MAISONNEUVE FRACTURE OF ANKLE JOINT

1. MAISONNEUVE FRACTURE OF
ANKLE JOINT - A CRITICAL ANALYSIS
REVIEW
JAN BARTON´ICEK, MD, DSC
STEFAN RAMMELT, MD, PHD
MICHAL TUCEK, MD, PHD
FEBRUARY 2022 · VOLUME 10, ISSUE 2 · E21.00160
JOURNAL CLUB
DR. SHUBHANSHU RANJAN SINGH

2. INTRODUCTION
 Defination – Fracture of the proximal 1/4th of
fibula with rupture of ATFL and the
interosseous tibiofibular ligament.
 Incid. 3.5 to 7.0%
 5th and 6th decade for men and women resp.

3. MECHANISM OF INJURY
 Pronation - External
rotation mechanism
 Possible Supination-
External rotation
mechanism

4. CLINICAL EXAMINATION
 Pain and swelling
 Difficulty in walking

5. IMAGING
 XRAY - Ankle
AP/Lateral/Mortise
 CT Scan –
i. Position of the distal
fibula in the fibular
notch FN
ii. Anatomy and
displacement of a #of
PM

9. IMAGING
 Recently advances on weight-bearing in CT
for syndesmotic injuries
 MRI to look for ligament injury but not on
instability.
 Arthroscopy allows excellent accuracy in the
diagnosis of syndesmotic instability and
additional intra-articular injuries.

10. PATHOANATOMY
 Injury to the Proximal Aspect of the Fibula
 Injury to the Tibiofibular Syndesmosis and the
IOM
 a/w Anterior/posterior/lateral malleolus, lateral
collateral ligaments
 Distal Tibia and the Distal Fibula distance
widened by >2 mm, fibula in 10° external
rotation.

11. TREATMENT
 Treatment depends on the
1. Displacement
2. The fragment size
3. Articular involvement

12. TREATMENT
 Main goal anatomic reduction of the distal
fibula into the Fibular notch.
 ER, displacement, and shortening of the fibula
by >2 mm
 Internal fixation of a proximal fibular #is not
required (d/to CPN injury)

13. TREATMENT
Medial Malleolar #
 Reduction of MM helps to maintain the
position of the talar dome.
Rupture of the DL
 medial instability following fibular fixation
 interposition of the ligament prevents reduction
 syndesmotic instability

14. TREATMENT
PM #
 Depends on
i. Size
ii. FN
iii. Articular involvement

15. TREATMENT
Rupture or Avulsion of the ATFL
Restore,
 FN integrity
 Joint congruity
 Mortise stability.

16. TREATMENT (Non operative)
 For non displaced #s without latent diastasis

17. TREATMENT(Surgical
Technique)
Sequence of Reduction and Fixation
1. Distal fibula within the FN.
2. MM #s assists in maintaining tibiotalar
alignment.

18. TREATMENT(Surgical
Technique)
Approaches and Patient Positioning
 Distal tibia and the ATFL requires short AL
approach with the patient in the supine
position.
 Bump is placed beneath the calf in order to
avoid ant. shifting of the distal fibula in FN.
 AM/PM may also be reduced and fixed via a
single oblique lateral approach.

19. TREATMENT(Surgical
Technique)
 ORIF MM or DL repair are performed via a
medial approach
 Displaced PM # PL approach with the patient
in the prone position
 Fixation ofAL distal tibia and fibula via a short
anterolateral approach

20. TREATMENT(Surgical
Technique)
 Suture button with 1 or 2 solid screws for
axially unstable high fibular #s, including MF.
 Implant placement >4 cm above the tibial
plafond.
 Insertion of the 2 implants at 1 to 4 cm above
the tibial plafond

22. POST OPERATIVE CARE
 A short leg cast or splint is applied until there
is wound-healing.
 Patients are mobilized with protected weight
bearing with a special boot or a cast for 6 to 8
weeks.
 There is no general need to remove
transsyndesmotic screws(recommended >3
month).

23. Outcomes of Surgical
Treatment

25. RELATED JOURNAL
 During surgery, arthroscopy performed on 4
cases mean age 24.5 and result helping in
identifying a/w intra-articular lesions in MFs.
 Yoshimura I, Naito M, Kanazawa K, Takeyama A, Ida T. Arthroscopic findings in Maisonneuve fractures.
J Orthop Sci. 2008 Jan;13(1):3-6.

26. RELATED JOURNAL
 4.5-mm cortical screw through both tibial cortices (n =
30)
 Two 3.5-mm cortical screws engaging only 1 cortex of
the tibia (n = 34).
 Quadricortical screws were removed after 2 months
 Tricortical screws were removed only in the case of
discomfort.
 Result was syndesmosis fixation with 2 tricortical
screws for early function.
 After 1 year no significant differences between the 2
groups
 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.

27. RELATED JOURNAL
 Suture-button fixation is better than
syndesmosis screw fixation at 3 months, at 12
months postop
 Suture button fixation is simple, safe, effective,
faster recovery, no need to remove implant.
 Thornes B, Shannon F, Guiney AM, Hession P, Masterson E. Suture-button syndesmosis fixation: accelerated
rehabilitation and improved outcomes. Clin Orthop Relat Res. 2005 Feb;(431):207-12.

28. Outcome of Surgical Treatment
 Ankle # with syndesmotic disruption, the most
important prognostic factor is Anatomic
reduction of the distal fibula into the Fibular
Notch.

29. SUMMARY
 MF of the Ankle is ATFL lesion and a high
fibular #.
 CT is warranted to detect frequently
associated #s such as posterior or anterior
distal tibial avulsions.
 Open reduction of the tibiofibular syndesmosis
under direct vision and intra- or postoperative
CT is generally recommended
 Anatomic reduction of the distal fibula into the
FN is the most important prognostic factor.

30. THANKYOU