View
619
Download
4
Category
Preview:
Citation preview
Ankle fractures: controversies, syndesmosis & posterior malleolus
Dr.Rajiv Shah‘Foot & Ankle Orthopaedics’Foot & Ankle SurgeonPresident, Indian Foot & Ankle Society
Ankle fractures are surrounded by many controversies!!
Ankle fractures are not that simple as we think!
Early surgery(within first 24 hours) is with better outcome!
Recent literature
Timing of surgery
Late presentations & poor skin condition…
Wait up to 7 days
Joint spanning ex-fix
‘Wrinkle sign’
No recent data Early surgery
prevents blister formation!
If present, wait Avoid incising
through blisters
Literature?
Blisters
Concerns: PID & DM Increased post-op pain +
swelling Early ROM is achieved if
tourniquet is not used! (Konrad G et al – CORR, 2005 )
Recent Literature
Use of tourniquet
Medial swelling Medial tenderness Medial ecchymosis If –ve then stable
lateral malleolar fracture
Recent Literature
Stable v/s unstable lat.malleous # Old Literature
Medial examination - poor predictor
Manual stress test Gravity stress test Trial of weight
bearing & reanalysis
Restoration of fibular length Medial exploration /Fixation Post malleolar fixation Assessment of mortise
stability Syndesmotic fixation
Fixation chronology
Not hard & fast!Achieving fibular length & syndesmotic stability are more important!!
If fibula is comminuted, medial side may be reduced first
Fix if posterior malleolus #
>then 25% Articular step of >
2mm Persistent
subluxation of joint
Recent Literature
Posterior malleolus # Old Literature
Every posterior malleolar fracture should be fixed!
Forms part of incisura
Very important for syndesmotic stability
Gardner (2006) demonstrated that posterior malleolar fixation restored 70% of syndesmosis stability compared with 40% after syndesmotic screw insertion!
Routine X-rays have got poor diagnostic value! External rotation lateral view, a must!CT Scan – gold standard
Posterior malleolus # Attachment of strong PITFL makes it mandatory to fix posterior malleolus fracture
Not the size of fragment but the stability of ankle is more significant!
Fix them posterior to anterior between peronei and FHL!
Occurs in 23% of ankle fractures
If deltoid is also injured then there is marked instability
Anatomical reduction is a must!
Syndesmosis injury
Anterior inferior tibio-fibular ligament
Posterior inferior tibio-fibular ligament
Interosseous ligament
Medial ligaments
History Pain &
swelling Ecchymosis Tenderness at
syndesmosis
Clinical diagnosisSpecial tests
Squeeze test
External rotation stress test
Dorsiflexion of ankle + syndesmosis squeeze or tapping relieves pain
Radiological diagnosisX-raysStress viewsCT Scan
Increased Tibio-fibular clear space Tibio- fibular overlap
Increased medial Clear Space Disturbed Talocrural angle
Lateral talar shift sign
Ankle instability sign
Larger medial clear space than superior clear (ankle joint) space
Gravity stress test CT Scan – Gold standardCT definition of anatomic syndesmosis?Surest CT sign = Tibiotalar line
Line from AL fibula to ant.tubercle of tibia, 1 cm above plafond on axial CT cutMUST BE WITH IN TWO MM FROM ANTERIOR SURFACE OF TIBIAMRI
Syndesmotic ligament injury Associated injuries – Talar dome OCD -28% Bone bruise -24% ATFL -74%
Hook test-pull fibula laterally & take image
Five tests
Intra-operative diagnosis
External rotation test – hold leg & rotate foot externally & take AP image
Tap test – push tap forward in syndesmosis & see widening
Modified cotton’s test – pull fibula posteriorly & take LAT image
Ballottement test – rock/slide fibula anteroposteriorly
Arthroscopy has increasing role in diagnosis!Open & make sure!Fragment in syndesmosis = open
Fibula to tibia 25-30 degree
PL to AM 2 cm above &
parallel to joint line
Screw
Syndesmotic fixation
• No mechanical advantage of 4.5 mm over 3.5 mm in tricortical fixation • 4.5 mm superior mechanically in quadricortical fixation• 3.5mm more likely to break (Panchbari et al)• Avoid cannulated screws• Larger diameter screws provide great resistance to shear forces
3.5mm or 4.5 mm?
