4/30/2019
5 wk old, 325 lbs, male
Foot and Ankle Specialist
Resurgens Orthopedics
General Assessment
 Age
 How, when, why, what, etc
 Occupation
 Significant PMH
 Physical Exam
 Unusual Circumstances
 Additional studies
 Set expectations
Just OK is NOT OK
BMI 42
Erroll J Bailey MD
Atlanta, GA
IntraOp Reduction – OK?
 YOUNG ADULT
 FELL DOWN STAIRS
 SECURITY GUARD, DRINKER
 NO DIABETES BUT +
NEUROPATHY
 EXTERNALLY ROTATED HIPS,
SKIN/SWELLING OK,
MORBIDLY OBESE
 SHOULD I CT SCAN?
 THIS IS YOUR FIRST
OPERATION - ARTHRITIS
ORIF TRIMALLEOLAR FX
1st post op visit
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Orif – bone graft – compression

1 month f/u hook plate – syndesmosis repair
 Walked in office with
walking boot holding
crutches

 3+ ankle swelling

 pain

3 months post op - revision Broken Hardware

 delayed union pain

Intra-op hardware removal Fusion - 8 months after injury

 Cloudy material out
of lateral gutter

 Not foul smelling

 Waited for cultures

which were negative

 Then took back

Continued lateral gutter Posterior pain
pain

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9 months from beginning

CT SCAN

Still with lateral pain Still with posterior pain

CT SCAN Treatment Plan

 Cast

 Non-weightbearing

 Exogen Bone Stimulator

 Time

10 months Added AFO

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16 months 24 Months

No pain, wants plate out General Concepts

 9% of all fractures

 In US, every 2
minutes an ankle fx

 < 50 yrs age = men

 > 50 yrs = women

General Concepts General Concepts

 Alcohol and slippery  Strive for perfect anatomic reduction, fibular length
surfaces in 33%
 Young pts greater than 1mm, ORIF

 Simple twisting >  Elderly pts can tolerate up to 2mm

sports injury
 Always consider ambulatory needs
 Diabetes/Obesity in
middle aged/older  10% anatomically reduced still get DJD

 85% non-anatomically reduced get DJD

 Ligament tears and
cartilage tears  18 months good threshold for DJD
common

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Classification and Diagnosis Radiographic analysis

 Open wounds  AP, Lat, Mortise views

 95% pts with ankle injuries

 Neurovascular exam
 Assess other joints
 Proximal fibula
(maisonneuve)
 Medial tenderness -
poor deltoid predictor
value
get Xray but only 15%
positive for fracture
(Ottowa study)
 Stress views
 CT Scan – Pilon/Triplane
fxs
 MRI – Salter-Harris fxs,
talar dome injuries,
syndesmotic ligaments

Ankle Fracture
Ankle Fracture Ligaments
Ligaments

lateral medial posterior Not just bone injury

Fracture Classification Fracture Classification

 Weber
 3 types based on
 Weber Classification – Easiest location of fibula fx

 Weber A
 Lauge-Hansen – More Complex
 Weber B

 OTA – Forget about it  Weber C

- Syndesmosis

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Fracture Classification Rational for Treatment

 Lauge-Hansen  Conservative care
 Based on MOI
○ PER –
does work
pronation/external
rotation  Thorough
○ I-IV assessment of pt’s
needs
○ PA –
pronation/abduction  Risks include
○ SER –
stiffness, loss of
supination/external reduction, muscle
rotation
○ I-IV atrophy, cartilage
degeneration
○ SA –
supination/adduction

Conservative Treatment Herscovici, JBJS Br 2007 –

Lateral Malleolus Fractures Conservative Tx Medial Malleolus
 Many clinical studies  Isolated Medial
with 30 year f/u show Malleous fractures
good results
 57 pts
 Cast slight inversion
 Some suggest up to x 6 wk, then boot,
5mm displacement if
medially intact
PT
 55 healed, 2
nonunion (3-4 mm)
 CT shows
displacement is  Mean ROM 52 deg
internal rotation of  Recommended
proximal fragment highly

Remember William Hamilton MD

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Rational for ORIF Addition Evidence

 Ramsey and  Most practical in the athlete with unclear medial injury
Hamilton 1976 JBJS  Anatomic bone to bone contact

 Faster healing
1 mm shift of talus in
mortise leads to a  Faster recovery
42% change in  Earlier return to weight bearing
contact area
 Earlier return to physical therapy

 Shorter duration of pain and swelling

Indications for Treatment Ankle fusion

 Failure to restore these anatomic
relationships? Posttraumatic Arthritis

Ankle Replacement This is fun BUT this is salvage

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Current Topics SYNDESMOSIS CONCEPTS

