A Maisonneuve fracture of the ankle involves a proximal fibular fracture with rupture of the anterior talofibular ligament and interosseous tibiofibular ligament. It is important to anatomically reduce the distal fibula into the fibular notch through open reduction of the tibiofibular syndesmosis under direct vision. Computed tomography is warranted to detect additional fractures, and anatomic reduction of the distal fibula is the most important prognostic factor.

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