Malunited Ankle Fractures

Selene G. Parekh, MD, MBAAssociate Professor of Surgery

Partner, North Carolina Orthopaedic ClinicDepartment of Orthopaedic Surgery

Adjunct Faculty Fuqua Business SchoolDuke University

Durham, NC919.471.9622

http://seleneparekhmd.comTwitter: @seleneparekhmd

Ankle Joint

• 3 articulations• Fibula secondary stabilizer

• Talus• Trapezoidal – wider anteriorly• DF – ER 4.2o

• PF – IR 1.4o

• Distal fibula w/ DF• Lateral translation 1-2mm• ER

Malunited Ankle Fractures

• Isolated lateral malleolar ankle fractures

• Potts/Bimalleolar ankle fractures

• Cotton/Trimalleolar ankle fractures

• Syndesmotic injuries

Malunited Ankle Fractures

• Shortening and lateral rotation of distal fibula

• Widening of mortise, lateral tilt talus

• Most common

Importance

• 1 mm shift of the talus 42% reduction in the tibiotalar contact area increase stress on the articular cartilage

• Serious and persistent dysfunction

Symptoms

• Difficulty walking

• Pain & edema

• Cosmetic changes

Guidelines

• Little in the literature to guide approaches and techniques

• Anecdotal experiences

• Cite literature where available

3 Guiding Concepts

• Restore alignment of the entire lower extremity

• Restoration of the articular surface

• Restoration of painless ankle motion

Preoperative Evaluation

• History• Physical

• Tenderness• ROM

• Imaging• Xrays• CT• MRI• Nuclear medicine

Issues to Consider

• Medical conditions• Diabetes, ESRD• Neuropathy• Dermal issues• Nicotine use

• Bony issues• Alignment• Bony quality and nonunion• Changes in joint (arthritic)

Issues to Consider

• Skin• Lesions• Prior incisions• Contractures

Imaging

• Radiographs• Weightbearing ankle xrays

• Asymmetry of the medial and lateral clear spaces• Talar tilt > 2mm• Talar subluxation• Lateralization of the talus• Eccentric joint space narrowing• Arthritic changes• Fibular shortening

Imaging

• Radiographs• Fibular shortening

• Compare to contralateral/uninjured side

75o-86o

Imaging

• Radiographs• Fibular shortening

• 3 criteria of normal distal fibular length

1. Equal jt space2. Intact Shenton line3. Unbroken curve

between lateral talus and peroneal groove

Imaging

• CT scan• Arthritic changes• Fibular shortening• Fibular rotational malunion• Syndesmotic widening

• >2mm difference b/t anterior & posterior distances from the fibula to the incisura

Management

• Nonoperative• NSAIDS• Steroid injections• Activity modifications• Orthoses and braces

Surgical Plan

• Approach bone

• Osteotomy

• Mobilize bone

• Clean medial gutter

• Fixation

Approach

• Surgical approach

• Osteotomies• Fibular• Tibial• Supramalleolar

• Fixation• Ex-fix• Internal fixation• Combo

• Bone grafts (auto and allografts) and orthobiologics

Case 1

• Mid 50s diabetic

• Diagnosed with “the gout”

Case 1

Varus malunion

Flexion malunion

Case 1

• Fibular and tibial osteotomy• Biplanar

• MAC ex-fix• “multiaxial compression”

Case 1

Case 1

Case 1

1 yr post-op

Walking

Pain free

No assistive device

Case 2

• Fibular shortening – courtesy of Dr. Kadakia

Case 2

Case 2

Case 2

Literature

• Fibular osteotomy• 1976 – Hughes, JBJS-A

• 28 cases fibular malunion lengthening• 22 VG/G• 6 Poor• No correlation

• Time since accident• Age of patient• Type initial treatment

Literature

• Malunited ankles• 1985 – Weber and Simpson• 23 cases

• 17 G/E• 6 Poor pre-existing arthritis

RE ECT

the ankle

the foot