Lecture 40 parekh malunited ankle fracture

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  1. 1. Malunited Ankle Fractures Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
  2. 2. Ankle Joint 3 articulations Fibula secondary stabilizer Talus Trapezoidal wider anteriorly DF ER 4.2o PF IR 1.4o Distal fibula w/ DF Lateral translation 1-2mm ER
  3. 3. Malunited Ankle Fractures Isolated lateral malleolar ankle fractures Potts/Bimalleolar ankle fractures Cotton/Trimalleolar ankle fractures Syndesmotic injuries
  4. 4. Malunited Ankle Fractures Shortening and lateral rotation of distal fibula Widening of mortise, lateral tilt talus Most common
  5. 5. Importance 1 mm shift of the talus 42% reduction in the tibiotalar contact area increase stress on the articular cartilage Serious and persistent dysfunction
  6. 6. Symptoms Difficulty walking Pain & edema Cosmetic changes
  7. 7. Guidelines Little in the literature to guide approaches and techniques Anecdotal experiences Cite literature where available
  8. 8. 3 Guiding Concepts Restore alignment of the entire lower extremity Restoration of the articular surface Restoration of painless ankle motion
  9. 9. Preoperative Evaluation History Physical Tenderness ROM Imaging Xrays CT MRI Nuclear medicine
  10. 10. Issues to Consider Medical conditions Diabetes, ESRD Neuropathy Dermal issues Nicotine use Bony issues Alignment Bony quality and nonunion Changes in joint (arthritic)
  11. 11. Issues to Consider Skin Lesions Prior incisions Contractures
  12. 12. Imaging Radiographs Weightbearing ankle xrays Asymmetry of the medial and lateral clear spaces Talar tilt > 2mm Talar subluxation Lateralization of the talus Eccentric joint space narrowing Arthritic changes Fibular shortening
  13. 13. Imaging Radiographs Fibular shortening Compare to contralateral/uninjured side 75o-86o
  14. 14. Imaging Radiographs Fibular shortening 3 criteria of normal distal fibular length 1. Equal jt space 2. Intact Shenton line 3. Unbroken curve between lateral talus and peroneal groove
  15. 15. Imaging CT scan Arthritic changes Fibular shortening Fibular rotational malunion Syndesmotic widening >2mm difference b/t anterior & posterior distances from the fibula to the incisura
  16. 16. Management Nonoperative NSAIDS Steroid injections Activity modifications Orthoses and braces
  17. 17. Surgical Plan Approach bone Osteotomy Mobilize bone Clean medial gutter Fixation
  18. 18. Approach Surgical approach Osteotomies Fibular Tibial Supramalleolar Fixation Ex-fix Internal fixation Combo Bone grafts (auto and allografts) and orthobiologics
  19. 19. Case 1 Mid 50s diabetic Diagnosed with the gout
  20. 20. Case 1 Varus malunion Flexion malunion
  21. 21. Case 1 Fibular and tibial osteotomy Biplanar MAC ex-fix multiaxial compression
  22. 22. Case 1
  23. 23. Case 1
  24. 24. Case 1 1 yr post-op Walking Pain free No assistive device
  25. 25. Case 2 Fibular shortening courtesy of Dr. Kadakia
  26. 26. Case 2
  27. 27. Case 2
  28. 28. Case 2
  29. 29. Literature Fibular osteotomy 1976 Hughes, JBJS-A 28 cases fibular malunion lengthening 22 VG/G 6 Poor No correlation Time since accident Age of patient Type initial treatment
  30. 30. Literature Malunited ankles 1985 Weber and Simpson 23 cases 17 G/E 6 Poor pre-existing arthritis
  31. 31. RE ECT the ankle the foot