A Closer Look At Supplemental Fixation Techniques For High Risk Ankle Trauma
The surgeon would place the screws from lateral to medial through the fibular plate and drive them into the tibia, purchasing all four cortices. I currently recommend the use of syndesmotic screw fixation for all unstable diabetic ankle fractures, especially those with poor bone stock. One may also employ syndesmotic screw fixation for lateral malleolar fractures with an associated deltoid ligament rupture to further stabilize the ankle mortise.7
Surgeons may use multiple or stacked plates for severely comminuted distal tibia or pilon fractures. Multiple plates offer increased stability and help neutralize the deforming forces that may occur over the time it takes for the bone to heal. This added stability helps prevent late collapse and malunion. One should only consider multiple plates if the soft tissue permits.
Intramedullary nail fixation with percutaneous reduction of the fracture has the advantage of limited soft tissue disruption and preserves the soft tissue envelope around the fracture site. With the introduction of a new fibular rod system, one may now consider this fixation method for unstable fibula fractures in the elderly or patients with diabetes, neuropathy and/or peripheral vascular disease.
Static and dynamic external fixation constructs may further stabilize and enhance the overall fixation construct. One can supplement an internal fixation construct with a static external fixator.10 Transarticular fixation is another method to stabilize a severe diabetic foot and ankle fracture.11 The disadvantage of transarticular fixation is the iatrogenic injury created across the articular surface. Often, this is not a major concern, particularly among people with diabetes and neuropathy with loss of sensation.
The surgeon must understand the advantages and disadvantages of the selected fixation construct and also recognize how the particular fixation will affect the biologic events necessary for healing. All fractures require mechanical stability along with sufficient vascularity to allow for an environment that is conducive to healing. The surgeon should note the fracture pattern, consider the soft tissue envelope and recognize the potential for the development of complications. The presence of infection and/or ischemia will affect fixation choice as well. In general, surgeons should tailor the choice of fixation on an individual basis. At times, certain situations may require creativity to achieve a successful outcome.
Dr. Bevilacqua is an Associate of Foot and Ankle Surgery at North Jersey Orthopaedic Specialists in Teaneck and Englewood, N.J. He is board certified in both Foot and Reconstructive Rearfoot and Ankle Surgery by the American Board of Podiatric Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons.