- Email: [email protected]
Revision of malunited ankle fractures
Clin Podiatr Med Surg 21 (2004) 385 – 391
Revision of malunited ankle fractures Toby Branfoot, MB BS, FRCSEd (Tr & Orth), FIMC RCSEd, MSc, DA(UK), Dip Orth Tech St. James’s University Teaching Hospital, Beckett Street, Leeds LS9 7TF, UK
‘‘Ankle’’ fractures may be rotational injuries of the malleoli characterized in the Lauge-Hansen or Danis-Weber classifications, or axial compression-shear pilon fractures of the distal tibia. The treatment of malleolar ankle fractures is often straightforward [1], with some successfully treated conservatively [2,3] and operative reduction and stabilization providing good results [4– 6] even in the elderly [7] if a fully congruent mortise and a level joint line is achieved [8]. The final result depends on the type of fracture sustained and the treatment applied [9]; results are poor when these treatment objectives are not achieved [10]. Medial malleolar involvement tends to indicate poorer results [11], as does a trimalleolar fracture with a large (greater than 25% of the joint surface) posterior malleolar fragment [12]. Poor results following ankle fracture are also associated with nonunion or malunion [13 – 16], often leading to chronic pain [17]. Malunion of the fibula without restoration of anatomical alignment leads to talar tilt and degenerative arthritis [18]. Occasionally problems are the result of partial growth arrest following childhood injuries, leading to a progressive malorientation of the joint line [19]. Malunion may occur in the fibula or medial malleolar fragments, either by inadequate reduction at initial treatment (conservative or operative) or by failure to stabilize the reduction achieved surgically or in a cast. When fibular shortening is present, ankle reconstruction can be achieved by fibular lengthening and can provide an alternative to early arthrodesis for deformity and pain [20]. Good results have been reported even a long time after injury and in the presence of arthrosis [21,22], although the results of correction are poorer if this procedure is delayed [23]. It is far more preferable to restore a malunited ankle to a functional level than to allow the patient to continue to experience pain and to wait until degenerative arthritis requires that an arthrodesis be performed [24]. Arthrodesis as a salvage procedure is notorious, complications after tibiotalar arthrodesis involve nonunion, malunion, infection, and wound breakdown with reported rates
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of up to 50% [25 – 27]. More recently, distraction arthroplasty or ankle replacement may be worth considering [28].
Assessment With ankle fractures, one must decide whether the joint is salvageable. If there are not extensive degenerate changes present, then revision of the fixation to achieve anatomical alignment is recommended. An osteotomy of the fibula may be required if it is malunited. Age and arthrosis are not contraindications [29], even if this procedure allows only for an easier arthrodesis subsequently [30]. Significant improvements in ankle scoring have been reported in patients following this approach [30,31]. Assessment of the malunion should address the following:
Fibula malunion or nonunion? Medial malleolus malunion or nonunion? Posterior malleolus malunion or nonunion? Widening of the mortise or talar tilt? Loose bodies? Nonunion of the fibula may occur and be painful [23,32]. Malunion of the fibula is typically shortening or external rotation [33]. Two mm of shortening or 5 degrees of external rotation leads to abnormal tibiotalar joint contact pressures [34], with 30 degrees of external rotation reducing tibial-talar surface contact by one third [35]. This increased joint contact pressure may lead to degenerate changes developing [20], although other factors may be involved [36]. Restoration of fibular length, necessary for a good clinical result, can be estimated radiographically by the bimalleolar angle [20]. Posterior malloeli fractures of more than 25% of the articular surface are potentially significant if malunited [12], but a satisfactory reduction and stability is often achieved by reduction and fixation of the fibula alone [37]. Not all Weber C fractures are associated with disruption of the syndesmosis [38], but if there is diastasis, this must be corrected. It is most commonly seen in severe Weber C injuries [39,40]. There may be talar shift associated with fibula malunion, but this may not be apparent on plain radiographs [41] and should be evaluated by CT scan if suspected [42]. Malreduction of the fibula can result in symptomatic malreduction of the syndesmosis [43]. If malalignment of the ankle is suspected, weight-bearing plain films of the foot and tibia, including long-leg alignment films, should be obtained to evaluate the joint angle and the mechanical axis [44 – 47]. Other diagnoses for pain and problems following an ankle fracture should be considered, including synovitis [48], loose bodies, osteochondral injuries [49], ligament tears [50], and synovial impingement [51,52]. Further imaging of the ankle using ultrasound [53,54], MRI [55,56] (standard, or with MR arthrography
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[57]), or arthroscopy [58] should be used if the history or examination suggest these problems. Comorbidities must be considered. There is a high incidence of complications following surgery for ankle fractures in diabetics, and malunions in such patients may be asymptomatic [59].
