Ankle Fractures Syllabus
2014-10-21
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10/21/2014 Ankle Fractures: Controversies & Challenges Assessment of injury, classification Ashish Shah, MD Assistant Professor Orthopaedics [Foot & Ankle] University of Alabama, Birmingham , AL USA. Disclosure Consultant Arthrex Tornier Ankle fractures involve a spectrum of injury patterns from simple to complex, such that these injuries are not always “just an ankle fracture. 1 10/21/2014 Case 1 58 year old WM comes with 2 weeks history of trivial trauma. Presentation in the clinic walking without any support. Pain level 2/10 Is it normal??? Am I missing something here?? Case 2 38 year old WM fell in the backyard and got ankle fracture. Came to the ER walking with pain level 1/10. Doesn’t sound Normal?? Case 3 47 year old female with ORIF ankle fracture [1 year ago], still complaining about 7/10 pain with ambulation. Fracture seems to be healed but what next?? 2 10/21/2014 Ankle Fractures Why Should I worry about ankle fractures? 1 mm of lateral translation of the talus reduced surface contact area in the ankle joint by 42%; lateral translation of 2mm by 64%. Ramsey P.L., Hamilton W.: J Bone Joint Surg Am 1976; 58: 356-357 2 mm of shortening or lateral shift of the fibula, or external rotation > 5 degrees, increases contact forces in the ankle joint leads to early ankle arthritis. Thordarson D.B., Motamed S.,et al J Bone Joint Surg Am 1997; 79: 1809-1815 Significant loss of tibiotalar contact with posterior malleolar fractures involving greater than 33% of the joint surface. Hartford JM et al. CORR 1995; 320: pp. 182187 3 10/21/2014 The ankle joint is subject to enormous forces across a relatively small surface area of contact, with up to 1.5 times body weight with gait and greater than 5.5 times body weight with more strenuous activity. Lets recall our basic Anatomy structures in the next couple of slides. Jon C. Thompson Netter’s Concise Orthopaedic Anatomy, CHAPTER 10, 337-383 4 10/21/2014 Posterior Tibial Tendon Injury During Injury Irritation secondary to Tension Bend wiring/screws Progressive tear and flattening of foot. Jon C. Thompson Netter’s Concise Orthopaedic Anatomy, CHAPTER 10, 337-383 Syndesmosis Carr JB, Trafton PG Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed,, 1998, WB Saunders 5 10/21/2014 Classification System The two most commonly used classification systems are the Lauge-Hansen and DanisWeber ( [AO] Müller) systems. The Lauge-Hansen system is based on the suspected injury mechanism. Fractures are categorized by a combination of foot position and direction of force. Lauge-Hansen N: Arch Surg 1948; 56: pp. 259-317 The Danis-Weber system is based on the level of the fibula fracture and is divided into three types. This system is easier to remember and has more relevance to operative decision making. Weber BG: Die Verletzungen des oberen Sprunggelenkes Mast and Teipner first combined these in 1980 Supination-External Rotation SER I failure of the anteriorinferior tibiofibular ligament (AITFL) SER III failure of the posterior-inferior tibiofibular ligament (PITFL) or posterior malleolus fracture SER II a spiral oblique fibula fracture at or just above the ankle mortise SER IV tension failure of the deep deltoid ligament or transverse avulsion fracture of the medial malleolus 6 10/21/2014 Supination-External Rotation Medial tenderness, swelling, and ecchymosis are poor predictors of deltoid incompetence. Michael Clare Foot and Ankle Clinics of North America 01/2009; 13(4):593-610. If no medial widening stess radiographs Gravity/External Rotation stress If stable be placed in a prefabricated fracture boot and allowed to weight-bear to tolerance; repeat weight-bearing radiographs are obtained 5–7 days later. SER IV tension failure of the deep deltoid ligament or transverse avulsion fracture of the medial malleolus SER II a spiral oblique fibula fracture at or just above the ankle mortise SER III failure of the posterior-inferior tibiofibular ligament (PITFL) or posterior malleolus fracture 7 10/21/2014 Supination-Adduction Injury Lauge –Hansen Supination-Adduction Injury Supination-Adduction Injury 10%–20% of ankle fractures Avulsion fracture of lateral malleolus/lateral ligament injury & vertical shear fracture of Medial Malleolous . Association with medial Tibial plafond impaction injury. Michael Clare Foot and Ankle Clinics of North America 01/2009; 13(4):593-610. Pronation-Abduction Lauge –Hansen Pronation-Abduction injury 8 10/21/2014 Pronation-Abduction Michael Clare Foot and Ankle Clinics of North America 01/2009; 13(4):593-610. Transverse avulsion fracture of the medial malleolus. (II) failure of the AITFL and PITFL (III) a transverse fibula fracture at or above the ankle mortise with communution. Check for syndesmois Integrity. Lateral Tibial Plafond should be inspected for any impaction. Mast J.:. In Müller M.E., Allgöwer M., Manual of internal fixation. New York: SpringerVerlag, 1991, Lauge –Hansen Pronation-External Rotation injury Pronation-External Rotation Michael Clare Foot and Ankle Clinics of North America 01/2009; 13(4):593-610. (I) Tension failure of the deep deltoid ligament or transverse avulsion fracture of the medial malleolus (II) failure of the AITFL (III) a spiral oblique fibula fracture above the ankle mortise (IV) failure of the PITFL or posterior malleolus fracture Commonly associated with instability of the syndesmosis. 9 10/21/2014 Weber Classification System Type A: Infrasyndesmotic Injury Carr JB, Trafton PG: Jupiter JB, Levine AM, Trafton PG, editors: Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed, 1998. Type B: Transsyndesmotic Injury Carr JB, Trafton PG: Jupiter JB, Levine AM, Trafton PG, editors: Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed, 1998. 10 10/21/2014 Carr JB, Trafton PG: Jupiter JB, Levine AM, Trafton PG, editors: Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd ed, 1998. Type C: Suprasyndesmotic Injury Assessment of the Injury History Of Injury 11 10/21/2014 Smoking Diabetes History of primary Rx. Level of Pain Past Medical History : Cardiac Disease. Neuropathy ??: Diabetes, Alcohol, Thyroid, Nerve Injury/Neuromascular Disorder Recalling our cases Case 1 Alcoholic Neuropathy Case 2 Diabetic Neuropathy 12 10/21/2014 Evaluation of the Patient Skin Condition. Vascularity/ Capillary Refill R/o Compartment Syndrome. Check nerve status on the uninjured leg. Wrinkle Sign?? Stable Fracture Immobilization in AO splint. Elevation. Surgery in 10-14 days. surgical treatment for an ankle fracture [except irreducible dislocation/open fracture] is certainly not an emergency and can therefore be completed as an elective procedure in 10-14 days. 13 10/21/2014 Unstable Fracture/Fracture Dislocation. Attempt Close reduction & splinting followed by re-xray. If unreduced take in the OR for closed reduction & Ex-Fix Application vs Definitive Fixation. If open fracture/ poor skin condition. – Closed ReductionExternal Fixator & Debridement Presentation in the clinic at 3 weeks of injury[in the splint] without any reduction. Reduction Attempted in the cast-room. Patient was taken to the OR on the same day for the ORIF Radiographic Evaluation Xrays 3 views [AP/ Mortise/ Lateral view of the injured and opposite ankle]. Knee xrays if suspicious about maisonneuve injury. CT Scan 14 10/21/2014 Case 3 cont. Failed to Identify the syndesmotic injury. Fibular Osteotomy, Syndesmotic Fusion. The medial clear space on mortise views should be less than 4 mm. The superior joint space within 2 mm medially of its width laterally. The joint space should be relatively symmetric. 15 10/21/2014 Medial Clear Space > 4mm The talar tilt angle (<2 mm). The talocrural angle is 83 degrees ± 4 degrees and normally within 2 degrees of the opposite ankle. Mann’s Surgery of the Foot and Ankle. Walling, Art, et al Pages 2003-2040 A 1 Parallel joint space. 2, Spike of fibula pointing to the level of the subchondral bone of the tibia. 3, Unbroken curve between the lateral talar articular surface and recess of the distal fibula. The subchondral bone that forms the Shenton line should be intact. Weber BG, Simpson LA: Corrective lengthening osteotomy of the fibula. Clin Orthop Relat Res 199:61-67, 1985.) 