Application of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

SUN Zhenhui ^1,2 , CHEN Yu ² ,  ZHANG Hui ² , LI Nan ¹ , ZHANG Tao ¹ , MA Xinlong ¹ , YANG Zhi ³

1. Foot and Ankle Department of Orthopaedics, Tianjin Hospital, Tianjin, 300211, P.R.China;
2. Foot and Ankle Center of Orthopaedics, West China Hospital of Sichuan University, Chengdu Sichuan, 610041, P.R.China;
3. School of Biomedical Engineering, Capital Hospital of Beijing, Beijing, 100069, P.R.China;

Corresponding author：

ZHANG Hui, Email: caesarzh@163.com

Keywords：

Ankle fracture; pronation injury; anatomical approach; osteoligaments repair; internal fixation

DOI：

10.7507/1002-1892.201904044

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To investigate the safety and effectiveness of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures.Methods The clinical data of 53 patients with pronation ankle fractures between April 2015 and October 2016, who were treated with anatomical approach osteoligaments repair technique applied for fracture reduction and internal fixation, were analysed retrospectively. There were 35 males and 18 females with an average age of 33.1 years (range, 18-60 years). The cause of injury included traffic accidents in 27 cases, tumbling in 5 cases, fall from height in 4 cases, twisted injury in 6 cases, sports injuries in 4 cases, and bruises in 7 cases. According to Lauge-Hansen classification, there were 44 cases of pronation external rotation stage Ⅳ and 9 cases of pronation abduction stage Ⅲ. The interval between injury and operation was 4-10 days (mean, 7 days). Postoperative pain and function of ankles were assessed by American Orthopedic Foot and Ankle Score (AOFAS) and visual analogue pain scale (VAS) score. The medial clear space (MCS), tibiofibular clear space (TFCS), distal fibular tip to lateral process of talus (DFTL), the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle were measured by X-ray films and CT of bilateral ankle joints.Results The tourniquet application time was 55-90 minutes (mean, 72.5 minutes); the frequency of fluoroscopy was 5-13 times (mean, 8.9 times). All incisions healed by first intention and no infection, deep vein thrombosis occurred after operation. All patients were followed up 28-48 months (mean, 36 months). There was no significant difference in postoperative MCS, TFCS, DFTL, the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle between bilateral ankle joints (P>0.05). At last follow-up, no ankle instability occurred and the degenerative changes of ankle joints (Kellgren-Lawrence grading Ⅱ) occurred in 5 cases. The average AOFAS score of the ankle joint was 90.84 (range, 85-95); mean VAS score was 1.23 (range, 0-5). The average dorsiflexion and plantar flexion of ankle joints was 20.24° (range, 15-25°) and 42.56° (range, 30-50°), respectively.Conclusion Anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures can expose the talocrural joint and lower tibiofibular syndesmosis clearly, repair the osteoligaments injury directly, and assist the syndesmosis and talocrural joint reduction, and decline the incidence of ankle degeneration.

Citation： SUN Zhenhui, CHEN Yu, ZHANG Hui, LI Nan, ZHANG Tao, MA Xinlong, YANG Zhi. Application of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(11): 1351-1357. doi: 10.7507/1002-1892.201904044 Copy