Operative management Malunion of the fibula can be addressed by revision of the fixation or an osteotomy, which can be horizontal, oblique (re-creating the old fracture) [60], or Z shaped [61]. Restoration of the correct length [62] and rotation is achieved,
Fig. 1. A malunited ankle at presentation, and after revision.
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sometimes with the addition of iliac crest bone graft [60], and stabilized with a compression plate (Fig. 1)[33,63,64]. A diastasis must be reduced by correction of the fibula reduction if malaligned, and by exploration or debridement of soft tissues, initially at the tibiofibular syndesmosis and then medially if they prevent restoration of the mortise [23]. One [42,65] or two [60] diastasis screws (3.5 or 4.5 mm), or a synthetic suture [66], should be used to stabilize the syndesmosis 2 cm above the tibiotalar joint [67]. Anatomical reduction is the vital step here; ankle position during tightening is no longer thought to be important [68]. A weak anterior tibiofibular ligament can be reinforced with plantaris or a split peroneous longus tendon graft [69,70]. The joint may be debrided through an arthrotomy in the same procedure [29,30]. It has been suggested that chondral lesions and the remains of torn ligaments can be the cause of symptoms of syndesmosis instability, rather than ligament laxity [50]. Open arthrotomy or arthroscopic assessment with possible debridement should be considered [71]. Loose bodies can be similarly removed [72]. Displacement of the posterior malleolus fragment may be significant if it comprises 25% or more of the joint surface. Late corrective osteotomy can lead to significant improvements in patients’ pain and function [73]. This may be performed through a posterolateral or transfibula approach [60]. Significant joint malalignment after fracture can be treated by realignment osteotomy with internal fixation [74] or Ilizarov techniques [19,75,76] to restore normal ankle biomechanics and minimize further degenerative changes [77,78]. Callotasis procedures using a circular frame will allow weight bearing during the healing phase and are not associated with the shortening created by closingwedge osteotomies. Subtle postoperative adjustments to the foot’s position can be made, which are not possible after internal fixation using a plate.
Summary Malunion of an ankle fracture can lead to considerable pain and loss of function. Restoration of the normal anatomical alignments can restore function and minimize the onset of degeneration that will lead to severe arthrosis requiring an arthrodesis.
References [1] Miller SD. Controversies in ankle fracture treatment. Indications for fixation of stable Weber type B fractures and indications for syndesmosis stabilization. Foot Ankle Clin 2000;5(4):841 – 51. [2] Bauer M, Bergstrom B, Hemborg A, Sandegard J. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clin Orthop 1985;199:17 – 27. [3] Hughes JL, Weber H, Willenegger H, Kuner EH. Evaluation of ankle fractures: non-operative and operative treatment. Clin Orthop 1979;138:111 – 9. [4] Makwana NK, Bhowal B, Harper WM, Hui AW. Conservative versus operative treatment for
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[29] Marti R, Raaymakers EL. Secondary interventions in malunited fractures of the ankle joint. Orthopade 1990;19(6):400 – 8. [30] Cheng YM, Huang PJ, Chen SK, Tien YC, Lin SY, Chen LH, et al. Salvage operation for neglected ankle fractures. Kaohsiung J Med Sci 1997;13(10):618 – 25. [31] Chiu FY, Wong CY, Chen TH, Lo WH. Delayed treatment of ankle fracture. Zhonghua Yi Xue Za Zhi [Taipei] 1994;53(4):233 – 7. [32] Millard IL. Painful non-union of lateral malleolus fractures: three case reports. J Ark Med Soc 1980;76(1):332 – 4. [33] Davis JL, Giacopelli JA. Transfibular osteotomy in the correction of ankle joint incongruity. J Foot Ankle Surg 1995;34(4):389 – 99. [34] Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg [Am] 1997;79(12):1809 – 15. [35] Curtis MJ, Michelson JD, Urquhart MW, Byank RP, Jinnah RH. Tibiotalar contact and fibular malunion in ankle fractures. A cadaver study. Acta Orthop Scand 