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Repairing Ankle Fractures: Hot Topics and Insights
About 250,000 people in the United States have ankle fractures every year and 7% of those are open fractures, noted Jason St. John, DPM, MS, at yesterday’s APMA National session. He said fixation options for distal fibula fractures include lateral plates, posterior plates, intermetatarsal screws, intermetatarsal nails, lag screws, or external fixation. He said the approach can help dictate fibular fixation, and one should consider skin and bone quality.
Weber and Krause, in a retrospective analysis of 70 patients with lateral malleolar fractures, found 30 patients had a posterolateral antiglide plate removed due to discomfort or peroneal tendinitis.1 However, Dr. St. John said Ahn and colleagues found a low incidence of peroneal tendon symptoms associated with posterior antiglide plating for lateral malleolar fractures.2
In a study of 442 patients with distal fibula fractures, Dr. St. John noted Sop and colleagues found compression and locked plate techniques had low reoperation rates, and that placing 1/3 tubular plating posteriorly may decrease the risks of symptomatic implant and infection.3 In a study of 18 cadavers, Minihane and colleagues found posterolateral antiglide plates showed improved biomechanical stability compared to lateral locking plates in osteoporotic bone.4
Is direct visualization effective for syndesmotic fractures? In a study of 149 patients with syndesmotic ankle injury, Miller and colleagues found malreductions reduced in the direct visualization group.5 Gardner and colleagues asserted that the known morbidity of postoperative syndesmotic malreduction should lead to heightened vigilance for intraoperative assessment of accurate syndesmosis reduction.6
In a study of 120 patients with syndesmotic disruptions, Moore and colleagues found either three or four cortices of fixation can be used when stabilizing syndesmotic injuries of the ankle.7 In contrast, Dr. St. John said Høiness and colleagues found syndesmosis fixation with two tricortical screws to be safe and improves early function, but after one year, noted no significant differences between patients with one or two screws as far as functional score, pain, or dorsiflexion.8 Wikerøy and colleagues noted functional results in patients with syndesmotic injuries with either three or four screws after a follow-up of 8.4 years.9
Dr. St. John noted there is no consensus on fixation types for these fractures.
Alissa Parker, DPM, FACFAS, noted there are no randomized controlled trials to support routine intramedullary fixation of fibular fractures. She said the goal is promoting anatomic reduction and providing ankle joint stability.
Schumann and colleagues evaluated 151 patients following intramedullary nail fixation for fibular fractures.10 The authors concluded that intramedullary nailing facilitates accurate anatomic reduction, excellent fracture union rates, low complication rates, and early weight-bearing. In a cadaver study of 20 limbs, Smith and colleagues noted greater torque to failure and better maintenance of the fibular construct for intramedullary fibular nails compared to standard plating.11
When should the posterior malleolus be directly repaired? Dr. Parker notes no consensus in the literature as to which fragment size of the posterior malleolus should be internally fixed.12 In a survey study, Gardner and colleagues found significant variation on most aspects of posterior malleolar ankle fracture treatment, specifically that factors other than fragment size most impacted surgical indications.13 The authors noted newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. In a study of 151 patients, Miller and colleagues noted the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures with prone positioning and direct fixation of the posterior malleolus.14
When pursuing deltoid ligament repair, Nicholas Powers, DPM, FACFAS, noted up to 40% of ankle fractures have an associated deltoid injury on arthroscopic exam. He cautioned that a normal medial clear space on radiograph will not exclude a deltoid injury. Dr. Powers noted the general consensus in the literature is it is better to reduce the medial clear space than do syndesmotic repair, as there is less need for hardware removal.
In a study of 192 patients, Salameh and colleagues noted deltoid ligament repair showed superior early and late radiological correction of the medial clear space, but no differences in the functional outcome and complications rate.15 Ryba and colleagues, in a study of 37 patients, found isolated lateral ankle fixation is adequate for medial ankle stabilization in bimalleolar equivalent fractures, and that primary deltoid repair is not indicated.16
Dr. Powers also discussed ankle fractures in patients with neuropathy, fragility, and infection.
Diabetic peripheral neuropathy impairs balance and can lead to falls, and Dr. Powers noted neuropathy is an important factor in detecting bone healing complications. In a study of 46 patients with diabetes, El-Tantawy and colleagues found a less-invasive arthrodesis technique of trans-calcaneal retrograde nailing to be reproducible and effective for salvage of unstable diabetic ankle fractures in insensate feet.17
Physically fragile patients, mostly older people with osteoporosis, sustain low-energy ankle fractures and Dr. Powers noted bimalleolar, trimalleolar and pilon fractures are common. He cited data showing patients with ankle fractures may have a two-year mortality rate of 23%.18
As for patients with infections, Klouche and colleagues studied 20 patients who underwent septic ankle arthrodesis with internal fixation, attaining satisfactory fusion in 89.5% of patients and eradicating infection in 85%.19
References
1. Weber M, Krause F. Peroneal tendon lesions caused by antiglide plates used for fixation of lateral malleolar fractures: the effect of plate and screw position. Foot Ankle Int. 2005 Apr;26(4):281-5. doi: 10.1177/107110070502600403. PMID: 15829211.
