Chronic trimalleolar fx

dislocation
Duane Anderson, MD
SCH
July 2016
25 yo male with 3 week old injury
 challenges
• Difficult dissection because of dense scar and
deformity
• Mobilizing the talus into anatomic position is
difficult
• Avoiding too much dissection so that you
maximize healing potential of the fxs
• Knowing where to cut to mobilize the talus
 What is disrupted?
• The anterior tibiofibular ligament is torn
• The ankle capsule is completely torn
 What is intact?
• The deltoid ligament is intact
• The posterior tibio-fibular ligament is intact
and attached to the posterior malleolus
fragment
• The anterior talofibular ligament is intact it is
important to keep it intact so that the distal
fibula follows the talus into its anatomic
location
 What is displaced?
• Medial malleolus fracture remains with the
talus because of the deltoid ligament
• The posterior malleolus is detached from the
posterior tibia and remains with the distal
fibula because of the posterior tibio-fibular
ligament
• The distal fibula is displaced posterior and
proximal and in this case is healed in this
position
 Steps of the operation
• Make a long medial incision, incise the
periosteum along the fx lines as closely as
possible, there are two fragments of the medial
malleolus here
• Cut the scar and capsular tissue anteriorly to
expose the anterior talus, stripping anterior tibial
periosteum is NOT necessary
• Posteriorly mobilize between the posterior
malleolus and the posterior tibia and expose the
posterior talus, removing scar and pericapsular
tissue
 Steps of the operation fibula
• Incise along the fibula
• Cut the periosteum along the fx lines as close as
possible
• Osteotomize the fibula along the fx lines
• Cut along the anterior distal fragment and
remove excess scar in the area of the anterior
tibia-fibular ligament, avoid cutting the anterior
talo-fibular ligament
• Preserve the posterior and distal attachments of
the distal fibula
Place a medium pin from the medial
side to the joint surface
Logical sequence
• Advance the pin across
the joint once the talus
is anatomic position
both radiographically
and by sight
• then rebuild the medial
malleolus and lateral
malleolus around it
• Bone graft was done
medially in fx clefts
from the anterior tibia
Final xray
 After care
• 8 weeks in a cast nonwtbearing
• Remove transarticular pin
• Start mobilization