16 10/21/2014 Shenton’s line. Fibular Length and Rotation Restoration of fibular length and rotation is critical in reestablishing a stable ankle mortise, and can be assessed with xray “Shenton’s line” Operative versus Nonoperative Treatment Single Break: Stable Double Break: Unstable Neer CS: Injuries of the ankle joint: evaluation. Conn State Med J 1953; 17: pp. 580 Mann’s Surgery of the Foot and Ankle. Walling, Art et al. Pages 2003-2040 Radiographic criteria can be misleading because they are based on a two-dimensional static picture of a three-dimensional dynamic joint. 17 10/21/2014 Timing of the Surgery Abrasions should be cleansed and dressed. when practical, within a few hours if abrasions are present. After 12 to 24 hours, deep or dirty abrasions can contraindicate surgery until they have resolved Early closed reduction and elevation with a compressive dressing and splinting are important in preventing edema and the development of fracture blisters. Fracture blisters adjacent to planned skin incisions do not appear to cause wound problems unless they are blood filled. Giordano CP et al. CORR 1994; 307: pp. 214-221 In the presence of intradermal edema (peau d'orange), marked subcutaneous edema, or fracture blisters : Delay until wrinkle sign, epithelialization of the abrasion. Syndesmotic Injury Thank You. 18 10/21/2014 Modalities of treatment in Ankle injuries Dr. Rajesh Simon Consultant, Lakeshore Hospital, Kochi, Kerala DISCLOSURE • I have no financial interest, affiliation or any other relation ship for any commercial product or any disclosure to be made. Roentgenogram At least 3 views Mortise view 1 10/21/2014 Evaluation: Radiographic Antero-posterior View • Tibiofibular overlap > 6mm • Talar tilt • Talocrural angle:83⁰ +/-4 ? Comparison Radiograph Supra syndesmotic injury Evaluation: Radiographic Lateral View •Posterior Malleolus •Talar subluxation •Distal fibular translation &/or angulation •Syndesmotic relationship •Associated or occult injuries • Lateral process talus • Posterior process talus • Anterior process calcaneus 2 10/21/2014 Evaluation: Radiographic Other Imaging Modalities • Stress Views • Gravity • Manual • CT • Articular involvement • Posterior malleolus • MRI • Ligament and tendon injury • Talar dome lesions • Syndesmosis injuries Understand the patho-anatomy of the Fracture before treatment. Infra syndesmotic Trans syndesmotic Supra syndesmotic AO Danis Weber classification Infrasyndesmotic Supination Adduction 3 10/21/2014 AO Danis Weber classification Transsyndesmotic Supination External rotation AO Danis Weber classification Suprasyndesmotic pronation external rotation Understanding the injury helps in reversing the injury and helps to achieve closed temporary reduction Immediate reduction necessary 4 10/21/2014 • Splintage in situ slab Success of treatment •Anatomical integrity of ankle •Correct length of fibula •Exact position of fibula in fibular notch 2mm of shortening or lateral shift increases contact forces OA ankle •Integrity of syndesmotic ligaments 1 mm lateral talar displacement reduces tibiotalar contact surface up to 46 % Ramsey and Hamilton JBJS 1976 Definitive treatment Decision Making Understanding the fracture stability Fibular fractures 1. With a stable ankle mortise usually heals uneventfully. 2. With an unstable ankle mortise heal with significant functional problems…because instability allows for talar shift. 5 10/21/2014 TIMING Disaster to operate Lateral malleolus TBW Cancellous screw 6 10/21/2014 Medial malleolus •Type of fixation depend on size of medial malleolus •Standard fixation is two 4mm cancellous screws •TBW for small fragments • Medial injury: vertical shear type medial malleolar fracture • BEWARE OF IMPACTION • • • 7 10/21/2014 Weber B ( Supination External Rotation) •Unstable fractures •Reduction of fibula = reduction of joint Options Lag screw and neutralisation plate Antiglide plate and lag screw Hanging Mortise view Decision Making • • • • Base your decision to operate on your findings and the risk:benefit ratio in isolated fibular fracture Weber 2/ SER types 8 10/21/2014 Type C (Pronation External Rotation ) • • • • HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON Type C (Pronation External Rotation ) • Final Objective Restore: • Fibular length and rotation • Ankle mortise • Syndesmotic stability • Options • Lag screw and neutralization plate • Compression plating • Bridge plating Remember 1/3rd tubular plate usually recommended LCP in osteoprotic comminutions Plate should be twisted – Mal rotation 9 10/21/2014 Posterior malleolus Hartford’s experiment Size Decrease tibio talar contact area • 25% 4% • 33% 13% • 50% 22% Hartford et al 1995 Tibiotalar contact area: contribution of posterior malleolus and deltoid ligament CORR, 320, 182-7 Posterior Malleolus Fractures: Radiographic Evaluation • Indication for fixation: > 25% joint surface on lateral view • Fracture pattern • Variable • Difficult to assess on standard lateral radiograph • Fracture orientation not purely in coronal plane • Larger laterally than medially & obliquely oriented Suggested X-rays • External rotation lateral view [Decoster FAI 2000] • CT scan [Haraguchi JBJS 2006] Posterior Malleolus Fracture 67% 19% Type I- posterolateral oblique type Type II- medial extension type 14% Type III- small shell type Haraguchi et al. JBJS 2006 10 10/21/2014 Posterior Malleolus Fractures: Indications for Fixation • Stability • Posterior translation of talus • ER of talus [syndesmotic widening] • A step off or gap more than 2-3mm after reduction of the lateral and medial fragments Incision Post mall fixationBetween Peronei and FHL 11 10/21/2014 Fibula fixation Ant to Peronei Post op Thanks Dr. Sunil/ Dr. Sarang Take home message • Understand the patho anatomy and treat accordingly • Ankle instability is key indication for surgery • Regain Length and alignment of fibula • Assess the Posterior malleolus and Syndesmosis • Know surgical technique and proper implant 12 10/21/2014 13 10/21/2014 The Syndesmosis "What, When, and How" Anish R. Kadakia MD Assistant Professor Northwestern University Department of Orthopedic Surgery Historic radiographic criteria • Radiographic evaluation of the tibiofibular syndesmosis Harper & Keller Foot Ankle 1989 – Radiographs taken of 12 mounted fresh cadaver lower extremity specimens – “Normal” radiographic criteria reported • Tibiofibular clear space (AP & mortise views) < 6 mm • Tibiofibular overlap (mortise view) > 1 mm Materials & methods 1415 consecutive pts aged 18 – 65 with complete series of ankle radiographs evaluated at University of Michigan’s foot & ankle clinic (Shah AS, Kadakia AR et. al. Foot Ankle Int. 2012) 392 pts (218 F, 174 M) with normal ankle radiographs included 83 sets of bilateral normal radiographs compared 1 10/21/2014 Tibiofibular overlap (mortise) 120 Number of Patients 100 80 60 40 20 0 <0 0 -1 1.1 - 2 2.1 - 3 3.1 - 4 4.1 - 5 5.1 - 6 6.1 - 7 7.1 - 8 >8 Tibiofibular Overlap (Mortise), mm 4.9% pts < 0 mm 7.7% pts < 1 mm Example Lack of overlap Diminutive anterior tibial tubercle Rectangular-shaped syndesmosis 34 yo F L talonavicular ganglion Tibiofibular clear space (mortise) 4.3% pts > 6 mm 180 160 Number of Patients 140 120 100 80 60 40 20 0 0.0 - 1 1.1 - 2 2.1 - 3 3.1 - 4 4.1 - 5 5.1 - 6 6.1 - 7 7.1 - 8 Tibiofibular Clear Space (Mortise), mm 2 10/21/2014 Comparison radiographs • In our series, mortise tibiofibular clear space is the most useful measurement when comparing to contralateral radiographs – 75% of contralateral radiographs within 1 mm – 95% of contralateral radiographs within 2 mm • Measure of tibiofibular clear space relatively independent of ankle rotation Pneumaticos et al Foot Ankle Int 2002 When should we fix it? 1. Absolute values are not reliable given the variability noted. 2. Use contralateral mortise radiograph for comparison, sideto-side difference in tibiofibular clear space of 2 mm suggests syndesmotic disruption. 3. Overlap does not guarantee an intact syndesmosis! 