Foot and Ankle Update

Transcription

1 Foot and Ankle Update 2019 Instructional Course Hiro Tanaka

2 It s your on-call weekend Objectives We are going to apply evidence based treatment for 2 patients who are admitted under your care 1. Dislocated trimalleolar fracture in a 38 year old male football player 2. Displaced ankle fracture in a 76 year old frail female

3 Prevent malunion = arthritis & pain Maintain function = ROM ankle and subtalar joints Treat soft tissues = no infection Displaced Trimalleolar fracture in a 38 year old male footballer

4 Why is Talar Shift bad? 1mm talar shift = 42% decreased tibio-talar contact surface area Ankle incongruity is poorly tolerated and results in abnormal loads on the articular cartilage

5 This is a soft tissue injury with an associated fracture

6 Should we be operating quickly?

7 Beware operating through blistered, swollen tissue

8 Span Scan Plan

9 Principles Half Pins Insert half pins away from Zone of Injury Use Safe Corridoor Do not compromise future fixation

10 Principles Safe Zones

11 Principles Calcaneal Pin Insert Steinman / Denham pin from medial to lateral Lateral side Sural nerve and peroneal tendons at risk Medial side Artery and medial calcaneal branch of tibial nerve Use blunt dissection

12 Principles Ligamentotaxis

13 Principles Final construct Aim for Delta Frame (triangle) Add in metatarsal pin for further stability and keep ankle in neutral Careful of Tibialis Anterior and EHL

14 14

15 Posterior malleolus Indication for fixation? Size Instability Syndesmosis Joint impaction

16 Does size matter? Schiedt 1992 JOT Vrahas 1994 JOT / Raasch 1992 JBJS Hartford 1995 CORR (key reference)

17 Pathoanatomy

18 Why CT Posterior Malleolar fractures?

19 Joint impaction

20 Which technique? Front or back?

21 AP screws

22 Posterolateral approach Direct visualization of fracture Removal of joint impaction fragments More robust fixation Posterior antiglide fixation of lateral side

23 Positioning Prone Good visualisation, difficult MM access Lateral Lazy lateral

24 Interval PB and FHL

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26 Antiglide fixation for Weber B fractures

27 Clinical evidence for posterolateral approach Type 1 fracture -> Posterior fixation Type 2 fracture -> Medial fixation Type 3 fracture -> Syndesmotic stabilisation

28 No 1 priority for high energy ankle fracture is soft tissue management Key Points Urgent Span, Scan and Plan Wait days til soft tissue resolution Fixation method depends on CT configuration of Posterior Malleolar fracture

29 Displaced ankle fracture in a 76 year old frail lady 29

30 Why is there Talar Shift? Deep deltoid ligament rupture or medial malleolar fracture results in talar shift

31 Why does this happen? Malunion Non-union Failure

32 Should we be operating? Yes Better functional outcome (Operative) No Better functional outcome (non-operative) Twice the mortality with non-operative treatment

33 Tibio-talar-calcaneal nail Very stable construct. Allows early mobilization Minimises soft tissue damage Technically difficult operation

34 Pro-tibia locking plate Locking plate with multiple syndesmotic screws Very stable construct. Allows early mobilization More soft tissue damage Technically easier operation

35 Clinical evidence? Higher complications and reoperations in the IMN group Recommend Pro-tibia fixation if soft tissues allow

36 Ankle fracture treatment in the elderly has to be patient specific considering co-morbidities, bone quality and mobility Key Points Poor mobility and high co-morbidity Best with conservative treatment Good mobility with poor soft tissues e.g diabetic Hindfoot nail Otherwise Pro-tibia fixation