Foot and Ankle Update 2019 Instructional Course Hiro Tanaka
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
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
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
This is a soft tissue injury with an associated fracture
Should we be operating quickly?
Beware operating through blistered, swollen tissue
Span Scan Plan
Principles Half Pins Insert half pins away from Zone of Injury Use Safe Corridoor Do not compromise future fixation
Principles Safe Zones
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
Principles Ligamentotaxis
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
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Posterior malleolus Indication for fixation? Size Instability Syndesmosis Joint impaction
Does size matter? Schiedt 1992 JOT Vrahas 1994 JOT / Raasch 1992 JBJS Hartford 1995 CORR (key reference)
Pathoanatomy
Why CT Posterior Malleolar fractures?
Joint impaction
Which technique? Front or back?
AP screws
Posterolateral approach Direct visualization of fracture Removal of joint impaction fragments More robust fixation Posterior antiglide fixation of lateral side
Positioning Prone Good visualisation, difficult MM access Lateral Lazy lateral
Interval PB and FHL
Antiglide fixation for Weber B fractures
Clinical evidence for posterolateral approach Type 1 fracture -> Posterior fixation Type 2 fracture -> Medial fixation Type 3 fracture -> Syndesmotic stabilisation
No 1 priority for high energy ankle fracture is soft tissue management Key Points Urgent Span, Scan and Plan Wait 10-14 days til soft tissue resolution Fixation method depends on CT configuration of Posterior Malleolar fracture
Displaced ankle fracture in a 76 year old frail lady 29
Why is there Talar Shift? Deep deltoid ligament rupture or medial malleolar fracture results in talar shift
Why does this happen? Malunion Non-union Failure
Should we be operating? Yes Better functional outcome (Operative) No Better functional outcome (non-operative) Twice the mortality with non-operative treatment
Tibio-talar-calcaneal nail Very stable construct. Allows early mobilization Minimises soft tissue damage Technically difficult operation
Pro-tibia locking plate Locking plate with multiple syndesmotic screws Very stable construct. Allows early mobilization More soft tissue damage Technically easier operation
Clinical evidence? Higher complications and reoperations in the IMN group Recommend Pro-tibia fixation if soft tissues allow
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