Abstract
Aims
Occult posterior malleolar fractures (PMFs) associated with tibial shaft fractures are thought to occur most commonly in spiral fracture types of the tibia. We hypothesize that tibial diaphyseal fracture patterns would be associated with certain PMFs, highlighting the pathomechanics of the injury.
Methods
A retrospective review was performed on data collected between 1 January 2013 and 9 November 2020. The inclusion criteria were patients aged over 16 years with a diaphyseal tibial fracture who had undergone a CT of the affected lower limb. The Mason and Molloy posterior malleolar fracture classification system was used to describe the morphology of the PMFs.
Results
There were 764 diaphyseal fractures identified. Of these, 442 met the inclusion criteria. A total of 107patients (24.21%) had PMF extensions. The classification of the PMFs according to Mason and Molloy revealed eight type 1 fractures (7.48%), 60 type 2A (56.07%), six type 2B (5.61%), and 33 type 3 fractures (30.84%). The most common PMF seen in this study was the minor rotational pilon (type 2A). PMFs generally occur in combination with spiral diaphyseal fractures (42A1, 42B1, 42C1, and 43A1). The majority of PMFs were undisplaced pre-surgical intervention. Only the 2B subtype (major rotational pilon) had a significant association with fracture displacement.
Conclusion
This study highlighted an association between spiral tibial shaft fractures and type 2A posterior malleolus fractures. Unlike the PM fractures of the ankle, the majority of PM fractures associated with tibia fractures are undisplaced. We theorize that unlike the force transmission in ankle fractures, where the rotational force is in the axial plane in a distal-proximal direction, in the PM fractures related to tibia fractures, the rotational force in the axial plane progresses from proximal-distal. Therefore, the force transmission which exits posteriorly, finally dissipates the force and is thus unlikely to displace.
Cite this article: Bone Jt Open 2025;6(4):446–453.
Keywords: Posterior malleolar fracture, Tibial shaft fracture, Morphology, Articular extension, Spiral fracture, posterior malleolus fractures, tibial shaft fractures, tibial fractures, fractures of the ankle, posterior malleolar fractures, diaphyseal tibial fractures, diaphyseal fractures, tibia, tibial diaphyseal fracture, lower limb
Introduction
Diaphyseal tibial fractures account for approximately 1.9% of all adult fractures.1 A 2019 registry review in Finland found an annual incidence of 15.6 in males and 11.5 per 100,000 person-years in females.2 There are several studies that have demonstrated a that high proportion of diaphyseal tibial fractures have ipsilateral occult posterior malleolus fractures (PMFs), ranging from 22% to 92%.3-5 These include several retrospective studies, which are of low-quality evidence. The presence of occult PMFs is of importance when treating diaphyseal tibial fractures, as there is an increased risk of intraoperative displacement if the tibia is fixed with a “tibia first” approach compared to a “malleolus first” approach.6
In ankle fracture management, there has been a recent change in the importance of the posterior malleolus in ankle stability. This has included change to the surgical management of these injuries. Modern treatment is guided by the use of classification systems such as Haraguchi et al,7 Bartoníček et al,8 and Mason and Molloy.9,10 These employ CT to aid the diagnosis of posterior malleolar fractures. The Mason and Molloy classification highlights the concept of a rotational pilon (type 2A and 2B), which is related to a loaded talus with a rotational force applied to the ankle, which has been subsequently validated by other authors.9,11 The classification has been used to allow surgeons to plan their reduction of the posterior malleolar fracture, and the approach and fixation methods. 10,12,13
Recent work by Hendrickx et al3 highlighted distal third and spiral tibial shaft fracture patterns as independent predictors of occult PMF, as well as finding the most common PMF pattern to be the Haraguchi type 1 (Mason and Molloy type 2A). Our aim in this study is to further evaluate the morphology of the PMF associated with diaphyseal tibial fractures, using the Mason and Molloy classification.3 We hypothesize that tibial diaphyseal fracture patterns will be associated with certain PMF morphology highlighting the pathomechanics of the fracture.