 Syndesmosis – How and When ?  A fibrous articulation
in which ligaments
unite opposing
 Ankle Arthroscopy – Yes or No? surfaces
 Anterior and
Posterior tibiofibular
 Deltoid – Fix or Not?
ligament AND the
interosseous
 Plating Concepts – Where, What, How? membrane

Syndesmosis function Syndesmosis in general

 Provide stability  Estimated 10% all ankle fxs involve
syndesmosis
 Alllow distal fibula to
rotate 12 deg
 Syndesmotic fixation in diastasis,
 AITF and PITF Maisonneuve, instability after fixation
ligaments primary
stabilizers
 Method of fixation of syndesmosis
 Int trans ligament keeps debatable( screw vs rope construct)
fibula in notch

 Interosseus is a buffer  Remove the screw? Hardware irritation or

to axial load reduced ROM after 4-6 months

Syndesmosis Diagnostic Tips Post malleolus fracture

 Squeeze Test

 External Rotation Test

(knee at 90)

 Tibiofibular clear space <

5mm

 Medial clear space < 4

mm

 Tibiofibular overlap > 10

mm

 Cotton test (3-4mm)

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Posterior Malleolar Percutaneous

Maisonneuve Fracture Repair with syndesmosis

Posterior Malleolus Intraoperative Imaging

 Posterior Malleolar fx over 25% - ORIF  Mortise and Lateral
sufficient
 X-ray often underestimates  Stress test to access
syndesmosis
 Restoration of fibula length should reduce
 Cadaveric studies show
lateral stress test better
 K Wire fixation of fragment than external rotation
(Stofel et al, 2009 JBJS)
 Screw from ant/med direction to post/lat or post/ant
(difficult)  Can intraop fluro
accurately assess
syndesmosis? (3D image
 Isolated medial malleolus can heal without ORIF or Post CT?) Frank et al,
2012 JBJS

ORIF WITH SIDEWINDER PLATE

ORIF Syndesmosis - plate SYNDESMOTIC SCREW

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Syndesmosis Repair Techniques Arthroscopy in Ankle Fractures

 Cottom et al, F & A 2008, 25  Takao et al, 2003
pts, Tightrope good fixation
JBJS British
 Tornetta et al JBJS 2001 –
screw fixation ankle does not  Lui et al, 2005,
have to be at 90 degrees
Arthroscopy
 Moore et al, F&A Int 2006,
either 3 or 4 cortices sufficient
 Hinterman et al 2000
 Ahmad et al, F&A Int, 2009 –
JBJS British
4 cortices with screw is
biomechanically stronger
All suggest helpful in
 Stuart et al, F&A Int, 2011 – diagnosis/reduction of
The bigger the screw the syndesmosis. 79% have
better (4.5 mm), may cause chondral lesions
discomfort

Role of Ankle Arthroscopy in

Acute Ankle Fractures
Chan KB et al
 Chan KB et al, Arthroscopy 2016  Osteochondral
Lesions Present In:

- 254 pts, retrospective - Weber A – Zero

- Weber B – 26%
- ORIF ankle fractures with arthroscopy - Weber C – 24%
- Weber A 6 pts - Iso Med Mall – 20%
- Weber B 177 pts
70% had osteochondral
- Weber C 51 pts lesions
- Isolated Medial Malleolar fxs – 20 pts

Ankle arthroscopy for ankle

Chan KB et al fracture (techniques)
 Syndesmotic Rupture  Sherman T et al, Arthroscopy Tech,
2015
- Weber A – Zero
- Weber B – 52% - skin wrinkling important sign
- Weber C – 92% - find superficial peroneal nerve laterally
- Isolated Med Mall – 20% - light traction recommended
- joint pre-insufflated
Association between deep deltoid tear and
syndesmosis disruption needing screw was - hematoma evacuation before
stat significant in Weber B but not C
- under 30 mins

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Sherman T, et al Leontaritis N et al, JBJS 2009

 63 – 73 % osteochondral lesions in ankle fracture  Arthroscopically
Detected Intra-Articular
Lesions Associated with
 Those with osteochondral lesions do worse Ankle Fractures

 The larger the lesion the poorer outcome - 283 patients

 Helps remove loose bodies, identify ligamentous - 73% chondral lesions

injury better
- Type IV pronation-
 Lateral ankle impingment and PTT imposed in external rotation and
medial malleolus fracture supination-external rotation
more likely to be
associated with 2 or more
 Contraindications are N/V injury, swelling, open fxs lesions

Medial Reduction Look WHAT ABOUT THE DELTOID?

