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Percutaneous fixation of Maisonneuve and Maisonneuve-type fractures: a minimally invasive approach
Injury Vol. 29, No. 8, pp. 619±622, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0020-1383/98 $19.00 + 0.00
PII: S0020-1383(98)00149-1
Percutaneous fixation of Maisonneuve and Maisonneuve-type fractures: a minimally invasive approach E. M. H. Obeid, M. Amr, P. Hirst and A. S. Paul
The University Department of Orthopaedic Surgery, Manchester Royal Infirmary, Manchester, U.K.
We report five cases of Maisonneuve and Maisonneuve-type fractures which were treated with a single suprasyndesmotic percutaneous diastasis screw with good radiological and functional results. This is an effective and a minimally invasive procedure which we recommend. # 1998 Published by Elsevier Science Ltd. All rights reserved. Injury, Vol. 29, No. 8, 619±622, 1998
Introduction High fibular fracture with syndesmotic disruption is considered as an external rotation injury, or pronation eversion stage iii as described by LaugeHansen [1] and modified by Yde [2] and others [3]. Maisonneuve fracture of the fibula consists of a fracture of the proximal fibula proximal to the distal tibio±fibular joint which is associated with an ankle fracture or deltoid ligament rupture [4]. Several methods of treatment are described including nonoperative as well as various methods of surgical intervention [5].
Surgical technique The procedure is performed under anaesthesia with the patient supine on the operating table. Continuous X-ray screening is used. Manipulation is performed to reduce the syndesmosis. The foot is held in neutral dorsiflexion and the leg in internal rotation. Make a 1 cm incision on the lateral aspect of the distal fibula above the level of the syndesmosis (verify position by X-ray screening). Drill through three cortices into the fibula and tibia using a 2.5 mm drill bit from lateral to medial, or drill from
Figure 1. X-ray of the right ankle showing midshaft fibular fracture with lateral talar shift
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Injury: International Journal of the Care of the Injured Vol. 29, No. 8, 1998
posterolateral to anteromedial if the leg is held in the neutral position. Insert a 3.5 mm cortical screw of appropriate length after tapping. Do not engage the far tibial cortex. Verify position of the screw by X-ray screening. Close wound using steristrips. Apply plaster of Paris cast.
Case presentation Case one A 30 year old male, sustained an external rotation injury to his right foot resulting in a Maisonneuve fracture of the fibula with rupture of the medial ligament complex. He was treated with a single percutaneous suprasyndesmotic screw fixation, which completely stabilised the diastasis. The fixation was supported by a below knee plaster. The syndesmotic screw was removed at six weeks, and the patient was allowed to mobilise freely. Five month review showed a stable diastasis and ankle mortise with no talar shift. Case two A 23 year old male injured his right leg following a fall from a height, he sustained a Maisonneuve-type injury with rupture of the deltoid ligament and a spiral midshaft fibular fracture with talar shift
(Figure 1). A suprasyndesmotic percutaneous screw and a plaster cast were used (Figure 2). A review few months following removal of the diastasis screw revealed a stable ankle. Case three A 20 year old male patient sustained an eversion football injury to his right ankle resulting in a proximal fibular fracture with rupture of the medial ligament. This was treated along the same line of treatment of the previous cases. Six months follow up showed complete radiological healing of the fracture with no talar shift. Case four A 60 year old man was knocked down by a car. He sustained a displaced medial malleolar fracture with a midshaft short oblique fibular fracture with tibio± fibular diastasis. The skin over the medial malleolus was badly contused. This was treated by manipulation of the medial malleolus into an anatomical position, the fibula was stabilised with a single suprasyndesmotic percutaneous screw. This secured and stabilised the diastasis. A plaster cast was applied for six weeks. Further follow up showed complete healing of both fractures.