4. If Normal ankle has 8mm of overlap and injured ankle has 4mm of overlap => INJURY Mal-reduced PL fragment = Malreduced syndesmosis 3 10/21/2014 Syndesmotic Fixation w/ Mal reduced Post Mall (Moore et al. Foot Ankle Int. 2006) 79 days PO ORIF Post Mall can be enough 4 10/21/2014 Final PO Rarely – require additional ORIF syndesmosis 5 10/21/2014 1 year PO Logical Protocol 2mm Side to Side Difference Medial Clear Space Widening with Prox fibular Fracture Medial Clear Space widening w/o Fibular Fx Medial Clear Space widening after ORIF fibula MRI confirmation of Syndesmotic Injury Posterior Malleolus Fracture Obtain CT or MRI to assess displacement Anatomic => Can ORIF syndesmosis alone Displaced => ORIF Posterior malleolus Anterior Tib/Fib wide => ORIF Posterior Malleolus AND Syndesmosis 6 10/21/2014 HOW? Old Controversies 3.5mm or 4.5mm? No biomechanical advantage of the 4.5mm screw (Thompson MC and Gesink DS, Foot Ankle Int. 2000) 3 or 4 cortices? No significant difference in outcome at a mean f/u of 8.4 years (Wikeroy AK. J Orthop Trauma. 2010) No significant difference in outcome at a mean f/u of 150 days (Moore JA. Foot Ankle Int. 2006) Hardware Removal? No clinical superiority noted with removal of HWR New Controveries Plate and Screws May decrease risk of fibular fracture Plate and Locked Screws May decrease mal-reduction as screws cannot “drive” the fibula into a mal-reduced position Plate with 1 screw and 1 Suture button Suture button may allow superior reduction as cannot “drive” the fibula Suture button may “back-up” screw fixation NO Data to support these claims 7 10/21/2014 Suture Button Fixation Why? Eliminate need for hardware removal? May allow more physiologic movement – theoretically conducive toward soft tissue healing. Excessive motion however – is detrimental Sagittal Plane Relevance Fibula is more unstable in the sagittal plane after sectioning of the syndemosis (Candal-Couto JJ. et. al. Injury, 2004) Sectioned the AITFT/IOL/PITFL Hook test performed in both planes Mean Displacement o Coronal – 1.5mm o Sagittal – 8.8mm Additional sectioning of Deltoid Mean Displacement o Coronal – 3.2mm o Sagittal – 11.7mm Sagittal Plane Relevance Biomechanical evaluation (Klitzman R. et. al. Foot Ankle Int. 2010) Single suture button vs. single tri-cortical screw Increased motion of the fibula in the sagittal plane with the suture button compared to intact NOT restoring the primary instability pattern Fibula will follow the posterior malleolus and leads to mal- reduction when considering this as a uni-planar injury. May appear closed on the AP However, can be posterior subluxated. 8 10/21/2014 What about 2 Suture Buttons? Biomechanical Comparison (Soin SP et. al. Foot Ankle Int. 2009) 2 diverging suture buttons Single 3.5mm screw NO Difference in the fibular movement in any plane. Reduction – Most Critical Aspect Where do I apply the clamp? Anatomic axis of the syndesmosis Lateral Malleolar Ridge Central point of the medial tibial cortex 1cm Proximal to the joint Reduction 9 10/21/2014 Reduction Oblique placement will lead to malreduction Adding PM fracture made things worse for A3 Do NOT have to “crush” it. Over-compression of the articular surface can occur. Why this can lead to malreduction Posterior Lip Intact Slight malrotation may “self correct” s/p HWR 10 10/21/2014 Poster Mall Fx + Sagittal Instability = Bad News Poster Mall Fx + Sagittal Instability + Bad Clamp = Worse Slightly “over-reduced” – (Will NOT correct s/p HWR) (Miller AN, et. Al. Foot Ankle Int. 2009) 11 10/21/2014 Summary How? No clearly superior method Critical Points Location – Approximately 2cm above plafond Superior stability compared to 3.5cm above plafond Minimize risk of placement within the tib-fib joint. May risk injury to peroneal artery – clinical relevance unknown Reduction is critical – open and observe reduction if needed. (Unfortunately, still risk of malreduction) If screw – no smaller than 3.5mm If suture button – utilize 2 in diverging fashion. Single suture button allows more motion than normal My preferred method With Fibular ORIF Single 3.5mm tri-cortical screw with quad-cortical drill hole Without Fibular ORIF 4 hole plate with 2 central holes for syndesmotic screw 2 3.5mm screws PO protocol NWB 6 weeks WBAT in CAM walker weeks 6-12 WBAT in ASO weeks 12 until HWR (weeks 