1992;63(3):326 – 9. [36] Vrahas M, Fu F, Veenis B. Intraarticular contact stresses with simulated ankle malunions. J Orthop Trauma 1994;8(2):159 – 66. [37] Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg [Am] 1988; 70(9):1348 – 56. [38] Harris IA, Jones HP. The fate of the syndesmosis in type C ankle fractures: a cadaveric study. Injury 1997;28(4):275 – 7. [39] Mosier-LaClair S, Pike H, Pomeroy G. Syndesmosis injuries: acute, chronic, new techniques for failed management. Foot Ankle Clin 2002;7(3):551 – 65. [40] Pankovich AM. Fractures of the fibula proximal to the distal tibiofibular syndesmosis. J Bone Joint Surg [Am] 1978;60(2):221 – 9. [41] Yablon IG, Leach RE. Reconstruction of malunited fractures of the lateral malleolus. J Bone Joint Surg [Am] 1989;71(4):521 – 7. [42] Harper MC. Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22(1):15 – 8. [43] Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg [Am] 1984;66(4):490 – 503. [44] Chao EY, Neluheni EV, Hsu RW, Paley D. Biomechanics of malalignment. Orthop Clin North Am 1994;25(3):379 – 86. [45] Paley D, Tetsworth K. Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur. Clin Orthop 1992;280:48 – 64. [46] Paley D, Herzenberg JE, Tetsworth K, McKie J, Bhave A. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am 1994;25(3):425 – 65. [47] Tetsworth K, Paley D. Malalignment and degenerative arthropathy. Orthop Clin North Am 1994; 25(3):367 – 77. [48] Martin DF, Curl WW, Baker CL. Arthroscopic treatment of chronic synovitis of the ankle. Arthroscopy 1989;5(2):110 – 4. [49] Tol JL, Struijs PA, Bossuyt PM, Verhagen RA, van Dijk CN. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int 2000;21(2):119 – 26. [50] Ogilvie-Harris DJ, Reed SC. Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy 1994;10(5):561 – 8. [51] Bonnin M, Bouysset M. Arthroscopy of the ankle: analysis of results and indications on a series of 75 cases. Foot Ankle Int 1999;20(11):744 – 51. [52] Ogilvie-Harris DJ, Mahomed N, Demaziere A. Anterior impingement of the ankle treated by arthroscopic removal of bony spurs. J Bone Joint Surg [Br] 1993;75(3):437 – 40. [53] Fessell DP, van Hols beeck M. Ultrasound of the foot and ankle. Semin Musculoskelet Radiol 1998;2(3):271 – 82. [54] Rawool NM, Nazarian LN. Ultrasound of the ankle and foot. Semin Ultrasound CT MR 2000; 21(3):275 – 84.
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[55] Erickson SJ, Johnson JE. MR imaging of the ankle and foot. Radiol Clin North Am 1997; 35(1):163 – 92. [56] Recht MP, Donley BG. Magnetic resonance imaging of the foot and ankle. J Am Acad Orthop Surg 2001;9(3):187 – 99. [57] Kramer J, Recht MP. MR arthrography of the lower extremity. Radiol Clin North Am 2002; 40(5):1121 – 32. [58] Rasmussen S, Hjorth JC. Arthroscopic treatment of impingement of the ankle reduces pain and enhances function. Scand J Med Sci Sports 2002;12(2):69 – 72. [59] McCormack RG, Leith JM. Ankle fractures in diabetics. Complications of surgical management. J Bone Joint Surg [Br] 1998;80(4):689 – 92. [60] Hansen ST. Nonunions, malunions and avascular necrosis. In: Hansen Jr ST, editor. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott Williams & Wilkins; 2000. p. 123 – 44. [61] Weber D, Friederich NF, Muller W. Lengthening osteotomy of the fibula for post-traumatic malunion. Indications, technique and results. Int Orthop 1998;22(3):149 – 52. [62] Weber BG. Lengthening osteotomy of the fibula to correct a widened mortice of the ankle after fracture. Int Orthop 1981;4(4):289 – 93. [63] Dehne R, Connolly JF. Fibular lengthening to correct a malunited ankle fracture. Nebr Med J 1986;71(11):404 – 6. [64] Ward AJ, Ackroyd CE, Baker AS. Late lengthening of the fibula for malaligned ankle fractures. J Bone Joint Surg [Br] 1990;72(4):714 – 7. [65] Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle 1989;9(6):290 – 3. [66] Seitz Jr WH, Bachner EJ, Abram LJ, Postak P, Polando G, Brooks DB, et al. Repair of the tibiofibular syndesmosis with a flexible implant. J Orthop Trauma 1991;5(1):78 – 82. [67] McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int 1997;18(5):262 – 6. [68] Tornetta III P, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg [Am] 2001;83(4):489 – 92. [69] Grass R, Rammelt S, Biewener A, Zwipp H. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int 2003;24(5):392 – 7. [70] Sefton GK, George J, Fitton JM, McMullen H. Reconstruction of the anterior talofibular ligament for the treatment of the unstable ankle. J Bone Joint Surg [Br] 1979;61(3):352 – 4. [71] Reynaert P, Gelen G, Geens G. Arthroscopic treatment of anterior impingement of the ankle. Acta Orthop [Belg] 1994;60(4):384 – 8. [72] van Dijk CN, Scholte D. Arthroscopy of the ankle joint. Arthroscopy 1997;13(1):90 – 6. [73] Weber M, Ganz R. Malunion following trimalleolar fracture with posterolateral subluxation of the talus—reconstruction including the posterior malleolus. Foot Ankle Int 2003;24(4): 338 – 44. [74] Mangone PG. Distal tibial osteotomies for the treatment of foot and ankle disorders. Foot Ankle Clin 2001;6(3):583 – 97. [75] Paley D. The correction of complex foot deformities using Ilizarov’s distraction osteotomies. Clin Orthop 1993;293:97 – 111. [76] Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the femur and tibia by detailed preoperative planning and the Ilizarov techniques. Orthop Clin North Am 1990;21(4):667 – 91. [77] Stamatis ED, Myerson MS. Supramalleolar osteotomy: indications and technique. Foot Ankle Clin 2003;8(2):317 – 33. [78] Tetsworth KD, Paley D. Accuracy of correction of complex lower-extremity deformities by the Ilizarov method. Clin Orthop 1994;301:102 – 10.
Revision of malunited ankle fractures Toby Branfoot, MB BS, FRCSEd (Tr & Orth), FIMC RCSEd, MSc, DA(UK), Dip Orth Tech St. James’s University Teaching Hospital, Beckett Street, Leeds LS9 7TF, UK
‘‘Ankle’’ fractures may be rotational injuries of the malleoli characterized in the Lauge-Hansen or Danis-Weber classifications, or axial compression-shear pilon fractures of the distal tibia. The treatment of malleolar ankle fractures is often straightforward [1], with some successfully treated conservatively [2,3] and operative reduction and stabilization providing good results [4– 6] even in the elderly [7] if a fully congruent mortise and a level joint line is achieved [8]. The final result depends on the type of fracture sustained and the treatment applied [9]; results are poor when these treatment objectives are not achieved [10]. Medial malleolar involvement tends to indicate poorer results [11], as does a trimalleolar fracture with a large (greater than 25% of the joint surface) posterior malleolar fragment [12]. Poor results following ankle fracture are also associated with nonunion or malunion [13 – 16], often leading to chronic pain [17]. Malunion of the fibula without restoration of anatomical alignment leads to talar tilt and degenerative arthritis [18]. Occasionally problems are the result of partial growth arrest following childhood injuries, leading to a progressive malorientation of the joint line [19]. Malunion may occur in the fibula or medial malleolar fragments, either by inadequate reduction at initial treatment (conservative or operative) or by failure to stabilize the reduction achieved surgically or in a cast. When fibular shortening is present, ankle reconstruction can be achieved by fibular lengthening and can provide an alternative to early arthrodesis for deformity and pain [20]. Good results have been reported even a long time after injury and in the presence of arthrosis [21,22], although the results of correction are poorer if this procedure is delayed [23]. It is far more preferable to restore a malunited ankle to a functional level than to allow the patient to continue to experience pain and to wait until degenerative arthritis requires that an arthrodesis be performed [24]. Arthrodesis as a salvage procedure is notorious, complications after tibiotalar arthrodesis involve nonunion, malunion, infection, and wound breakdown with reported rates
E-mail address: [email protected] 0891-8422/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cpm.2004.03.001
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of up to 50% [25 – 27]. More recently, distraction arthroplasty or ankle replacement may be worth considering [28].