Figure 2. Post-operative X-ray showing a suprasyndesmotic screw fixation
Obeid et al.: Percutaneous fixation of Maisonneuve fractures
Case five A 36 year old man sustained a football injury to his left leg. X-ray revealed a Maisonneuve fracture of the proximal fibula with a displaced medial malleolar fracture and diastasis of the mortise . This was treated by percutaneous screw stabilisation of the diastasis and cancellous screw fixation of the medial malleolus through an open procedure (Figure 3). The diastasis screw was removed after six weeks. Six month following injury stress views of the ankle showed a stable ankle mortise (Figure 4).
Discussion A Maisonneuve fracture is a high fibular fracture which was described by Jaque Gilles Maisonneuve in 1840 [6]. In a cadaveric study he described a rupture of the medial collateral ligament or fracture of the medial malleolus with proximal third fibular fracture. Lauge-Hansen [1] classified it as an external rotation injury. In the Danis and Weber [7] classifi-
Figure 3. X-ray of the left tibia and fibula following fixation of a Maisonneuve fracture
621
cation it falls in the C-type category. It is considered as a type C3 by the AO-ASIF group [8]. There are variants of this injury, Slawski [9] reported a proximal fibular fracture associated with distal fibular fracture at the level of the tibiofibular syndesmosis. Pankovich [10] studied 17 cases of this injury, and classified it into five stages. He described two patterns; pronation external rotation and a less common supination external rotation. Treatment of Maisonneuve and Maisonneuve-type fracture varied. Merril [11] suggested that these are often more stable than generally assumed, and for injuries with only a partial syndesmosis disruption non-operative treatment is recommended. Lock et al. [12] recommended conservative treatment if no medial malleolar fracture was present and the medial joint line was not widened. Pankovich [10] described various methods of surgical treatment. Yoblin [13] restored the fibular length by traction through a towel clip at the lateral malleolus, and the reduction was then maintained with a suprasyndesmotic screw. Open reduction of the high fibular fracture is carried out if the fibular length could not be restored. De Sousa [14] suggested the following as the best sequence of treatment: (1) restoration of fibular length, (2) repair of the anterior tibiofibular ligament and (3) fixation of an associated posterior malleolar fracture if it involves 25% of the articular surface or more, and (4) when necessary open reduction and internal fixation of the fibula with screws and plate, and only then (5) use of suprasyndesmotic screw if instability is noted on stressing the repaired fibula. We report here a minimally invasive procedure. Three of the patients sustained a proximal fibular fracture with rupture of the deltoid ligament; these were treated by a single percutaneous suprasyndesmotic screw under X-ray control which closed the syndesmosis and restored the ankle mortise. This was supplemented with a short leg plaster cast. The fourth patient sustained a displaced medial malleolar fracture with an oblique mid fibular fracture. This was treated by manipulation of the medial malleolus and fixation of the fibula with a single suprasyndesmotic screw. The medial malleolus was not internally fixed due to the poor condition of the skin. This was also supplemented with a short leg cast. The fifth case (classic Maisonneuve fracture) was treated along the same line of treatment, the displaced medial malleolus was fixed though a medial incision. This method stabilises the diastasis, restores the ankle mortise, and minimises the talar shift which is considered to be the most important determining factor in the outcome of the functional result [15].
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Injury: International Journal of the Care of the Injured Vol. 29, No. 8, 1998
Figure 4. Stress views of the left ankle six months following removal of a diastasis screw
Conclusion We conclude that a single percutaneous suprasyndesmotic diastasis screw fixation for treating Maisonneuve and Maisonneuve-type fractures is an easy, effective and minimally invasive procedure giving a good functional outcome.
References 1 Lauge-Hansen N. Fractures of the ankle, II. Combined experimental ±surgical and experimental± roentgenologic investigation. Arch. Surg. 1950; 60: 957±985. 2 Yde J. The Lauge-Hansen classi®cation of malleolar fractures. Acta Orth. Scand. 1980; 51(1): 181±189. 3 Pettrone F. A., Gail M., Fee D., Fitzpatric T. and VanHerpe L. B. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J. Bone Joint Surg. 1983; 65A(1): 667±766. 4 Rockwood and Green, Fractures in Adults, fourth edn. Lippincot-Raven, 1996, p. 2217. 5 Duchesneau S. and Fallat L. The Maisonneuve fracture. J. Foot Ankle Surg. 1995; 34(5): 422±428. 6 Maisonneuve M. J. G. Recherches sur la fracture du perone. Arch. Genet. Med. 1840; 7(5): 165±187. 7 Campbell Operative Orthopaedics, 9th edn. Mosby, 1998, pp. 2044±2045.