16-20) Screws may break Thank You 12 Posteriorly Unstable & Osteoporotic Ankle Fractures Prof. V. K. Panchbhavi MD, FACS Chief Division of Foot & Ankle Surgery Director Foot & Ankle Fellowship Program University of Texas Medical Branch Galveston, Texas, USA Disclosures Consultant – Stryker / SBi Editor-in-Chief – Techniques in Foot & Ankle Surgery - LWW Editorial Board / Reviewer – FAI /JBJS / CORR / Orthopaedia.com / FootEducation.com Research Funds – Arthrex and Wright Medical – 2008/9 Department of Orthopedic Surgery and Rehabilitation Objectives What is different ? Do standard methods of stabilization work? What are special concerns ? Department of Orthopedic Surgery and Rehabilitation 1 Posteriorly Unstable Ankle Fractures Instability Instability Spiral SAD SER What is the mechanism, direction of forces ? Oblique fracture plane “Hyperplantarflexion” 2 In which direction is this ankle fracture most unstable ? Instability 3 4 Biomechanical Study Gardner MJ et al Clin Orthop Relat Res 2006 Jun;447:165-71 Fixation of PM fractures provides greater syndesmotic stability – 10 cadaver PER with PM fragment model – Fixation of PM – 70 % stability restored – Fixation of Syndesmosis – 40 % stability restored – External rotation tested – not posterior instability Department of Orthopedic Surgery and Rehabilitation 5 PER Small size PM 6 Posteriorly unstable PER Size does not matter Instability does !! as does the direction and plane of instability !! Oblique fracture plane Posteriorly unstable Prone position 7 Deep fascia Sural nerve Peroneals retracted Fascia over FHL 8 FHL exposed FHL retracted Fracture & PM exposed 9 Buttress plate contour Buttress plate contour Don’t follow the curve Buttress plate contour 10 Get a ‘true’ lateral image Fibular fracture exposed Fracture reduction and Plating 11 PM unobstructed by fibular plate Prone position easier for PM / LM Prone position ‘strange’ for MM 12 Oblique fracture plane Sloppy lateral with platform for leg PM + LM MM 13 14 Position not so ‘strange’ for MM 15 Osteoporotic Ankle Fractures 16 Living longer and more active What are the special issues ? You must be kidding !! Don’t bear weight Co morbidities – Poor balance / Dementia – Diabetes, PVD Poor soft tissue envelope Poor bone quality 17 88 yr F Walked unaided before ---- now stays home and manages few steps with frame 12 Wks. Cast Rx can fail ORIF Rx can fail too 18 ORIF – standard fixation – can fail What should we do different ?? Augmented ORIF Hook Plate and Tibia-Pro-Fibula Screws 80 Yr F - Fit and active 19 ‘Wrinkle ready’ for ORIF at 2 wks. 20 The ‘wrong’ bend The ‘Right’ Curves 21-11-02 16-03-02 76 yrs. F 21 22-03-02 Intraoperative images 22-03-02 Syndesmosis screws even if syndesmosis is intact Not to repair syndesmosis But to get additional purchase in tibia 11-06-03 3 months 22 6 wk Avoid SC dissection Avoid creating flaps Longer incision better Avoid self retainers 23 Panchbhavi VK, Mody MG, Mason WT: Combination of Hook Plate and Tibia Pro-Fibular Screw Fixation of Osteoporotic Ankle Fracture. Foot Ankle Int. 26(7) 510- 515: 2005 n= Malunion Wound breakdown AOFAS Olerud Molander Standard Tx 15 1 2 HP+TPFS Tx 16 0 0 57 » 83 37 » 43 55 » 81 42 » 50 N=31 (55-90) Av – 71 years FU – 18 months How stable should be the fixation?? Enough to allow the elderly bear full weight 24 What next ?? Can we augment bone ?? Augmenting bone with CaSO4 + CaPO4 25 Screws pull out shatters bone……………………..leaves bone almost intact Augmented with CaS04+CaP04 Panchbhavi VK, Valluraupalli S, Morris R, Patterson R: The Use of Calcium Sulphate and Calcium Phosphate Composite Graft to Augment Screw Purchase in Osteoporotic Ankles Foot Ankle Int. 29(6) 2008 Department of Orthopedic Surgery and Rehabilitation 26 Panchbhavi VK, Valluraupalli S, Morris R, Patterson R: The Use of Calcium & Calcium Phosphate Composite Graft to Augment Screw Purchase in Osteoporotic Ankles Foot Ankle Int. 29(6) 2008 Department of Orthopedic Surgery and Rehabilitation 27 Summarizing…Principles Study the fracture plane and direction of instability Spiral Oblique 28 A-P instability requires stable butress