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Malunited Ankle Fractures
Selene G. Parekh, MD, MBAAssociate Professor of Surgery
Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery
Adjunct Faculty Fuqua Business SchoolDuke University
Durham, NC919.471.9622
http://seleneparekhmd.comTwitter: @seleneparekhmd
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
Malunited Ankle Fractures
• Isolated lateral malleolar ankle fractures
• Potts/Bimalleolar ankle fractures
• Cotton/Trimalleolar ankle fractures
• Syndesmotic injuries
Malunited Ankle Fractures
• Shortening and lateral rotation of distal fibula
• Widening of mortise, lateral tilt talus
• Most common
Importance
• 1 mm shift of the talus 42% reduction in the tibiotalar contact area increase stress on the articular cartilage
• Serious and persistent dysfunction
Symptoms
• Difficulty walking
• Pain & edema
• Cosmetic changes
Guidelines
• Little in the literature to guide approaches and techniques
• Anecdotal experiences
• Cite literature where available
3 Guiding Concepts
• Restore alignment of the entire lower extremity
• Restoration of the articular surface
• Restoration of painless ankle motion
Preoperative Evaluation
• History• Physical
• Tenderness• ROM
• Imaging• Xrays• CT• MRI• Nuclear medicine
Issues to Consider
• Medical conditions• Diabetes, ESRD• Neuropathy• Dermal issues• Nicotine use
• Bony issues• Alignment• Bony quality and nonunion• Changes in joint (arthritic)
Issues to Consider
• Skin• Lesions• Prior incisions• Contractures
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
Imaging
• Radiographs• Fibular shortening
• Compare to contralateral/uninjured side
75o-86o
Imaging
• Radiographs• Fibular shortening
• 3 criteria of normal distal fibular length
1. Equal jt space2. Intact Shenton line3. Unbroken curve
between lateral talus and peroneal groove
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
Management
• Nonoperative• NSAIDS• Steroid injections• Activity modifications• Orthoses and braces
Surgical Plan
• Approach bone
• Osteotomy
• Mobilize bone
• Clean medial gutter
• Fixation
Approach
• Surgical approach
• Osteotomies• Fibular• Tibial• Supramalleolar
• Fixation• Ex-fix• Internal fixation• Combo
• Bone grafts (auto and allografts) and orthobiologics
Case 1
• Mid 50s diabetic
• Diagnosed with “the gout”
Case 1
Varus malunion
Flexion malunion
Case 1
• Fibular and tibial osteotomy• Biplanar
• MAC ex-fix• “multiaxial compression”
Case 1
Case 1
Case 1
1 yr post-op
Walking
Pain free
No assistive device
Case 2
• Fibular shortening – courtesy of Dr. Kadakia
Case 2
Case 2
Case 2
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
Literature
• Malunited ankles• 1985 – Weber and Simpson• 23 cases
• 17 G/E• 6 Poor pre-existing arthritis
RE ECT
the ankle
the foot