Assessment With ankle fractures, one must decide whether the joint is salvageable. If there are not extensive degenerate changes present, then revision of the fixation to achieve anatomical alignment is recommended. An osteotomy of the fibula may be required if it is malunited. Age and arthrosis are not contraindications [29], even if this procedure allows only for an easier arthrodesis subsequently [30]. Significant improvements in ankle scoring have been reported in patients following this approach [30,31]. Assessment of the malunion should address the following:
Fibula malunion or nonunion? Medial malleolus malunion or nonunion? Posterior malleolus malunion or nonunion? Widening of the mortise or talar tilt? Loose bodies? Nonunion of the fibula may occur and be painful [23,32]. Malunion of the fibula is typically shortening or external rotation [33]. Two mm of shortening or 5 degrees of external rotation leads to abnormal tibiotalar joint contact pressures [34], with 30 degrees of external rotation reducing tibial-talar surface contact by one third [35]. This increased joint contact pressure may lead to degenerate changes developing [20], although other factors may be involved [36]. Restoration of fibular length, necessary for a good clinical result, can be estimated radiographically by the bimalleolar angle [20]. Posterior malloeli fractures of more than 25% of the articular surface are potentially significant if malunited [12], but a satisfactory reduction and stability is often achieved by reduction and fixation of the fibula alone [37]. Not all Weber C fractures are associated with disruption of the syndesmosis [38], but if there is diastasis, this must be corrected. It is most commonly seen in severe Weber C injuries [39,40]. There may be talar shift associated with fibula malunion, but this may not be apparent on plain radiographs [41] and should be evaluated by CT scan if suspected [42]. Malreduction of the fibula can result in symptomatic malreduction of the syndesmosis [43]. If malalignment of the ankle is suspected, weight-bearing plain films of the foot and tibia, including long-leg alignment films, should be obtained to evaluate the joint angle and the mechanical axis [44 – 47]. Other diagnoses for pain and problems following an ankle fracture should be considered, including synovitis [48], loose bodies, osteochondral injuries [49], ligament tears [50], and synovial impingement [51,52]. Further imaging of the ankle using ultrasound [53,54], MRI [55,56] (standard, or with MR arthrography
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387
[57]), or arthroscopy [58] should be used if the history or examination suggest these problems. Comorbidities must be considered. There is a high incidence of complications following surgery for ankle fractures in diabetics, and malunions in such patients may be asymptomatic [59].
Operative management Malunion of the fibula can be addressed by revision of the fixation or an osteotomy, which can be horizontal, oblique (re-creating the old fracture) [60], or Z shaped [61]. Restoration of the correct length [62] and rotation is achieved,
Fig. 1. A malunited ankle at presentation, and after revision.
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T. Branfoot / Clin Podiatr Med Surg 21 (2004) 385–391
sometimes with the addition of iliac crest bone graft [60], and stabilized with a compression plate (Fig. 1)[33,63,64]. A diastasis must be reduced by correction of the fibula reduction if malaligned, and by exploration or debridement of soft tissues, initially at the tibiofibular syndesmosis and then medially if they prevent restoration of the mortise [23]. One [42,65] or two [60] diastasis screws (3.5 or 4.5 mm), or a synthetic suture [66], should be used to stabilize the syndesmosis 2 cm above the tibiotalar joint [67]. Anatomical reduction is the vital step here; ankle position during tightening is no longer thought to be important [68]. A weak anterior tibiofibular ligament can be reinforced with plantaris or a split peroneous longus tendon graft [69,70]. The joint may be debrided through an arthrotomy in the same procedure [29,30]. It has been suggested that chondral lesions and the remains of torn ligaments can be the cause of symptoms of syndesmosis instability, rather than ligament laxity [50]. Open arthrotomy or arthroscopic assessment with possible debridement should be considered [71]. Loose bodies can be similarly removed [72]. Displacement of the posterior malleolus fragment may be significant if it comprises 25% or more of the joint surface. Late corrective osteotomy can lead to significant improvements in patients’ pain and function [73]. This may be performed through a posterolateral or transfibula approach [60]. Significant joint malalignment after fracture can be treated by realignment osteotomy with internal fixation [74] or Ilizarov techniques [19,75,76] to restore normal ankle biomechanics and minimize further degenerative changes [77,78]. Callotasis procedures using a circular frame will allow weight bearing during the healing phase and are not associated with the shortening created by closingwedge osteotomies. Subtle postoperative adjustments to the foot’s position can be made, which are not possible after internal fixation using a plate.
Summary Malunion of an ankle fracture can lead to considerable pain and loss of function. Restoration of the normal anatomical alignments can restore function and minimize the onset of degeneration that will lead to severe arthrosis requiring an arthrodesis.
References [1] Miller SD. Controversies in ankle fracture treatment. Indications for fixation of stable Weber type B fractures and indications for syndesmosis stabilization. Foot Ankle Clin 2000;5(4):841 – 51. [2] Bauer M, Bergstrom B, Hemborg A, Sandegard J. Malleolar fractures: nonoperative versus operative treatment. A controlled study. Clin Orthop 1985;199:17 – 27. [3] Hughes JL, Weber H, Willenegger H, Kuner EH. Evaluation of ankle fractures: non-operative and operative treatment. Clin Orthop 1979;138:111 – 9. [4] Makwana NK, Bhowal B, Harper WM, Hui AW. Conservative versus operative treatment for
T. Branfoot / Clin Podiatr Med Surg 21 (2004) 385–391
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