Methods
A retrospective evaluation of a prospectively collected trauma database involving all surgically treated trauma patients presenting to a level I major trauma centre was undertaken. The protocol was reviewed by the Liverpool orthopaedic and trauma service research review board (submission no. 22 - 26), and was evaluated to be a service evaluation project so therefore did not require ethical approval. Patients were identified using the departmental prospectively stored electronic patient record system (Bluespier international, UK). All tibial shaft fractures on the database were identified and considered for inclusion in the study. The database was analyzed between 1 January 2013 and 9 November 2021. Inclusion criteria were all patients aged over 16 years with a diaphyseal tibial fracture who had undergone a preoperative CT of the affected limb. Both closed and open fractures were included. Determination of requirement for CT was decided by the treating surgeon, or was obtained on admission due to additional trauma sustained. The exclusion criteria were patients aged under 16 years and tibial fractures which extended proximally into the plateau. Our primary outcome in this study was to assess the morphology of PMFs associated with tibial shaft fractures as described in ankle fractures using the Mason and Molloy classification.9 Secondary outcomes included age, sex and AO/OTA classification.14
Image analysis
All imaging data were analyzed using the hospital’s Picture Archiving and Communication System (Carestream Vue PACS; Carestream Heath, USA). When a PMF was present, its morphology was categorized using the CT scan as described by Mason and Molloy (Figure 1).9 Fracture displacement was categorized using CT as a displacement greater than 1 mm at the distal tibial articular surface. Factors recorded included patient demographics, fibular fracture morphology, fibular fracture level, direction of tibial fracture extension, level of tibial fracture (using 1 Müller square from ankle articular surface to indicate distal fracture), and AO/OTA classification.14 Two independent observers (DM, HS) performed all radiological observations, including the categorization by AO/OTA classification and Mason and Molloy classifications. 7,12
Fig. 1.
Mason and Molloy fracture types related to tibial shaft fractures.
Statistical analysis
All data were assessed using SPSS v. 25.0 (IBM, USA). In all scaled non-parametric data-related samples, Wilcoxon signed-rank test was used, with a p-value < 0.05 considered significant. Furthermore, descriptive statistics were presented with means and SDs for continuous variables. Frequencies and percentages were presented for categorical variables. CIs were calculated for all variables. Statistical analysis using the Cohen’s Kappa statistic for inter-rater agreement was performed and inter-rater agreement was calculated. The intraclass correlation using intraclass correlation coefficient (ICC) was interpreted according to Landis and Koch where slight agreement = 0.00 to 0.20, fair agreement = 0.21 to 0.40, moderate agreement = 0.41 to 0.60, substantial agreement = 0.61 to 0.80, and almost perfect agreement being greater than 0.81. For the reliability of the ICC, a 95% CI was set. Kurtosis and skewness were used to test if data were parametric.
Results
There were 764 diaphyseal fractures identified. Of these, 442 (57.85%) met the inclusion criteria, with 322 patients (42.15%) excluded as per exclusion criteria. A total of 107 patients had PMF extensions (24.21%) and a further 128 patients (28.96%) had intra-articular extensions that were not PMFs. Regarding the patients with PMF extensions, there were 64 males (59.81%) and 43 females (40.19%). The age range was 22 to 87 years (median 46; 95% CI 43.02 to 48.96).
Of the 107 PMFs identified, the classification of the PMFs according to the Mason and Molloy classification revealed eight type 1 (7.48%), 60 type 2A (56.07%), six type 2B (5.61%), and 33 type 3 fractures (30.84%). The most common posterior malleolar fracture seen in this study was the rotational pilon (type 2A). The crosstabulation of the AO/OTA classification with the Mason and Molloy classification is illustrated in Table I.14 As shown in both Table I and Table II, PMFs generally occur in combination with spiral diaphyseal fractures (42A1, 42B1, 42C1, and 43A1). In comparison, non PMF extensions most commonly occur with metadiaphyseal fractures or complex (42C1 to 3) diaphyseal fractures. When analyzing the fibular injury in tibial fractures with associated PMFs, the most common associated injury occurs with spiral or oblique fibular fractures (Table III).
Table I.
