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Lecture 40 parekh malunited ankle fracture

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Lecture 40 parekh malunited ankle fracture

  1. 1. Malunited Ankle Fractures Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
  2. 2. Ankle Joint • 3 articulations • Fibula  secondary stabilizer • Talus • Trapezoidal – wider anteriorly • DF – ER  4.2o • PF – IR  1.4o • Distal fibula w/ DF • Lateral translation 1-2mm • ER
  3. 3. Malunited Ankle Fractures • Isolated lateral malleolar ankle fractures • Potts/Bimalleolar ankle fractures • Cotton/Trimalleolar ankle fractures • Syndesmotic injuries
  4. 4. Malunited Ankle Fractures • Shortening and lateral rotation of distal fibula • Widening of mortise, lateral tilt talus • Most common
  5. 5. Importance • 1 mm shift of the talus  42% reduction in the tibiotalar contact area  increase stress on the articular cartilage • Serious and persistent dysfunction
  6. 6. Symptoms • Difficulty walking • Pain & edema • Cosmetic changes
  7. 7. Guidelines • Little in the literature to guide approaches and techniques • Anecdotal experiences • Cite literature where available
  8. 8. 3 Guiding Concepts • Restore alignment of the entire lower extremity • Restoration of the articular surface • Restoration of painless ankle motion
  9. 9. Preoperative Evaluation • History • Physical • Tenderness • ROM • Imaging • Xrays • CT • MRI • Nuclear medicine
  10. 10. Issues to Consider • Medical conditions • Diabetes, ESRD • Neuropathy • Dermal issues • Nicotine use • Bony issues • Alignment • Bony quality and nonunion • Changes in joint (arthritic)
  11. 11. Issues to Consider • Skin • Lesions • Prior incisions • Contractures
  12. 12. Imaging • Radiographs • Weightbearing ankle xrays • Asymmetry of the medial and lateral clear spaces • Talar tilt > 2mm • Talar subluxation • Lateralization of the talus • Eccentric joint space narrowing • Arthritic changes • Fibular shortening
  13. 13. Imaging • Radiographs • Fibular shortening • Compare to contralateral/uninjured side 75o-86o
  14. 14. Imaging • Radiographs • Fibular shortening • 3 criteria of normal distal fibular length 1. Equal jt space 2. Intact Shenton line 3. Unbroken curve between lateral talus and peroneal groove
  15. 15. Imaging • CT scan • Arthritic changes • Fibular shortening • Fibular rotational malunion • Syndesmotic widening • >2mm difference b/t anterior & posterior distances from the fibula to the incisura
  16. 16. Management • Nonoperative • NSAIDS • Steroid injections • Activity modifications • Orthoses and braces
  17. 17. Surgical Plan • Approach bone • Osteotomy • Mobilize bone • Clean medial gutter • Fixation
  18. 18. Approach • Surgical approach • Osteotomies • Fibular • Tibial • Supramalleolar • Fixation • Ex-fix • Internal fixation • Combo • Bone grafts (auto and allografts) and orthobiologics
  19. 19. Case 1 • Mid 50s diabetic • Diagnosed with “the gout”
  20. 20. Case 1 Varus malunion Flexion malunion
  21. 21. Case 1 • Fibular and tibial osteotomy • Biplanar • MAC ex-fix • “multiaxial compression”
  22. 22. Case 1
  23. 23. Case 1
  24. 24. Case 1 1 yr post-op Walking Pain free No assistive device
  25. 25. Case 2 • Fibular shortening – courtesy of Dr. Kadakia
  26. 26. Case 2
  27. 27. Case 2
  28. 28. Case 2
  29. 29. Literature • Fibular osteotomy • 1976 – Hughes, JBJS-A • 28 cases fibular malunion  lengthening • 22 VG/G • 6 Poor • No correlation • Time since accident • Age of patient • Type initial treatment
  30. 30. Literature • Malunited ankles • 1985 – Weber and Simpson • 23 cases • 17 G/E • 6 Poor  pre-existing arthritis
  31. 31. RE ECT the ankle the foot

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