 Horisberger et al, J
Orthopedic Trauma,
2009

Untreated 20.4%
posttraumatic OA

Between 20 and 47
year latency period to
develop OA

WHAT ABOUT THE DELTOID? DELTOID LIGAMENT - REPAIR?

 Hinterman, JBJS 2000 – 40% incidence and 26% bimalleolar
 JONES CR, et al. J fxs unstable after ORIF
Ortho Trauma 2015
 Medial Ankle Instability (90% medial malleolar attachment-
superficial)
 ORIF fibula with  Valgus related deformities (PTT)
deltoid repair had
similar outcomes in  Future Ankle arthritis

SER 4(bimal equiv)  Growing interest in Joint replacement

compared to those
with syndesmotic  Earlier weight bearing and ROM

fixation  MRI, CT, Arthroscopy, Stress test-medial clear space > 5mm

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Dabash S., et al, Science Direct

Woo et al, Foot and Ankle, 2018
Nov 2018
 78 consecutive cases of deltoid rupture with  ADDING DELTOID LIG REPAIR, IS IT
ankle fracture
NECESSARY. SYSTEMATIC REVIEW
 17 month mean f/u
5 studies
 Deltoid rupture repair in case of syndesmotic
injury is superior 281 patients
137 ORIF with deltoid
 Superior in high grade unstable fractures
144 ORIF without deltoid repair
 HAVE A HIGH INDEX OF SUSPICION! Avg f/u 31 months

Dabash S, et al. Science Direct

Nov 2018
“The ultimate question………
 CONCLUSION  Do concerns or complications from the
medial incision plus increased OR time
CURRENT LITERATURE DOES NOT and expense justify attempts at
PROVIDE CLEAR INDICATION FOR improving outcomes for patients?
DELTOID REPAIR
 YES
SOME VALUE WITH HIGH FIBULA FX
AND SYNDESMOTIC REPAIRS

Comparison of fixation methods ANKLE FRACTURES

 Fibula – screws only,  42 YEAR OLD
plate, intramedulary MALE

 Fibula – one or two

LAG screws in young
pts BUT oblique fx
must be 2 times
diameter of bone
non comminuted,
non osteoporotic

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Comparison of fixation methods TRIMED HAND PLATING SYSTEM

 Fibula plate position
depends on level of
fracture, extent of
comminution and
soft tissue condition

MEDIAL MALLEOLUS FX SLED - 4 WEEKS POST OP

 26 YEAR OLD

 BALLET DANCER

ORIF SLED WITH CLUSTER Bimalleolar – sidewinder/screw

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Bimalleolar –Hook Plate and Sled
Comparison of fibular fixation
 Simpler  Slightly more difficult
 Wound/Screw irritation  Stronger construct
 Must be aware of distal
joint screw insertion
 Peroneal tendon irritation
 Lateral plate
weaker(Schaffer/Manoli
JBJS 1987)
LATERAL PLATING
Locking or Non-locking Plate?
 No significant difference
in infection, reoperation
rate, complications or
healing
 $800 more per locking
plate @ 60,000 cases =
$50 million
 Use in osteoporosis,
immobilization time, soft
tissue damage
(Minihane et al, 2006 J
Ortho Trauma)
from most distal screw and
high rate hardware removal
(Weber et al, 2005 F&A Int)
POSTERIOR PLATING
4/30/2019
Parker, et al, JBJS Dec 2013
Screw Fixation Medial Mal Fxs
 Analyzed length,
partially threaded,
fully threaded for
strength
 30 mm partial and 45
mm threaded better
compression
 Engage physeal scar
 45 mm threaded best
Clinical comparison of plating
 Lamontagne et al,
2002, J Ortho Trauma
- no significant diff
OR time, TT, functional
score, loss of reduction
infection rate, screw
loosening
- BUT slightly higher
incidence of hardware
irritation, removal, wound
problems with lateral
plating (not stat signif)
Just OK is not OK
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IF I DO THIS IN YOUR TOWN CONCLUSIONS

 Check my swelling
 ANATOMIC REDUCTION – DEFINITE
 Arthroscopy - debride OCD’s

 Anatomically plate and screw  FIXATION/PLATING – VARIES consider fracture

fibula, locking plate if bad anatomy and stability needed
bone

 Repair my deltoid  ARTHROSCOPY – VARIES, but probably yes

 Cotton test for syndesmosis
 SYNDESMOSIS – DEFINITE but hardware varies,
 If unsure if loose, tight rope
consider patient’s specific needs

 If really sure, 4.5 screw, 4  DELTOID LIGAMENT – YES, BUT not definite (in
cortices literature)

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