1.	Mandi DM. Ankle fractures. Clin Podiatr Medic Surg, 2012, 29(2): 155-186.
2.	Warner SJ, Garner MR, Hinds RM, et al. Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures. J Orthop Trauma, 2015, 29(12): 574-578.
3.	Putnam SM, Linn MS, Spraggs-Hughes A, et al. Simulating clamp placement across the trans-syndesmotic angle of the ankle to minimize malreduction: A radiological study. Injury, 2017, 48(3): 770-775.
4.	Loizou CL, Sudlow A, Collins R, et al. Radiological assessment of ankle syndesmotic reduction. Foot (Edinb), 2017, 32: 39-43.
5.	Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
6.	Ntalos D, Rupprecht M, Grossterlinden LG, et al. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function-Clinical study and MRI evaluation. Injury, 2018, 49(6): 1220-1227.
7.	Ovaska MT, Mäkinen TJ, Madanat R, et al. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop, 2014, 38(1): 83-88.
8.	Walsh AS, Sinclair V, Watmough P, et al. Ankle fractures: getting it right first time. Foot (Edinb), 2018, 34: 48-52.
9.	Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
10.	Hinds RM, Schottel PC, Berkes MB, et al. Evaluation of Lauge-Hansen designation of Weber C fractures. J Foot Ankle Surg, 2014, 53(4): 434-439.
11.	Pankovich AM. Fractures of the fibula proximal to the distal tibiofibular syndesmosis. J Bone Joint Surg (Am), 1978, 60(2): 221-229.
12.	Luckino FA 3rd, Hardy MA. Use of a flexible implant and bioabsorbable anchor for deltoid rupture repair in bimalleolar equivalent Weber B ankle fractures. J Foot Ankle Surg, 2015, 54(3): 513-516.
13.	Hoekstra H, Rosseels W, Rammelt S, et al. Direct fixation of fractures of the posterior pilon via a posteromedial approach. Injury, 2017, 48(6): 1269-1274.
14.	Baker G, Mayne AIW, Andrews C. Fixation of unstable ankle fractures using a long hindfoot nail. Injury, 2018, 49(11): 2083-2086.
15.	Johnson JP, Vopat BG, Blankenhorn B. Use of a pin distractor as an aid for fixation of pronation-External rotation fibular fractures. Orthopedics, 2017, 40(1): e192-e194.
16.	Lee S, Lin J, Hamid KS, et al. Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg, 2019, 27(14): e648-e658.
17.	Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 1997, 18(3): 187-188.
18.	Panchbhavi VK, Gurbani BN, Mason CB, et al. Radiographic assessment of fibular length variance: the case for " fibula minus”. J Foot Ankle Surg, 2018, 57(1): 91-94.
19.	Metitiri O, Ghorbanhoseini M, Zurakowski D, et al. Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int, 2017, 38(4): 443-451.
20.	Lepojärvi S, Niinimäki J, Pakarinen H, et al. Rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int, 2016, 37(6): 627-635.
21.	Warner SJ, Schottel PC, Hinds RM, et al. Fracture-dislocations demonstrate poorer postoperative functional outcomes among pronation external rotation Ⅳ ankle fractures. Foot Ankle Int, 2015, 36(6): 641-647.
22.	Ray R, Koohnejad N, Clement ND, et al. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot Ankle Surg, 2019, 25(2): 180-185.
23.	Herscovici D Jr, Anglen JO, Archdeacon M, et al. Avoiding complications in the treatment of pronation-external rotation ankle fractures, syndesmotic injuries, and talar neck fractures. J Bone Joint Surg (Am), 2008, 90(4): 898-908.
24.	Miller AN, Barei DP, Iaquinto JM, et al. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma, 2013, 27(2): 100-106.
25.	Davidovitch RI, Weil Y, Karia R, et al. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg (Am), 2013, 95(20): 1838-1843.
26.	Lepojärvi S, Pakarinen H, Savola O, et al. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma, 2014, 28(4): 205-209.
27.	Smeeing DPJ, Briet JP, van Kessel CS, et al. Factors associated with wound- and implant-related complications after surgical treatment of ankle fractures. J Foot Ankle Surg, 2018, 57(5): 942-947.
28.	Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg (Br), 2000, 82(3): 345-351.
29.	Cedell CA. Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand, 1967, Suppl 110: 1-148.
30.	Bartoniček J, Rammelt S, Tuček M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
31.	Rigby RB, Scott RT. Role for primary repair of deltoid ligament complex in ankle fractures. Clin Podiatr Med Surg, 2018, 35(2): 183-197.
32.	Burns WC 2nd, Prakash K, Adelaar R, et al. Tibiotalar joint dynamics: indications for the syndesmotic screw--a cadaver study. Foot Ankle, 1993, 14(3): 153-158.
33.	Warner SJ, Fabricant PD, Garner MR, et al. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures. J Bone Joint Surg (Am), 2015, 97(23): 1935-1944.
34.	Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma, 2012, 26(7): 439-443.
35.	Chan KB, Lui TH. Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy, 2016, 32(11): 2373-2380.
36.	Wu Y, He QF, Lai LP, et al. Functional outcome of pronation-external rotation-Weber C ankle fractures with supracollicular medial malleolar fracture treated with or without syndesmotic screws: A retrospective comparative cohort study. Chin Med J (Engl), 2018, 131(21): 2551-2557.
37.	杨俊忠, 王成林, 曹开学, 等. 采用ORIF联合下胫腓螺钉治疗Lauge-Hansen分型旋前外旋型Ⅳ度踝关节骨折的临床疗效观察. 中国伤残医学, 2018, 26(19): 49-50.

