Tips and Tricks for Ankle and Calcaneus › media › 389006 › Ankle-Fractures-Yoon.pdf · Ankle...
Transcript of Tips and Tricks for Ankle and Calcaneus › media › 389006 › Ankle-Fractures-Yoon.pdf · Ankle...
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Ankle Fractures
Pat Yoon, MDMinneapolis Veterans Affairs Medical CenterAssistant Professor, University of Minnesota
OTA Residents Advanced Trauma Techniques Course January 20, 2017
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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)
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Improperly treated displaced
ankle fractures cause significant
long term morbidity
Your intervention makes a big difference!
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Weber A Weber B Weber C
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124
3
231
4
12 31
2
SER PER
SAD PAB
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• 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
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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
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Unstable versus StableGravity stress Manual stress
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Unstable versus Stable
Options:• Manual stress view• Gravity stress view• Repeat WB xrays
in 1 week
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Initial treatment –Reduce the talus • Debride any open wounds
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Initial treatment –Reduce the talus • Debride any open wounds
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Dilemma• Unstable in splint• Too swollen for
ORIF
• Reduce & place ex-fix
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• Open: ORIF at time of debridement• Closed: ORIF whenever soft tissues allow
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If irreducible closedOptions• Immediate ORIF if soft tissues reasonable• OR for reduction under GA then ex-fix
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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
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Lateral process
“Dime” sign
Tubercle
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Distal fibula fixation options
• Screws only• Lateral plating
– Percutaneous lateral plating
• Posterior plating• Intramedullary
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Medial malleolus
• Fixation options– Screws– K-wires– Hook plate– Antiglide plate– Tension band
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SyndesmosisInjuries
Courtesy Andy Sems MD
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• Manual versus clamp• Type of clamp• Amount of
compression• Direction of vector• Is overtightening
possible?
Reduction controversies
Miller AN, Barei DP JOT 2013
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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
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Improving our assessment
• Comparing lateral images in Intraop fluoro• Direct visualization• Intraoperative O-arm• Postop CT• Arthroscopy
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• 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
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Screws
Fixation options
Suture-endobuttons
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Suture-endobutton
• FiberWire with two endobuttons passed lateral to medial
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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
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Chaput Posterolateral malleolus
Recognize these patterns
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The posterior malleolus
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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
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Posterior mall Xrays
Haraguchi, JBJS 2006Mandell, Radiology 1971
Externally rotate leg 15°
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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
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Using “pilon map” technique described by Cole et al JOT 2013Mangnus et al JOT 2015
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Fix fibulaThen stress post mall on lateral xray Stable 75% of the time
Stress View
Harper, JBJS 1988
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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
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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