fixation Osteoporotic fractures require augmented fixation Thank You 29 10/16/2014 Emerging Truth from Controversies Dr Sampat S Dumbre Patil Noble Hospital, Magarpatta, Pune, Maharashtra, India. Controversies in ankle fractures Timing of fixation. Use of tourniquet. Med malleolar fixation Posterior malleolar fixation. Timing of Surgery. Dictated by soft tissue condition Joint spanning fixator helps Wait for skin wrinkles to appear 1 10/16/2014 International Orthopaedics March 2013, Volume 37, Issue 3, pp 489-494 The timing of ankle fracture surgery and the effect on infectious complications; A case series and systematic review of the literature A delay in surgery is associated with significant rise in infectious wound complications These fractures should preferably be treated within 24 hours Timing Reduce deformity as early as possible Span – Scan – Plan Fix within 24 hrs. or wait for a week Consider mechanism of injury Blisters No conclusive data to help management Early surgical intervention prevents blister formation Blisters allowed to resolve prior to surgery 2 10/16/2014 Tourniquet Concern in PVD and DM Increase in pain and swelling after use of tourniquet ROM restored early in non tourniquet group Konrad G et al - clinic orthop relat res. 2005 apr. Clin Orthop Relat Res. 2005 Apr;(433):189-94. Tourniquets may increase postoperative swelling and pain after internal fixation of ankle fractures. Konrad G, Markmiller M, Lenich A, Mayr E, Rüter A Level 1 (randomized controlled trial). Increased postop swelling & pain Better ROM Recommended not using a tourniquet Rational Sequence of Fixation in Trimalleolar Fractures Posterior malleolar fixation Medial exploration and fixation Restoration of fibular length Assessment of mortise stability 3 10/16/2014 Zhongguo Gu Shang. 2008 Apr;21(4):300-1. [Surgical treatment of pronation and supination external rotation trimalleolar fractures]. [Article in Chinese] Xu YQ1, Zhan BL, He FX, Wei HD. ORIF started with posterior, then medial and lateral malleolus and lastly the distal tibiofibular syndesmosis fixation in a sequence Rational sequence of fixation in trimalleolar fractures. Sequence depends on mechanism of injury and comminution Achieving fibula length is helpful If fibula is comminuted - medial malleolus can be reduced first Fixation of fibula Infrasyndesmotic- Screw / TBW / Plating Transsyndesmotic- Plate / Screw /TBW Suprasyndesmotic - Plating 4 10/16/2014 Fibula fixation with nail- or plate? Fibular Fracture Fixation Anti-glide Plate / Lateral plate Plate on post aspect Peroneal tendon irritation Low profile Lateral Malleolus Fixation with Deltoid Ligament Repair Deltoid ligament does not require routine exploration or repair Explored if: - Difficultly in reduction of fibular fracture - Interposition of ligament, periosteum, PT tendon 5 10/16/2014 J Orthop Trauma. 2014 Sep 2. [Epub ahead of print] Deltoid Ligament Repair vs. Syndesmotic Fixation in Bimalleolar Equivalent Ankle Fractures. Jones CR1, Nunley JA 2nd Conclusion Repairing deltoid vs. repairing syndesmosis Subjective, functional and radiological outcomes are comparable Strategies Trauma Limb Reconstr. 2012 Aug;7(2):73-85. doi: 10.1007/s11751-012-0140-9. Epub 2012 Jul 6. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Stufkens SA1, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. There is no evidence found for suturing but exploration is thought to be beneficial in case of interposition of medial structures. Medial Malleolar Fixation Tension Band Wiring One screw, one k wire Two screws Plate 6 10/16/2014 Int Orthop. 2014 Jan;38(1):83-8. doi: 10.1007/s00264-013-2168-y. Epub 2013 Nov 20. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Ovaska MT1, Mäkinen TJ, Madanat R, Kiljunen V, Lindahl J. Fixation of an associated medial malleolar fracture with other than two parallel screws were also associated with re-operation. Injury. 2014 Sep;45(9):1365-7. doi: 10.1016/j.injury.2014.05.031. Epub 2014 Jul 3. A clinical evaluation of alternative fixation techniques for medial malleolus fractures. Barnes H1, Cannada LK2, Watson JT1. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation Foot Ankle Int. 2014 May;35(5):471-7. doi: 10.1177/1071100714524553. Epub 2014 Feb 13. Comparison of surgical techniques of 111 medial malleolar fractures classified by fracture geometry. Ebraheim NA1, Ludwig T, Weston JT, Carroll T, Liu J • Transverse #s - TBW and lag screws- similar rates of union. TBW - less revision surgery / fewer complications • Oblique fractures- effectively treated with lag screws • Vertical #s - superior outcomes with buttress plating 7 10/16/2014 Medial Malleolar Fixation - TBW TBW loop thr. bone TBW loop around post screw Medial Malleolar Fixation - 2 Screws Buttress plate required for large fragment with vertical fracture 8 10/16/2014 Traditionally partially threaded screws are recommended for medial malleolar fixation Bone Joint J. 2013 Dec;95-B(12):1662-6. doi: 10.1302/0301-620X.95B12.30498. Screw fixation of medial malleolar fractures: a cadaveric biomechanical study challenging the current AO philosophy. Parker L1, Garlick N, McCarthy I, Grechenig S, Grechenig W, Smitham P Better fixation with 3.0 mm partially threaded or 4.5 mm fully threaded screws engage the physeal scar Posterior Malleolar Fixation Indications for fixation Post fragment >25%. Persistent subluxation of joint Better to fix posterior malleolus for syndesmotic stability and articular congruency. Posterior Malleolus Fixation When a posterior malleolar fracture is present, we recommend anatomic reconstruction, regardless of the size of the fracture fragment, to recreate the incisura; this obviates the need for syndesmotic screws Clin Orthop Relat Res. 2010 April; 468(4): 1129–1135. 9 10/16/2014 Post Malleolus Posterolateral fragment (Volkmann's triangle) attached to fibula Reduction of fibular fracture helps Separate screw fixation for medial malleolus Posterior Malleolus Fixation Anterior to Posterior Posterior to Anterior 10 10/16/2014 Chin Med J (Engl). 2013 Oct;126(20):3972-7. Advances and disputes of posterior malleolus fracture. Fu S1, Zou ZY, Mei G, Jin D. • Direct posterior malleolus fixation is suitable to stabilize syndesmotic injury. • Direct reduction and buttress plate fixation of posterior malleolus fracture through the posterolateral approach. Incision Fibula plating Ant to peronei Posterolateral approach for posterior malleolus Plating posterior malleolus Posterior malleolus exposure Case study 11 10/16/2014 Conclusion Timing – dictated by soft tissues Use of tourniquet – concerns in PVD & DM Medial exploration if soft tissues impinge Posterior malleolus - anatomic reconstruction 12 10/21/2014 Dr.Rajiv Shah Foot & Ankle Surgeon President, IFAS India Revision fixation Realignment with osteotomy Ankle replacement Fusion = ankle arthrodesis 1 10/21/2014 Duration may not matter! While there is no optimal time to perform reconstructions the fact is that… Patients continue to improve up to 7 years post reconstruction! Fibular lengthening Correction of talar tilt Fixation of medial malleolus Syndesmotic fixation Ligament reconstruction Releases Arthroscopy 2 10/21/2014 7 8 9 3 10/21/2014 10 11 12 4 10/21/2014 Malreduced ankle, syndesmosis widened, fibula rotated 13 5 10/21/2014 6 10/21/2014 20 Varus ankle: Medial open wedge supramalleolar Lateral close wedge supramalleolar Lateral displacement hindfoot osteotomy Valgus ankle: MCO if mild valgus Medial close wedge supramalleolar Lateral open wedge supramalleolar +/-Ligament reconstruction 21 7 10/21/2014 There is minimal deformity No infection No neuropathy No vascular compromise No AVN Good soft tissue envelope 24 8 10/21/2014 Fusion – young patient with global arthritis, gross deformities, infection, neuropathy, gross instability & bone loss 26 27 9 10/21/2014 28 30 10 10/21/2014 Young & active Age & activity Old & sedentary Revision TAR over Fusion Fusion Orthosis Osteotomy Minimal TAR Arthritis & deformity Global with deformity Fusion 11 10/21/2014 Infection diabetes Fusion Revision fixation?? Coronal plane malunion malunion in valgus Leave it alone Sagital plane malunion malunion in varus Revise 36 12
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