Crosstabulation of AO/OTA tibial fracture classification and Mason and Molloy posterior malleolar fracture classification.
| AO/OTA classification | 1, n (%) | 2A, n (%) | 2B, n (%) | 3, n (%) | Total, n (%) |
| 42A1 | 3 (1.8) | 41 (24.55) | 5 (2.99) | 27 (16.17) | 167 (37.78) |
| 42A2 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (2.56) | 39 (8.82) |
| 42A3 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 18 (4.07) |
| 42B1 | 2 (8.7) | 9 (39.13) | 0 (0.0) | 1 (4.35) | 23 (5.20) |
| 42B2 | 1 (3.1) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 32 (7.24) |
| 42B3 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (4.35) | 23 (5.20) |
| 42C1 | 0 (0.0) | 2 (28.57) | 0 (0.0) | 0 (0.0) | 7 (1.58) |
| 42C2 | 1 (5.56) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 18 (4.07) |
| 42C3 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 11 (2.49) |
| 43A1 | 1 (5.56) | 3 (16.67) | 0 (0.0) | 0 (0.0) | 18 (4.07) |
| 43A2 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.23) |
| 43A3 | 0 (0.0) | 1 (14.29) | 0 (0.0) | 0 (0.0) | 7 (1.58) |
| 43B1 | 0 (0.0) | 1 (9.09) | 1 (9.09) | 0 (0.0) | 11 (2.49) |
| 43B2 | 0 (0.0) | 2 (10.53) | 0 (0.0) | 1 (5.26) | 19 (4.30) |
| 43B3 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 3 (0.68) |
| 43C1 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 11 (2.49) |
| 43C2 | 0 (0.0) | 1 (3.03) | 0 (0.0) | 2 (6.06) | 33 (7.47) |
| 43C3 | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 1 (0.23) |
| Total | 8 (1.81) | 60 (13.57) | 6 (1.36) | 33 (7.47) | 442 (100.0) |
Table II.
Crosstabulation of articular extension (both PMF and non PMF types) with a heat map to illustrate the differences in distribution.
| AO/OTA classification | PMF extension, n (%) | Intraarticular extension, not PMF, n (%) | Total, n | Heat map legend | |
|---|---|---|---|---|---|
| 42A1 | 76 (45.51) | 19 (11.38) | 167 | 0 to 19.9% | |
| 42A2 | 1 (2.56) | 6 (15.38) | 39 | 20 to 39.9% | |
| 42A3 | 3 (16.67) | 18 | 40 to 59.9% | ||
| 42B1 | 12 (52.17) | 4 (17.39) | 23 | 60 to 79.9% | |
| 42B2 | 1 (3.13) | 6 (18.75) | 32 | 80 to 100% | |
| 42B3 | 1 (4.35) | 3 (13.04) | 23 | ||
| 42C1 | 2 (28.57) | 3 (42.86) | 7 | ||
| 42C2 | 1 (5.56) | 4 (22.22) | 18 | ||
| 42C3 | 3 (27.27) | 11 | |||
| 43A1 | 4 (22.22) | 3 (16.67) | 18 | ||
| 43A2 | 0 (0.0) | 1 | |||
| 43A3 | 1 (14.29) | 4 (57.14) | 7 | ||
| 43B1 | 2 (18.18) | 9 (81.82) | 11 | ||
| 43B2 | 2 (15.79) | 16 (84.21) | 19 | ||
| 43B3 | 0 (0.0) | 3 (100.0) | 3 | ||
| 43C1 | 0 (0.0) | 11 (100.0) | 11 | ||
| 43C2 | 3 (9.09) | 30 (90.91) | 33 | ||
| 43C3 | 0 (0.0) | 1 (100.0) | 1 | ||
| Total | 107 (24.21) | 128 (28.96) | 442 | ||
PMF, posterior malleolar fracture.
Table III.
