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Ankle Fractures
Pat Yoon, MDMinneapolis Veterans Affairs Medical CenterAssistant Professor, University of Minnesota
OTA Residents Advanced Trauma Techniques Course January 20, 2017
Disclosures• Reviewer
– Foot and Ankle International– Journal of the American Academy of Orthopaedic
Surgeons• Board of directors
– Surgical Implant Generation Network (SIGN)• Committees
– OTA Humanitarian Committee– AAOS Program Committee for Trauma– AOFAS Health Policy Committee
• Consultant– Arthrex Inc.– Paragon 28
• Paid Speaker– International Congress for Joint Reconstruction (ICJR)
Improperly treated displaced
ankle fractures cause significant
long term morbidity
Your intervention makes a big difference!
Weber A Weber B Weber C
124
3
231
4
12 31
2
SER PER
SAD PAB
• 240 videos with identifiable mechanism• 15 sets xrays obtainable• 5/8 SAD mechanisms SAD xray pattern• 2/7 PER mechanisms PER xray pattern
• 10 cadaver specimens• Recreate SER injury• Externally rotated until
both medial / laterally unstable
• 0/10 showed all 4 stages of SER pattern
Kwon JY, JBJS 2015
Kwon JY, JOT 2010
Descriptive classification
• Anatomic description– Lat mall, med mall,
and/or post mall
• Unstable versus stable– Medial clear space
1mm > superior clear space
– Any talar subluxation
Unstable versus StableGravity stress Manual stress
Unstable versus Stable
Options:• Manual stress view• Gravity stress view• Repeat WB xrays
in 1 week
Initial treatment –Reduce the talus • Debride any open wounds
Initial treatment –Reduce the talus • Debride any open wounds
Dilemma• Unstable in splint• Too swollen for
ORIF
• Reduce & place ex-fix
• Open: ORIF at time of debridement• Closed: ORIF whenever soft tissues allow
If irreducible closedOptions• Immediate ORIF if soft tissues reasonable• OR for reduction under GA then ex-fix
Operative Plan
• ORIF fibula• ORIF medial malleolus• Assess need for post mall fixation
– Lateral stress view– Gaps / stepoff– Use as syndesmosis fixation?
• Assess need for syndesmosis fixation– Mortise stress view– Cotton test
Lateral process
“Dime” sign
Tubercle
Distal fibula fixation options
• Screws only• Lateral plating
– Percutaneous lateral plating
• Posterior plating• Intramedullary
Medial malleolus
• Fixation options– Screws– K-wires– Hook plate– Antiglide plate– Tension band
SyndesmosisInjuries
Courtesy Andy Sems MD
• Manual versus clamp• Type of clamp• Amount of
compression• Direction of vector• Is overtightening
possible?
Reduction controversies
Miller AN, Barei DP JOT 2013
Traditional assessment of reduction may be
suboptimal
• Malreduction– 0-16% by radiographs– Up to 52% by CT scan
Gardner MJ FAI 2006
Kennedy MT Foot 2014
• Slight differences in leg rotation can lead to aberrant screw placement
Improving our assessment
• Comparing lateral images in Intraop fluoro• Direct visualization• Intraoperative O-arm• Postop CT• Arthroscopy
• 1 or 2 screws?• 3 or 4 cortices?• 3.5 or 4.5mm screws?• Stainless or bio?• Screws or TightRope?• Dorsiflex or plantarflex?• Remove or leave in?
Syndesmosis Controversies
Doesn’t MatterDoesn’t MatterDoesn’t MatterDoesn’t MatterDoesn’t MatterDoesn’t MatterDoesn’t Matter
Screws
Fixation options
Suture-endobuttons
Suture-endobutton
• FiberWire with two endobuttons passed lateral to medial
Potential advantages• Allows fibular translation and rotation• Avoids issue of screw removal and breakage• May potentially “autocorrect” malreductions
• Clinical results similar or somewhat better (AOFAS, plantarflexion better at 3 mos)
JBJS 2014
FAI 2015
JOT 2015
Chaput Posterolateral malleolus
Recognize these patterns
The posterior malleolus
How to not miss these
Boris & Dust, JOT 2008
• Double density medial tibia• Metaphyseal fx line across
distal tibia• Double joint line• Posterior talar subluxation• Posterior density in the
syndesmosis
Posterior mall Xrays
Haraguchi, JBJS 2006Mandell, Radiology 1971
Externally rotate leg 15°
CT scan for trimalleolar
• Changes decision to fix 25% of the time
• In half of those cases, the surgeon had initially said they did not need a CT scan
Gibson PD et al, JOT Published ahead of print
Using “pilon map” technique described by Cole et al JOT 2013Mangnus et al JOT 2015
Fix fibulaThen stress post mall on lateral xray Stable 75% of the time
Stress View
Harper, JBJS 1988
Fixing the posterior malleolus may stabilize the syndesmosis
• MRI: PITFL attached to all post mall fractures• Radiographic, outcomes scores similar between
syndesmosis screws & PM fixation alone• Note: 31 pts, 15mo f/u Miller, CORR 2011
Gardner, CORR 2006
• 15 PER IV w/ post mall - No complete PITFL tears• Cadaver part – PM fixation stiffer in ext rot than
syndesmosis screws
Summary
• Don’t miss unstable injuries– Stress views (manual or gravity)– Repeat weightbearing xrays in 1 week
• Our assessment of syndesmosis reduction needs to be improved
• Fixing the PM may fix the syndesmosis
Questions? [email protected]
Thank you