1. Mandi DM. Ankle fractures. Clin Podiatr Medic Surg, 2012, 29(2): 155-186.
2. Warner SJ, Garner MR, Hinds RM, et al. Correlation between the Lauge-Hansen classification and ligament injuries in ankle fractures. J Orthop Trauma, 2015, 29(12): 574-578.
3. Putnam SM, Linn MS, Spraggs-Hughes A, et al. Simulating clamp placement across the trans-syndesmotic angle of the ankle to minimize malreduction: A radiological study. Injury, 2017, 48(3): 770-775.
4. Loizou CL, Sudlow A, Collins R, et al. Radiological assessment of ankle syndesmotic reduction. Foot (Edinb), 2017, 32: 39-43.
5. Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
6. Ntalos D, Rupprecht M, Grossterlinden LG, et al. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function-Clinical study and MRI evaluation. Injury, 2018, 49(6): 1220-1227.
7. Ovaska MT, Mäkinen TJ, Madanat R, et al. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop, 2014, 38(1): 83-88.
8. Walsh AS, Sinclair V, Watmough P, et al. Ankle fractures: getting it right first time. Foot (Edinb), 2018, 34: 48-52.
9. Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
10. Hinds RM, Schottel PC, Berkes MB, et al. Evaluation of Lauge-Hansen designation of Weber C fractures. J Foot Ankle Surg, 2014, 53(4): 434-439.
11. Pankovich AM. Fractures of the fibula proximal to the distal tibiofibular syndesmosis. J Bone Joint Surg (Am), 1978, 60(2): 221-229.
12. Luckino FA 3rd, Hardy MA. Use of a flexible implant and bioabsorbable anchor for deltoid rupture repair in bimalleolar equivalent Weber B ankle fractures. J Foot Ankle Surg, 2015, 54(3): 513-516.
13. Hoekstra H, Rosseels W, Rammelt S, et al. Direct fixation of fractures of the posterior pilon via a posteromedial approach. Injury, 2017, 48(6): 1269-1274.
14. Baker G, Mayne AIW, Andrews C. Fixation of unstable ankle fractures using a long hindfoot nail. Injury, 2018, 49(11): 2083-2086.
15. Johnson JP, Vopat BG, Blankenhorn B. Use of a pin distractor as an aid for fixation of pronation-External rotation fibular fractures. Orthopedics, 2017, 40(1): e192-e194.
16. Lee S, Lin J, Hamid KS, et al. Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg, 2019, 27(14): e648-e658.
17. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 1997, 18(3): 187-188.
18. Panchbhavi VK, Gurbani BN, Mason CB, et al. Radiographic assessment of fibular length variance: the case for " fibula minus”. J Foot Ankle Surg, 2018, 57(1): 91-94.
19. Metitiri O, Ghorbanhoseini M, Zurakowski D, et al. Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int, 2017, 38(4): 443-451.
20. Lepojärvi S, Niinimäki J, Pakarinen H, et al. Rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography. Foot Ankle Int, 2016, 37(6): 627-635.
21. Warner SJ, Schottel PC, Hinds RM, et al. Fracture-dislocations demonstrate poorer postoperative functional outcomes among pronation external rotation Ⅳ ankle fractures. Foot Ankle Int, 2015, 36(6): 641-647.
22. Ray R, Koohnejad N, Clement ND, et al. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot Ankle Surg, 2019, 25(2): 180-185.
23. Herscovici D Jr, Anglen JO, Archdeacon M, et al. Avoiding complications in the treatment of pronation-external rotation ankle fractures, syndesmotic injuries, and talar neck fractures. J Bone Joint Surg (Am), 2008, 90(4): 898-908.
24. Miller AN, Barei DP, Iaquinto JM, et al. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma, 2013, 27(2): 100-106.
25. Davidovitch RI, Weil Y, Karia R, et al. Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg (Am), 2013, 95(20): 1838-1843.
26. Lepojärvi S, Pakarinen H, Savola O, et al. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma, 2014, 28(4): 205-209.
27. Smeeing DPJ, Briet JP, van Kessel CS, et al. Factors associated with wound- and implant-related complications after surgical treatment of ankle fractures. J Foot Ankle Surg, 2018, 57(5): 942-947.
28. Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg (Br), 2000, 82(3): 345-351.
29. Cedell CA. Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand, 1967, Suppl 110: 1-148.
30. Bartoniček J, Rammelt S, Tuček M. Posterior malleolar fractures: Changing concepts and recent developments. Foot Ankle Clin, 2017, 22(1): 125-145.
31. Rigby RB, Scott RT. Role for primary repair of deltoid ligament complex in ankle fractures. Clin Podiatr Med Surg, 2018, 35(2): 183-197.
32. Burns WC 2nd, Prakash K, Adelaar R, et al. Tibiotalar joint dynamics: indications for the syndesmotic screw--a cadaver study. Foot Ankle, 1993, 14(3): 153-158.
33. Warner SJ, Fabricant PD, Garner MR, et al. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures. J Bone Joint Surg (Am), 2015, 97(23): 1935-1944.
34. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma, 2012, 26(7): 439-443.
35. Chan KB, Lui TH. Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy, 2016, 32(11): 2373-2380.
36. Wu Y, He QF, Lai LP, et al. Functional outcome of pronation-external rotation-Weber C ankle fractures with supracollicular medial malleolar fracture treated with or without syndesmotic screws: A retrospective comparative cohort study. Chin Med J (Engl), 2018, 131(21): 2551-2557.
37. 杨俊忠, 王成林, 曹开学, 等. 采用ORIF联合下胫腓螺钉治疗Lauge-Hansen分型旋前外旋型Ⅳ度踝关节骨折的临床疗效观察. 中国伤残医学, 2018, 26(19): 49-50.

Previous Article
Outcome of corrective osteotomy of shortened medial foot column after old talar neck fracture
Next Article
Modified staging strategy in treatment of type C3 Pilon fractures

Chinese Journal of Reparative and Reconstructive Surgery

Application of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content