Crosstabulation of fibular fracture type with the Mason and Molloy posterior malleolar fracture classification.
| Fibular fracture | 1, n (%) | 2A, n (%) | 2B, n (%) | 3, n (%) | Total tibia fractures, n (%) |
|---|---|---|---|---|---|
| Spiral | 3 (2.91) | 26 (25.24) | 3 (2.91) | 12 (11.65) | 103 (23.30) |
| Oblique | 2 (1.75) | 10 (8.77) | 2 (1.75) | 6 (5.26) | 114 (25.79) |
| Transverse | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 11 (2.49) |
| Intact wedge | 0 (0.0) | 11 (21.15) | 1 (1.92) | 6 (11.54) | 52 (11.76) |
| Fragmentary wedge | 3 (5.77) | 7 (13.46) | 0 (0.0) | 3 (5.77) | 52 (11.76) |
| Segmental | 0 (0.0) | 4 (7.84) | 0 (0.0) | 2 (3.92) | 51 (11.54) |
| No fracture | 0 (0.0) | 2 (3.39) | 0 (0.0) | 4 (6.78) | 59 (13.35) |
| Total fibula fractures | 8 (1.81) | 60 (13.57) | 6 (1.36) | 33 (7.47) | 442 (100.0) |
The majority of PMFs were undisplaced pre-surgical intervention (Table IV). Only the 2B subtype had a significant association with fracture displacement. Most PMFs were occult fractures not visible on initial radiographs and diagnosed on CT only (Table V). Displacement as categorized by CT, was significantly correlated with visibility on radiograph (p < 0.001). When considering the AO/OTA classification, the Cohen’s Kappa statistic between the two reviewers was 0.747, demonstrating a substantial inter-rater agreement.14 In relation to the Mason and Molloy classification, the Cohen’s Kappa statistic was 0.805, demonstrating substantial inter-rater agreement.9
Table IV.
Crosstabulation of posterior malleolar fracture displacement with the Mason and Molloy classification.
| Fracture displacement | 1, n (%) | 2A, n (%) | 2B, n (%) | 3, n (%) | Total, n (%) |
|---|---|---|---|---|---|
| Undisplaced | 8 (100.0) | 54 (90.0) | 3 (50.0) | 26 (78.79) | 91 (85.05) |
| Displaced | 0 (0.0) | 6 (10.0) | 3 (50.0) | 7 (21.21) | 16 (14.95) |
| Total, n | 8 | 60 | 6 | 33 | 107 |
Table V.
Crosstabulation of posterior malleolar fracture visibility on plain radiographs with the Mason and Molloy classification.
| Visiblity | 1, n (%) | 2A, n (%) | 2B, n (%) | 3, n (%) | Total, n (%) |
| Visible on radiograph | 0 (0.00) | 6 (10.0) | 1 (16.67) | 4 (12.12) | 11 (10.28) |
| Occult fracture | 8 (100.0) | 54 (90.0) | 5 (83.3) | 29 (87.88) | 96 (89.72) |
| Total, n | 8 | 60 | 6 | 33 | 107 |
Discussion
Our primary outcome in this study was to assess the morphology of PMFs associated with tibial shaft fractures with the hypothesis that tibial diaphyseal fracture patterns will be associated with certain PMF morphology. This study has showed that PMFs are primarily associated with a rotational tibial fracture most commonly resulting a rotational pilon injury. The data have demonstrated that the rotational AO/OTA classifications (42A1, 42B1, 42C1, and 43A1) are the most common diaphyseal tibial fracture patterns to be associated with intra-articular extension to the posterior malleolus.14 Kempegowda et al6 and Hendrickx et al3 also reported that the predominant fracture pattern of tibial fracture was spiral. Additionally, when analyzing the associated fibular fracture pattern, the types of injury strongly favour a spiral fracture configuration. In relation to the Mason and Molloy classification, type 2A was the most common posterior malleolus fracture followed by type 3 (axially loaded posterior pilon).
