Ankle fracture spur sign is pathognomonic for a variant ankle fracture

Advances in the Surgical Management of Ankle Fractures

Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair.

LEVEL OF EVIDENCE

Level V, expert opinion.

Clinical Outcomes of Hyperplantarflexion Variant Compared With Supination External Rotation Ankle Fractures: A Matched-Cohort Analysis

Recent literature has reported an uncategorized hyperplantarflexion variant ankle fracture characterized by a posteromedial fragment separate from the posterior or medial malleolar fragments. The current study sought to determine whether the outcomes for surgically treated hyperplantarflexion variant fractures are similar to the more common supination external rotation (SER) IV fractures. A prospective registry of operatively treated ankle fractures was queried to create 2 age- and gender-matched cohorts: hyperplantarflexion variant and SER IV fractures. Each cohort had 23 patients (18 females), and matched pairs were within 2 years of age at the date of surgery. Patient demographics, comorbidities, and Foot and Ankle Outcomes Scores at minimum 12 months after the index surgery were compared. The cohorts were similar with respect to body mass index, the length of the clinical follow-up, medical comorbidities, dislocation rate, and postoperative articular incongruity (p > .05). Patient-reported outcomes demonstrated no statistically or clinically significant differences within any domain and were as follows: symptoms (70.8 versus 77.8, p = .11), pain (80.7 versus 85.0, p = .33), activities of daily living (83.7 versus 89.2, p = .23), sports (67.4 versus 73.4, p = .33), and quality of life (57.3 versus 63.9, p = .24) for the hyperplantarflexion and SER IV groups, respectively. No significant differences were found in the rang`e of motion for dorsiflexion (17.7° versus 18.1°, p = .52) or for plantarflexion (48.6° versus 47.1°, p = .71). Patients treated surgically for hyperplantarflexion variant ankle fractures have similar 1-year clinical outcomes when compared with the more common SER IV fracture patterns, provided that the injury is correctly identified preoperatively and treated appropriately.

Posterior malleolus exposure

Objectives

Posterior malleolus (PM) fractures are common in rotational ankle injuries, tibial plafond fractures, and distal third tibia fractures. Surgical indications continue to evolve as we improve our understanding of ankle and syndesmotic stability. These fractures remain technically challenging with respect to both exposure and fixation. Our biomechanical cadaveric study compared posterolateral versus modified posteromedial surgical approaches to define the following: maximal surface area exposed, and maximal screw trajectory obtainable for fixation.

Methods

Twelve fresh-frozen cadaver limbs were thawed at room temperature. Posterolateral and modified posteromedial approaches were performed on each limb. Margins of exposure were marked. A 2.5 mm drill was advanced at the extreme medial and lateral extents of each exposure, standardized at 1 cm proximal to the joint line and perpendicular to the bone. Computed tomography (CT) scans were performed to identify the maximal trajectory. Limbs were stripped of soft tissue, and the exposed bony surface area was measured using a validated laser surface-scanning technique.

Results

The modified posteromedial approach allowed for a larger exposed surface area compared to the posterolateral exposure (median 99% vs 64%, respectively; P < .05). The modified posteromedial approach allowed for instrumentation of up to a median of 77% of the posterior distal tibia as opposed to 46% through the posterolateral approach (P < .05).

Conclusion

The modified posteromedial approach allowed for increased exposure and wider access for instrumentation of the PM when compared to the posterolateral approach. We advocate use of this approach when addressing complex PM fractures, in particular the Haraguchi type 2 fracture pattern.

Posterior Malleolar Fractures: Changing Concepts and Recent Developments

Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.