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

Author(s): 
Graham A. Hamilton, DPM, and Travis L. Sautter, DPM

   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.

   Further clinical studies are needed to accurately determine clinical benefit but the authors have already noted clinical benefit in their patients with the use of arthroscopy in ankle fracture management.

Dr. Hamilton is affiliated with the Department of Orthopedics and Podiatric Surgery of Kaiser Permanente in Antioch, Calif. He is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Sautter is affiliated with the Department of Orthopedics and Podiatric Surgery of Kaiser Permanente in Antioch, Calif. He is an Associate of the American College of Foot and Ankle Surgeons.

Dr. Burks is a Fellow of the American College of Foot and Ankle Surgeons, and is board-certified in foot and ankle surgery. He is in private practice in Little Rock, Ark.

For further reading, see “Current Concepts In Ankle Arthroscopy” in the December 2007 issue of Podiatry Today or “A Pertinent Guide To Basic Ankle Arthroscopy” in the November 2003 issue.

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