Measurements of tibiofibular relationships made on axial CT images are reliable. Because of significant anatomic variation between individuals, using a patient's contralateral ankle for comparison provides a precise definition of normal tibiofibular relationships. These criteria allow for the detection of subtle variations in the tibiofibular relationships indicating instability and provide a tool for postoperatively assessing the reduction of the injured syndesmosis.

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Summary Background Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. Methods For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Findings Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0.83, 95% CI 0.63–1.09; p=0.18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1.91, 1.06–3.44; p=0.0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0.82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0.41) and sepsis (seven [1%] vs six [1%]; p=0.79). Interpretation In terms of reoperation rates the sliding hip screw shows no advantage, but some groups of patients (smokers and those with displaced or base of neck fractures) might do better with a sliding hip screw than with cancellous screws. Funding National Institutes of Health, Canadian Institutes of Health Research, Stichting NutsOhra, Netherlands Organisation for Health Research and Development, Physicians’ Services Incorporated.

Three patients with calcaneal fractures developed clawing of the lesser toes as a late sequela. Believing that this complication may be the result of contractures from an occult compartment syndrome of the foot, an investigation of the anatomical compartments of the foot was performed. The various compartments of 17 unembalmed adult lower limb specimens were injected with dyed gelatin in a controlled fashion. After freezing, the feet were sectioned either transversely or sagittally. The distribution of the dyed gelatin was then studied. Nine compartments were identified. These were the (1) medial, (2) superficial, (3) lateral, (4) adductor, (5-8) four interossei, and (9) calcaneal. The contents of each compartment was then studied as was the compartment's location in the foot and its position relative to other compartments. We identified a new, separate compartment which lies deep to the superficial compartment in the hindfoot area only. This compartment contains the quadratus plantae muscle. We have named it the "calcaneal" compartment to emphasize its hindfoot location. In addition, a communication was demonstrated between the calcaneal compartment and the deep posterior compartment of the leg through the retinaculum behind the medial malleolus, following the neurovascular and tendinous structures. Claw toe deformity following calcaneus fracture appears to be due to late contracture of the quadratus plantae muscle in the calcaneal compartment. A surgical technique for release of all of the foot compartments is described.

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