A Closer Look At Arthroscopy For Ankle Fractures And Post-Fracture Defects

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Graham A. Hamilton, DPM, and Travis L. Sautter, DPM

   A Tillaux injury almost always occurs in the adolescent within a year of complete closure of the distal tibial physis. This injury is a Salter-Harris type III fracture in which the lateral portion of the distal tibial physis is injured. The central and medial aspects of the tibial physis have closed, leaving the anterolateral aspect open and vulnerable to injury. An external rotation force on the foot may avulse the anterolateral quadrant of the tibial physis, which is bound to the fibula by the strong anterior tibiofibular ligament. This may result in a rectangular or pie-shaped fragment breaking off the distal tibial epiphysis.

Case Study Four: Treating A Triplane Fracture In A High School Football Player

   A healthy 15-year-old male sustained an injury in a high school football game. A CT scan confirmed a three-part intra-articular fracture. The coronal view noted no articular step-off but identified a 3 mm displacement. Three-dimensional CT reconstruction provided a very clear understanding of the fracture pattern.

   In order to restore articular congruity, the surgeon performed arthroscopic assisted fracture reduction. There was no evidence of any articular step-off and apposition of the fracture fragments. The surgeon fixated the fragments with cortical lag screws directed anterior to posterior and medial to lateral.

   The tibial triplane fracture is a complex fracture defined by sagittal, transverse and coronal components that courses in part along and in part through the physis, and enters the ankle joint. Classically, this fracture appears as a Sanders type III injury on the AP projection and as a type II injury on the lateral view.8,9 A CT scan is an invaluable tool in defining the fracture configuration and the amount of intra-articular displacement.

   Most classifications are based on three factors: medial or lateral location, the number of parts, and whether it is an intra- or extra-articular fracture. Fractures of the fibula may be present in conjunction with any triplane fracture. Three-part fractures have a propensity for intra-articular incongruity. These type of injuries leave a posterior metaphyseal-epiphyseal fragment that behaves like a Salter-Harris IV fracture. This fragment may migrate proximally and leave an articular step-off in the joint surface.

Case Study Five: When Chronic Syndesmotic Instability Occurs

   A 59-year-old male sustained a Grade II open trimalleolar ankle fracture while trying to apprehend two men who attempted to steal his car. The open injury also resulted in extensive capsular disruption. After malleolar reduction, the tibiotalar joint had anterior subluxation so surgeons inserted smooth transcutaneous Steinmann pins for further stabilization. The fractures and skin envelope progressed to healing in a fairly uneventful fashion with the ankle mortise appearing relatively well preserved. Surgeons removed the syndesmotic screws four months after the index procedure.

   The patient was then lost to follow-up. He reappeared roughly seven months after the screw removal, complaining of a swollen ankle. Radiographs demonstrated an unstable ankle syndesmosis that was clearly widened and a talus in valgus malposition.

   Looking at the reconstructive options, surgeons decided to attempt a joint salvage procedure as opposed to an ankle arthrodesis. The syndesmosis underwent bone grafts and surgeons performed a distal syndesmotic fusion. After obtaining a congruent joint, surgeons performed arthroscopy. The joint showed significant articular damage but at two years postoperatively, the patient is still functioning well.

In Summary

   Arthroscopy is a wonderful tool in the management of certain intra-articular fractures of the ankle. It assists in attaining anatomical reduction while minimizing disruption of the soft tissue envelope. Arthroscopy also enables the surgeon to debride the joint and address any articular defects primarily. This approach may offer the patient distinctive advantages in the future. Arthroscopy is also an excellent adjunct in the treatment of post-traumatic ankle pathology such as osseous malunion, synovitis, arthrofibrosis and chronic syndesmotic instability.

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