Ankle Fracture in the Athlete: Should I scope? What about the Deltoid? Do I have to repair? DAVID A PORTER, MDPHD METHODIST SPORTS MEDICINE/THE ORTHOPEDIC SPECIALISTS 201 PENNSYLVANIA PKWY INDIANAPOLIS, IN F/A CONSULTANT TO: INDIANAPOLIS COLTS, INDIANA U, PURDUE U, U OF INDPLS DPORTER@METHODISTSPORTS.COM Should I scope the ankle when fixing ankle fractures? Purpose: Do I need to scope all ankle fractures? 1. If you are proficient with ankle arthroscopy, then scope 2. If not, no study to date has shown clear advantage in outcomes with scope 3. Visualization is 1 o advantage 4. Learning curve, Sports MD know scope, Trauma docs do more fractures. 5. Sports F/A scope more ankle fx PROS - More extensive and better visualization - Chondral and fx reduction - Can treat loose bodies, OCL and soft tissue CONS - more time consuming 15-30 min extra - Technically demanding Introduction: Ankle fractures in the Athlete 1. 10 to15% of all athletic injuries occur at the ankle joint 2. Ankle fractures result from higher energy sports trauma 3. Fractures require displacement of the joint including dislocation 4. The risk for associated cartilage injury is high with fractures 5. Little has been written re: ankle fractures in the Athlete* 6. High rate of disability possible after ankle frx in the Athlete
*Porter, et al. Functional Outcome after Operative Treatment for Distal Fibula and Tibia Fractures in Young Athletes: FAI 2008 What does the Literature say? 1. Thordardson, 9 pts FAI 01 10 control group not scoped -8/9 fractures had chondral injury 89% -Compared to fracture tx without scope (n=10) -No difference in outcome, scope/no-scope 2. Ferkel, 48 pts Arthroscopy 02-63% chondral or OCL lesions -Treatment of lesion at time of surgery -Inc cartilage injury with synd tear 3. Ono, 105 pts Arthroscopy 04-20% chondral injuries -Shaving and loose body removal -Arthroscopic visualization of fx reduction -No true outcome eval undertaken 4. Leontaritis, 83 pts JBJS 09 More severe fracture pattern more intra-articular diagnostic value and better intra-articular frature pattern and severity, visualize reduction -20%-89% chondral injury with ankle fracture -Higher incidence with dislocation w/ fracture Scope Pictures, can see better than open
How do I scope the ankle with fracture care? 1. Can use leg holder and do scope and fx -Unilateral lithotomy leg 2. Can do set up for ankle fracture and then scope -Large bump under knee 3. I still use pump, quick scope, min deb, visualization and tx OCL 4. Remove loose bodies, cartilage 5. Standard anterior portals, posterior portals not typically necessary 6. Video What about the Deltoid? Do I have to repair it with ankle fractures? 1. More interest in fixing now. 2. If not, no study to date has shown clear advantage in outcomes with repair of the deltoid vs cast and non-weight bearing for non-op tx Deltoid 3. Sports F/A doing more 1 o repair 4. Trauma literature shows interest in early WB and early ROM 5. Repair may allow more early ROM/WB 6. Must suture deep deltoid before fixing lateral side, access, +/- anchors A PROS 1. More assurance of healing and stability-poor reconstruction of deltoid if chronic 2.? Earlier ROM and WB, interest 3. Dec stiffness with early ROM 4. Can visualize medial joint surface 5. Can treat loose bodies, OCL
B CONS 6. more time consuming, 15-20 min extra 7. Technically demanding for the deep deltoid 8. Must repair deep deltoid before lateral ORIF 9. Another incision EXTERNAL ROTATION LIGAMENT INJURY 1. Hinterman Medial Ankle Instability - Stage I-nonoperative Stage II- Brostrom - Stage III- II tx plus correct pron and PTT adv - Stage IV- TN arthrodeses 2. Why Deltoid does bad? 3. MCL knee = ATFL & CFL ankle 4. LCL knee = Deltoid ankle (tension side) 5. Varus knee thrust with ambulation, valgus ankle stress with weight-bearing midstance 6. Pronation of foot/ankle is normal 1. Baird JBJS 87 and Stromsoe 95 JBJS Not necessary to repair deltoid????? Casted? 2. Hsu FAI, Jones JOT, Yu, JFAS all 2015 HSU repair super. Deltoid in NFL ankle fractures Jones repair deltoid better than Synd screw in ankle fx Yu multicenter study repair effect way to avoid late instab. 3. Again, if. cast may not have advantage 4. If want to do early ROM and WB repair may protect for late instability 5. No clear science on approach, F/A sports tending toward repair. ANTERIOR DELTOID 1. CAN HAVE CONCOMMITANT MEDIAL AND LATERAL INSTABILITY BUT NOT COMMON with ligaments but common with ankle fracture (bony instab laterally) 2. MRI can visulaize DELTOID FIBERs medially and determine if rutpure 3. ANTERIOR DELTOID RESPONSIBLE FOR ER STABILTY 4. CAN BE REPAIRED, EVEN IF LATERAL SIDE OK 5. EXAM AND MECHANISM OF INJURY IMPORTANT TO HELP DISTINGUISH 6. STRESS XRAYS IF ANY DOUBT
BIBLIOGRAPHY Arthroscopy with Ankle fractures: Amendola, A, et al Ankle Arthroscopy: Outcomes in 79 consecutive patients. Arthroscopy vol 12 (5):565-573. 1996 Atesok, K, et al Arthroscopy-assisted fracture fixation. Knee Surg Sports Traumatol Arthrosc 19:320-329, 2011 Bonasia, D, et al. the Role of Arthroscopy in the Management of Fractures about the Ankle. JAAOS:226-235, 2011 Loren, G and Ferkel, R, Arthroscopic Assessment of Occult Intra-articular Injury in Acute Ankle Fractures. Arthroscopy 18(4):412-421, 2002 Leontartius, N, et al. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. JBJS Am 91:333-339, 2009 Nosewiscz, T, et al Prospective Computed Tomography Analysis of Osteochondral Lesions of the Ankle Joint Associated with Ankle Fractures. FAI 37(8):829-834, 2016. Ono, A, et al. Arthroscopically assisted treatment of ankle fractures: arthroscopic findings and surgical outcomes. Arthroscopy 20:627-631, 2004 Thordardson, DB, et al. The role of ankle arthroscopy on the surgical management of ankle fractures. FAI 22:123-125. Deltoid Repair with ankle Fractures
Baird, R and Jackson, ST, Fractures of the dial part of the fibula with associated disruption of the deltoid ligament. Treatment without repair of the deltoid ligament. JBJS Am 69(9):1346-52, 1987 Hsu, A, et al. Repair of acute superficial deltoid complex avulsion during ankle fracture fixation in National Football League Players. FAI 36(11):1272-8, 2015 Jones, C and Nunley, J Deltoid ligament repair versus sundesmotic fixation in bimalleolar equivalent ankle fractures. J Ortho Trauma 29(5):245-9, 2015. Stromsoe, K, et al. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. JBJS 77(6):920-1, 1995 Stufkens, S, et al. the diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strat Traum Limb Recon 7:73-85, 2012 Yu, G, etal. Repair of the acute deltoid ligament complex rupture associated with ankle fractures: A multicenter study. J Foot Ankle Surg54(2):198-202, 2015