Methods: This retrospective, radiographic study included all adult patients who were treated for an acute, unilateral, and unstable syndesmotic injury with a suture-button system and postoperative bilateral CT imaging. Included were isolated syndesmotic injuries and fracture cases. The number of syndesmotic ligaments injured, that is, 2-ligament (AiTFL+IOL) and 3-ligament (AiTFL+IOL+PiTFL), was rated for each patient. The quality of DTFJ reduction, as well as the anatomy of the tibial incisura, was rated based on the postoperative, bilateral CT images and the intraoperative DTFJ reduction was recalculated based on the drilling-tunnel deviation. The possible influence on the DTFJ malreduction rate was assessed. Results: A total of 147 patients were included, and 94 and 53 patients had a 2- and 3-ligament syndesmotic injury, respectively. In addition, 113 patients were treated with a single-button system, 26 with a double suture-button system, and 8 with a hybrid fixation (suture-button + screw). Malreduction was significantly higher in 3-ligament compared with 2-ligament injuries, both intraoperatively (51% vs 27%; P = .003) and postoperatively (28% vs 11%; P = .006). The tibial anatomy had no significant influence on the malreduction rates. No significant differences were seen per the different fixation devices used independent of the number of ligaments injured. Conclusion: This study did not find an influence of the incisura’s anatomy on the DTFJ malreduction rate. However, we did find that 3-ligament syndesmotic injuries carried a higher risk of intra- and postoperative malreduction compared with 2-ligament injuries.