In comparison to the PMFs witnessed in ankle fractures, the PMFs associated with tibial shaft fractures are overwhelmingly related to type 2A and type 3 fracture patterns. Previous studies on the pathoanatomy of ankle fractures had a much greater equality across the fracture patterns with Mason et al9 finding, on average, a 20.66% to 33.88% in each fracture morphology classification, the most common being a type 1 (Table VI). This finding illustrates that the mechanism of PMFs associated with tibial fractures is principally due to rotation. Furthermore, unlike PMFs associated with ankle fractures, the PMFs associated with tibial fractures are predominantly undisplaced. This is an interesting finding as it is suggestive that the torsional force from the diaphyseal tibial fracture propagates from proximal to distal, unlike the distal to proximal force transmission of an ankle fracture. The force dissipates at the completion of the PMF in tibial rotational injuries and therefore there is a high incidence of fractures which do not displace and thus are not routinely appreciated on a plain radiograph (Figure 2). As the type 2B fracture pattern illustrates a greater rotational force at the ankle, our study supports the proximal to distal rotational mechanism, with these fracture patterns having a statistically significant higher propensity to cause articular displacement.
Table VI.
Comparison of PMF type in this study to previous study on PMF in ankle fractures.
| Comparison | 1, n (%) | 2A, n (%) | 2B, n (%) | 3, n (%) | Total, n |
|---|---|---|---|---|---|
| This study | 8 (7.48) | 60 (56.07) | 6 (5.61) | 33 (30.84) | 107 |
| Ankle fracture9 | 41 (33.88) | 30 (24.79) | 25 (20.66) | 25 (20.66) | 121 |
PMF, posterior malleolar fracture.
Fig. 2.
Schematic showing force transmission in posterior malleolar fractures (PMFs) associated with tibial fractures occur from proximal to distal, resulting in predominantly type 2 Mason and Molloy fracture patterns, which are more vertical and typically undisplaced.
The Mason and Molloy classification type 2 subtypes description as a rotational mechanism has been validated by Xie et al,11 who found the incidence of intra-articular impacted fragments to be consistent with the talus impaction on the tibial articular surface in rotation, unlike the avulsion type mechanism described by Haraguchi et al.7 This study further endorses the rotational mechanism, with the tibial fracture morphology, fibular fracture morphology, and type of PMF indicating a rotational mechanism.
Studies using the Haraguchi et al7 classification either combined the Mason and Molloy type 2A and 3 fracture patterns into the same group (often referring to them as small and large types), or did not include type 3 at all.15-17 Mitchell et al4 and Bi et al18 used the Haraguchi classification in their papers on morphology of the PMF associated with a spiral tibia fracture, but, on the fracture maps, they incorrectly include what would be the type 3 Mason and Molloy classification or the type 4 Bartoníček8 classification in the lesser rotational injuries, thus illustrating the difficulty in using the Haraguchi classification for morphology description.4,18 Therefore, use of the Haraguchi classification in this study would not allow differentiation and pathomechanistic description of the fracture patterns.
A scoping review of methods of biomechanical testing of PMFs by Stake et al19 recommended the use of the Mason and Molloy classification due to it addressing the pathomechanism of the fracture, which is appropriate in this study in evaluating the pathomechanism related to PMF in tibial shaft fractures. It was noted there was 30.84% (33/107) type 3 fractures, which would indicate there are a proportion of fractures which have an axial load element to their mechanism of injury.
The other articular extensions outside the PMF subtypes were more common in the 42C type fractures (complex fractures) and, unsurprisingly, metaphyseal fractures (AO/OTA 43 subtypes).14 Although there was crossover in the complex spiral fractures between the PMF and non PMF articular extensions, the segmental and severe comminuted fractures were significantly more likely to have non-PMF intra-articular fracture. This is most likely due to a severe axial driving force of the talus causing fractures not only to the distal tibia articular surface but also to the metaphysis and diaphysis of the tibia. Dujardin et al20 also categorized pilon fractures by the different mechanisms, including different subtypes of very high-energy impaction injury and rotational injuries, which our study also supports.