8 MuÈller, M. E., AllgoÈwer, M., Schneider, R., Willeneger, H., Manual of Internal Fixation, 3rd edn. Springer, 1991, pp. 148±149. 9 Slawski D. P. and West C. Maisonneuve fracture with an associated distal ®bular fracture. Clin. Orth. 1995; 31(7): 193±198. 10 Pankovich A. M. Maisonneuve fracture of the ®bula. J. Bone Joint Surg. 1976; 58A(7): 337±342. 11 Merrill K. D. The Maisonneuve fracture of the ®bula. Clin. Orth. 1993; 287(7): 218±223. 12 Lock T. R., Schafer J. J. and Manoli A. Maisonneuve fracture: case report of a missed diagnosis. Ann. Emerg. Med. 1987; 16(7): 805±807. 13 Yablon I. G., Heller F. G. and Shouse L. The key role of the lateral malleolus in displaced fracture of the ankle. J. Bone Joint Surg. 1977; 59A(7): 169±173. 14 De Souza L. J., Gustilo R. B. and Meyer T. J. Results of the displaced external rotation±abduction fracture of the ankle. J. Bone Joint Surg. 1985; 67A(7): 1066±1074. 15 Ramsey P. L. and Hamilton W. Change in tibiotalar area of contact caused by lateral talar shift. J. Bone Joint Surg. 1976; 58A(7): 356±357.
Paper accepted 3 June 1998. Requests for reprints should be addressed to: Mr E. M. H. Obeid, 28, Ladywood Road, Old Hall, Warrington, Cheshire WA5 5QR, U.K. Tel.: 1925-470-178; Fax: 1925-6377-57; E-mail: [email protected].
PII: S0020-1383(98)00149-1
Percutaneous fixation of Maisonneuve and Maisonneuve-type fractures: a minimally invasive approach E. M. H. Obeid, M. Amr, P. Hirst and A. S. Paul
The University Department of Orthopaedic Surgery, Manchester Royal Infirmary, Manchester, U.K.
We report five cases of Maisonneuve and Maisonneuve-type fractures which were treated with a single suprasyndesmotic percutaneous diastasis screw with good radiological and functional results. This is an effective and a minimally invasive procedure which we recommend. # 1998 Published by Elsevier Science Ltd. All rights reserved. Injury, Vol. 29, No. 8, 619±622, 1998
Introduction High fibular fracture with syndesmotic disruption is considered as an external rotation injury, or pronation eversion stage iii as described by LaugeHansen [1] and modified by Yde [2] and others [3]. Maisonneuve fracture of the fibula consists of a fracture of the proximal fibula proximal to the distal tibio±fibular joint which is associated with an ankle fracture or deltoid ligament rupture [4]. Several methods of treatment are described including nonoperative as well as various methods of surgical intervention [5].
Surgical technique The procedure is performed under anaesthesia with the patient supine on the operating table. Continuous X-ray screening is used. Manipulation is performed to reduce the syndesmosis. The foot is held in neutral dorsiflexion and the leg in internal rotation. Make a 1 cm incision on the lateral aspect of the distal fibula above the level of the syndesmosis (verify position by X-ray screening). Drill through three cortices into the fibula and tibia using a 2.5 mm drill bit from lateral to medial, or drill from
Figure 1. X-ray of the right ankle showing midshaft fibular fracture with lateral talar shift
620
Injury: International Journal of the Care of the Injured Vol. 29, No. 8, 1998
posterolateral to anteromedial if the leg is held in the neutral position. Insert a 3.5 mm cortical screw of appropriate length after tapping. Do not engage the far tibial cortex. Verify position of the screw by X-ray screening. Close wound using steristrips. Apply plaster of Paris cast.
