Tips and Tricks for Ankle and Calcaneus › media › 389006 › Ankle-Fractures-Yoon.pdf · Ankle Fractures Pat Yoon, MD. Minneapolis Veterans Affairs Medical Center. ... Disclosures

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? patyoon@gmail.com

Thank you