The difference in pathomechanism and fracture morphology in this study has possible implications for the diagnosis and operative management of these fractures. Unlike trimalleolar ankle fractures, which have reported improved anatomical articular reduction and functional scores with direct approach rather than indirect approach and anteroposterior screw, in PMFs associated with tibia fractures, the undisplaced nature does not necessarily require the direct approach.21-23 In the context of the undisplaced PMFs seen with tibial shaft fractures, fixation is required mainly to prevent displacement if intramedullary nailing is being considered. Therefore, a direct approach to clear soft-tissue and intercalary fragments from the fracture site and ultimately reduce and fix is not usually required. Kempegowda et al6 described a significant increase in intraoperative displacement and poor anatomical reduction if the malleolus was not fixed first. Although this may overestimate the risk of displacement as not all patients in the study had a preoperative CT, the risk of displacement is real, and therefore we would advocate fixation of the PMF prior to intramedullary nailing. Furthermore, the fractures which do displace are more likely to be the type 2B fracture patterns, which are more suitable to a medial posteromedial incision, thus negating the need to have the patient prone during surgery.12,13
The findings of this study highlight some important differences between the pathoanatomy and pathomechanism of PMF seen in association with diaphyseal tibial fractures compared to ankle fractures. Further work on the biomechanics associated with this mechanism of injury may offer insights into the difference in fracture propagation. The Mason and Molloy classification gives a good correlation between the pathomechanism and the fracture pattern seen, however alterations to the previous suggested clinical management of the PMF using the algorithm developed from the classification may be warranted in this context.9,10
This study has limitations: it was a retrospective observational study which was dependent on preoperative CT to be included. Therefore, 340 patients were excluded, and thus the rate of PMF occult diagnosis may be skewed. Additionally, the choice to use CT preoperatively was surgeon-dependent. The biomechanics of the pathomechanism have been inferred from the fracture morphology, and further biomechanical testing will be required to test these theories.
In conclusion, when we assessed the morphology of PMFs associated with tibial shaft fractures, it was found that PMFs are primarily associated with a rotational tibial fracture, resulting in, most commonly, a rotational pilon injury. These differ from PMFs associated with ankle fractures in that they are predominantly the rotational pilon subtype and are usually undisplaced. We theorize that unlike the force transmission in ankle fractures, where the rotational force is in the axial plane in a distal to proximal direction, in the PMFs related to tibial fractures, the rotational force is in the axial plane progressing from proximal to distal. Therefore, the force transmission exits posteriorly, finally dissipates the force, and is thus unlikely to displace.
Take home message
- The most common posterior malleolar fracture (PMF) seen in this study was the minor rotational pilon (type 2A).
- The majority of PMFs were undisplaced pre-surgical intervention except the 2B subtype (major rotational pilon).
- There is a substantial association between spiral tibial shaft fractures and type 2A posterior malleolus fractures.
- We theorize that unlike the force transmission in ankle fractures, where the rotational force is in the axial plane in a distal-proximal direction, in the PMFs related to tibia fractures of the tibia, the rotational force in the axial plane progresses from proximal-distal.
Author contributions
D. Myatt: Conceptualization, Data curation, Formal analysis, Investigation, Writing – original draft
H. Stringer: Data curation, Formal analysis, Investigation
J. Chapman: Investigation
B. E. Fischer: Writing – review & editing
L. Mason: Conceptualization, Formal analysis, Methodology, Supervision, Writing – original draft, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
L. Mason is an implant designer and receives royalties from Orthosolutions; is a consultant for Stryker; and was the chair of the clinical practice committee for the British Orthopaedic Foot and Ankle Society, all of which are unrelated to this work. J. Chapman reports paid accommodation from Smith & Nephew and Orthofix, which are unrelated. B. E. Fischer discloses remuneration from DePuy Synthes, Smith & Nephew, and IdealMed, which are also unrelated.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
Ethical review statement
Ethical approval for this study was waived by the Liverpool Orthopaedic and Trauma Service research review board (submission no. 22-26) following protocol review, and was evaluated to be a service evaluation project and therefore did not require ethical approval.
Open access funding
The open access fee for this paper was self-funded.
Social media
Follow L. Mason on X @drlyndonmason or Instagram @drlyndonmason
© 2025 Myatt et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Contributor Information
Howard Stringer, Email: howard.stringer@nhs.net.
James Chapman, Email: james.champman@doctors.org.uk.
Ben E. Fischer, Email: ben.fischer@liverpoolft.nhs.uk.
Lyndon Mason, Email: lyndon.mason@aintree.nhs.uk.
Data Availability
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.