Case presentation Case one A 30 year old male, sustained an external rotation injury to his right foot resulting in a Maisonneuve fracture of the fibula with rupture of the medial ligament complex. He was treated with a single percutaneous suprasyndesmotic screw fixation, which completely stabilised the diastasis. The fixation was supported by a below knee plaster. The syndesmotic screw was removed at six weeks, and the patient was allowed to mobilise freely. Five month review showed a stable diastasis and ankle mortise with no talar shift. Case two A 23 year old male injured his right leg following a fall from a height, he sustained a Maisonneuve-type injury with rupture of the deltoid ligament and a spiral midshaft fibular fracture with talar shift
(Figure 1). A suprasyndesmotic percutaneous screw and a plaster cast were used (Figure 2). A review few months following removal of the diastasis screw revealed a stable ankle. Case three A 20 year old male patient sustained an eversion football injury to his right ankle resulting in a proximal fibular fracture with rupture of the medial ligament. This was treated along the same line of treatment of the previous cases. Six months follow up showed complete radiological healing of the fracture with no talar shift. Case four A 60 year old man was knocked down by a car. He sustained a displaced medial malleolar fracture with a midshaft short oblique fibular fracture with tibio± fibular diastasis. The skin over the medial malleolus was badly contused. This was treated by manipulation of the medial malleolus into an anatomical position, the fibula was stabilised with a single suprasyndesmotic percutaneous screw. This secured and stabilised the diastasis. A plaster cast was applied for six weeks. Further follow up showed complete healing of both fractures.
Figure 2. Post-operative X-ray showing a suprasyndesmotic screw fixation
Obeid et al.: Percutaneous fixation of Maisonneuve fractures
Case five A 36 year old man sustained a football injury to his left leg. X-ray revealed a Maisonneuve fracture of the proximal fibula with a displaced medial malleolar fracture and diastasis of the mortise . This was treated by percutaneous screw stabilisation of the diastasis and cancellous screw fixation of the medial malleolus through an open procedure (Figure 3). The diastasis screw was removed after six weeks. Six month following injury stress views of the ankle showed a stable ankle mortise (Figure 4).
Discussion A Maisonneuve fracture is a high fibular fracture which was described by Jaque Gilles Maisonneuve in 1840 [6]. In a cadaveric study he described a rupture of the medial collateral ligament or fracture of the medial malleolus with proximal third fibular fracture. Lauge-Hansen [1] classified it as an external rotation injury. In the Danis and Weber [7] classifi-
Figure 3. X-ray of the left tibia and fibula following fixation of a Maisonneuve fracture
621
cation it falls in the C-type category. It is considered as a type C3 by the AO-ASIF group [8]. There are variants of this injury, Slawski [9] reported a proximal fibular fracture associated with distal fibular fracture at the level of the tibiofibular syndesmosis. Pankovich [10] studied 17 cases of this injury, and classified it into five stages. He described two patterns; pronation external rotation and a less common supination external rotation. Treatment of Maisonneuve and Maisonneuve-type fracture varied. Merril [11] suggested that these are often more stable than generally assumed, and for injuries with only a partial syndesmosis disruption non-operative treatment is recommended. Lock et al. [12] recommended conservative treatment if no medial malleolar fracture was present and the medial joint line was not widened. Pankovich [10] described various methods of surgical treatment. Yoblin [13] restored the fibular length by traction through a towel clip at the lateral malleolus, and the reduction was then maintained with a suprasyndesmotic screw. Open reduction of the high fibular fracture is carried out if the fibular length could not be restored. De Sousa [14] suggested the following as the best sequence of treatment: (1) restoration of fibular length, (2) repair of the anterior tibiofibular ligament and (3) fixation of an associated posterior malleolar fracture if it involves 25% of the articular surface or more, and (4) when necessary open reduction and internal fixation of the fibula with screws and plate, and only then (5) use of suprasyndesmotic screw if instability is noted on stressing the repaired fibula. We report here a minimally invasive procedure. Three of the patients sustained a proximal fibular fracture with rupture of the deltoid ligament; these were treated by a single percutaneous suprasyndesmotic screw under X-ray control which closed the syndesmosis and restored the ankle mortise. This was supplemented with a short leg plaster cast. The fourth patient sustained a displaced medial malleolar fracture with an oblique mid fibular fracture. This was treated by manipulation of the medial malleolus and fixation of the fibula with a single suprasyndesmotic screw. The medial malleolus was not internally fixed due to the poor condition of the skin. This was also supplemented with a short leg cast. The fifth case (classic Maisonneuve fracture) was treated along the same line of treatment, the displaced medial malleolus was fixed though a medial incision. This method stabilises the diastasis, restores the ankle mortise, and minimises the talar shift which is considered to be the most important determining factor in the outcome of the functional result [15].
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Injury: International Journal of the Care of the Injured Vol. 29, No. 8, 1998
Figure 4. Stress views of the left ankle six months following removal of a diastasis screw
Conclusion We conclude that a single percutaneous suprasyndesmotic diastasis screw fixation for treating Maisonneuve and Maisonneuve-type fractures is an easy, effective and minimally invasive procedure giving a good functional outcome.
References 1 Lauge-Hansen N. Fractures of the ankle, II. Combined experimental ±surgical and experimental± roentgenologic investigation. Arch. Surg. 1950; 60: 957±985. 2 Yde J. The Lauge-Hansen classi®cation of malleolar fractures. Acta Orth. Scand. 1980; 51(1): 181±189. 3 Pettrone F. A., Gail M., Fee D., Fitzpatric T. and VanHerpe L. B. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J. Bone Joint Surg. 1983; 65A(1): 667±766. 4 Rockwood and Green, Fractures in Adults, fourth edn. Lippincot-Raven, 1996, p. 2217. 5 Duchesneau S. and Fallat L. The Maisonneuve fracture. J. Foot Ankle Surg. 1995; 34(5): 422±428. 6 Maisonneuve M. J. G. Recherches sur la fracture du perone. Arch. Genet. Med. 1840; 7(5): 165±187. 7 Campbell Operative Orthopaedics, 9th edn. Mosby, 1998, pp. 2044±2045.
8 MuÈller, M. E., AllgoÈwer, M., Schneider, R., Willeneger, H., Manual of Internal Fixation, 3rd edn. Springer, 1991, pp. 148±149. 9 Slawski D. P. and West C. Maisonneuve fracture with an associated distal ®bular fracture. Clin. Orth. 1995; 31(7): 193±198. 10 Pankovich A. M. Maisonneuve fracture of the ®bula. J. Bone Joint Surg. 1976; 58A(7): 337±342. 11 Merrill K. D. The Maisonneuve fracture of the ®bula. Clin. Orth. 1993; 287(7): 218±223. 12 Lock T. R., Schafer J. J. and Manoli A. Maisonneuve fracture: case report of a missed diagnosis. Ann. Emerg. Med. 1987; 16(7): 805±807. 13 Yablon I. G., Heller F. G. and Shouse L. The key role of the lateral malleolus in displaced fracture of the ankle. J. Bone Joint Surg. 1977; 59A(7): 169±173. 14 De Souza L. J., Gustilo R. B. and Meyer T. J. Results of the displaced external rotation±abduction fracture of the ankle. J. Bone Joint Surg. 1985; 67A(7): 1066±1074. 15 Ramsey P. L. and Hamilton W. Change in tibiotalar area of contact caused by lateral talar shift. J. Bone Joint Surg. 1976; 58A(7): 356±357.
Paper accepted 3 June 1998. Requests for reprints should be addressed to: Mr E. M. H. Obeid, 28, Ladywood Road, Old Hall, Warrington, Cheshire WA5 5QR, U.K. Tel.: 1925-470-178; Fax: 1925-6377-57; E-mail: [email protected].