Lecture 40 parekh malunited ankle fracture
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Mehr von Selene G. Parekh, MD, MBA
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Lecture 40 parekh malunited ankle fracture
- 1. Malunited Ankle Fractures Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. 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
- 3. Malunited Ankle Fractures • Isolated lateral malleolar ankle fractures • Potts/Bimalleolar ankle fractures • Cotton/Trimalleolar ankle fractures • Syndesmotic injuries
- 4. Malunited Ankle Fractures • Shortening and lateral rotation of distal fibula • Widening of mortise, lateral tilt talus • Most common
- 5. Importance • 1 mm shift of the talus 42% reduction in the tibiotalar contact area increase stress on the articular cartilage • Serious and persistent dysfunction
- 6. Symptoms • Difficulty walking • Pain & edema • Cosmetic changes
- 7. Guidelines • Little in the literature to guide approaches and techniques • Anecdotal experiences • Cite literature where available
- 8. 3 Guiding Concepts • Restore alignment of the entire lower extremity • Restoration of the articular surface • Restoration of painless ankle motion
- 9. Preoperative Evaluation • History • Physical • Tenderness • ROM • Imaging • Xrays • CT • MRI • Nuclear medicine
- 10. Issues to Consider • Medical conditions • Diabetes, ESRD • Neuropathy • Dermal issues • Nicotine use • Bony issues • Alignment • Bony quality and nonunion • Changes in joint (arthritic)
- 11. Issues to Consider • Skin • Lesions • Prior incisions • Contractures
- 12. 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
- 13. Imaging • Radiographs • Fibular shortening • Compare to contralateral/uninjured side 75o-86o
- 14. Imaging • Radiographs • Fibular shortening • 3 criteria of normal distal fibular length 1. Equal jt space 2. Intact Shenton line 3. Unbroken curve between lateral talus and peroneal groove
- 15. 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
- 16. Management • Nonoperative • NSAIDS • Steroid injections • Activity modifications • Orthoses and braces
- 17. Surgical Plan • Approach bone • Osteotomy • Mobilize bone • Clean medial gutter • Fixation
- 18. Approach • Surgical approach • Osteotomies • Fibular • Tibial • Supramalleolar • Fixation • Ex-fix • Internal fixation • Combo • Bone grafts (auto and allografts) and orthobiologics
- 19. Case 1 • Mid 50s diabetic • Diagnosed with “the gout”
- 20. Case 1 Varus malunion Flexion malunion
- 21. Case 1 • Fibular and tibial osteotomy • Biplanar • MAC ex-fix • “multiaxial compression”
- 22. Case 1
- 23. Case 1
- 24. Case 1 1 yr post-op Walking Pain free No assistive device
- 25. Case 2 • Fibular shortening – courtesy of Dr. Kadakia
- 26. Case 2
- 27. Case 2
- 28. Case 2
- 29. 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
- 30. Literature • Malunited ankles • 1985 – Weber and Simpson • 23 cases • 17 G/E • 6 Poor pre-existing arthritis