2. Ahn J, Kim S, Lee JS, Woo K, Sung KS. Incidence of peroneal tendinopathy after application of a posterior antiglide plate for repair of supination external rotation lateral malleolar fractures. J Foot Ankle Surg. 2016 Jan-Feb;55(1):90-3. doi: 10.1053/j.jfas.2015.07.007. Epub 2015 Sep 3. PMID: 26342665.
3. Sop A, Kali M, Spindel JF, Brown SM, Samanta D. Retrospective analysis of locked versus non-locked plating of distal fibula fractures. Injury. 2023 Feb;54(2):768-771. doi: 10.1016/j.injury.2022.11.049. Epub 2022 Dec 14. PMID: 36539311.
4. Minihane KP, Lee C, Ahn C, Zhang LQ, Merk BR. Comparison of lateral locking plate and antiglide plate for fixation of distal fibular fractures in osteoporotic bone: a biomechanical study. J Orthop Trauma. 2006 Sep;20(8):562-6. doi: 10.1097/01.bot.0000245684.96775.82. PMID: 16990728.
5. Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009 May;30(5):419-26. doi: 10.3113/FAI-2009-0419. PMID: 19439142.
6. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006 Oct;27(10):788-92. doi: 10.1177/107110070602701005. PMID: 17054878.
7. Moore JA Jr, Shank JR, Morgan SJ, Smith WR. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int. 2006 Aug;27(8):567-72. doi: 10.1177/107110070602700801. PMID: 16919207.
8. Høiness P, Strømsøe K. Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation. J Orthop Trauma. 2004 Jul;18(6):331-7. doi: 10.1097/00005131-200407000-00001. PMID: 15213497.
9. Wikerøy AK, Høiness PR, Andreassen GS, Hellund JC, Madsen JE. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. 2010 Jan;24(1):17-23. doi: 10.1097/BOT.0b013e3181bedca1. PMID: 20035173.
10. Schumann J, Burgess B, Ryan D, Garras D. A retrospective analysis of distal fibula fractures treated with intramedullary fibular nail fixation. J Foot Ankle Surg. 2023 Jul-Aug;62(4):737-741. doi: 10.1053/j.jfas.2023.03.005. Epub 2023 Mar 24. PMID: 36966965.
11. Smith G, Mackenzie SP, Wallace RJ, Carter T, White TO. Biomechanical comparison of intramedullary fibular nail versus plate and screw fixation. Foot Ankle Int. 2017 Dec;38(12):1394-1399. doi: 10.1177/1071100717731757. Epub 2017 Oct 3. PMID: 28971694.
12. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma. 2009 Jan;66(1):279-84. doi: 10.1097/TA.0b013e318187eb16. PMID: 19131839.
13. Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011 Apr;32(4):385-93. doi: 10.3113/FAI.2011.0385. PMID: 21733441.
14. Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018 Jan;39(1):99-104. doi: 10.1177/1071100717735839. Epub 2017 Oct 23. PMID: 29058951.
15. Salameh M, Alhammoud A, Alkhatib N, et al. Outcome of primary deltoid ligament repair in acute ankle fractures: a meta-analysis of comparative studies. Int Orthop. 2020 Feb;44(2):341-347. doi: 10.1007/s00264-019-04416-9. Epub 2019 Nov 27. PMID: 31776609; PMCID: PMC6968990.
16. Ryba D, Ernst J, Blair S, Motley TA. Follow-up evaluation of medial clear space and talar tilt after bimalleolar equivalent fracture fixation without primary deltoid repair. J Am Podiatr Med Assoc. 2021 Jul 1;111(4):Article_7. doi: 10.7547/19-047. PMID: 34478535.
17. El-Tantawy A, Atef A, Samy A. Trans-calcaneal retrograde nailing for secondary-displaced traumatic ankle fractures in diabetics with insensate feet: a less-invasive salvage-arthrodesis technique. Eur J Orthop Surg Traumatol. 2022 Jan;32(1):37-46. doi: 10.1007/s00590-021-02898-1. Epub 2021 Mar 9. PMID: 33687556.
18. Wiedl A, Förch S, Otto A, et al. Beyond hip fractures: other fragility fractures' associated mortality, functional and economic importance: a 2-year-follow-up. Geriatr Orthop Surg Rehabil. 2021 Nov 30;12:21514593211058969. doi: 10.1177/21514593211058969. PMID: 34868724; PMCID: PMC8637372.
19. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot Ankle Surg. 2011 Jan-Feb;50(1):25-30. doi: 10.1053/j.jfas.2010.10.011. PMID: 21172639.