Controversies: syndesmotic screw
No difference in outcomes between tri-cortical or quadri-cortical but QC can be removed easily if break and symptomatic
4 cortices are more likely to break as they are more stiffer
3 cortices or 4 cortices?
Controversies: syndesmotic screw
▪ No consensus▪ Two screws better on mechanical studies▪ Two screws better stability to torsional stress ▪ Stability is better with a screw through the plate▪ Stiff construct eliminates even more normal
motion
Single or double screw?
Controversies: syndesmotic screw
2.5 cm above ankle Less than 2 cm = chances of
synostosis More than 5cm = widening of
syndesmosis on external rotation
Where ?
Controversies: syndesmotic screw
Over tightening of syndesmosis is possible?!
Position of ankle in dorsiflexion during screw fixation does not matter but anatomic reduction does matter a great!
Position of ankle?
Controversies: syndesmotic screw
Every material steel, titanium or bio-absorbable showed similar results
Bio-absorbable – early return to work Bio-absorbable – FB reaction, wear,
osteolysis, ? Joint damage
SS , Titanium or bio-absorbable?
Controversies: syndesmotic screw
Allows natural movement of ankle Less likely to give malreduction No need for removal No difference b/w tightrope and screws
in biomechanics (cadaveric studies)
Screw orTight rope?
Controversies: syndesmotic screw
Supposed to be biomechanically better Some do require re operation (irritation
due to knot)/ suffer from osteolysis and sinkage
Have shown improved functional outcomes and early recovery
Screw or Tight rope?
Controversies: syndesmotic screw
No difference between outcome in fractures, loosened or removed screws
Tibiofibular space narrower in intact screw group
Screw removal advised for intact screws
Remove or retain?
Controversies: syndesmotic screw
Better AOFAS score when screw breaks or is removed
Walking prior to removal of screws does not affect outcome
Majority screw breaks
Remove or retain?
Controversies: syndesmotic screw
Tibiofibular space narrower in intact screw group
Increased ROM after screw removal Screw removal advised for intact screws ‘At 3 months follow up if ankle dorsiflexion
is not improving then screw removal’
Remove or retain?
Controversies: syndesmotic screw
25%-50% malreduction 80% reduced after screw removal Use of tight rope? Intra-op direct visualization reduced rate
of malreduction from 44% to 15%! Intra-op CT Post op CT
How to prevent malreduction?
Tibio fibular synostosis Reduced external rotation
How to salvage failed syndesmosis ?
Current Practice in USA
• 3.5mm screws 51%• 4.5mm screws 24%• Suture device 14%• 1 screw 44%• 2 screws 44%• 3 cortices 29%• 4 cortices 67%
• Routine removal 65% (95% OR)(3 months 49%, 4 months 37%, 6months 12%)
•Most common practice: 3.5 mm screw, 4 cortices routinely removed in OR at 3 months
Wide medial clear space after fibula reduction Difficult fibula reduction Difficult to maintain fibula reduction Medial exploration Interposition of deltoid, post tib tendon,
osteochondral fragments Routine repair of deltoid is controversial except
rupture with bony fragment or with association with extensive soft tissue damage
When?
Medial side exploration
Wound healing Deep infection Implant
loosening Loss of fixation
Problems
Fractures in elderlySolutions
Posterior antiglide plate Bicortical screws Fibula pro tibia screws + ex fix Hook plate IM fixation of fibula IM k wires + plate LCP Bone cement
augmentation Bone substitutes Medical management
Poor radiological outcome
Deep infection Revision rates Loss of fixation
& conversion in charcot
Problems
Fractures in diabeticsSolutions
Medical management
Two types of surgical guidelines
That’s all…Thank you all..
Recommended