Complex Ankle Research Articles

Varus deformity of the ankle in a pre-adolescent patient following an ankle fracture

In pre-adolescent patients supramalleolar osteotomies have been described to correct deformities following ankle fractures. However, the techniques described involve the harvesting of an iliacal graft. We report on a case of a 14-year-old girl who sustained a complex ankle fracture with a resultant hindfoot varus. The medial opening was maintained by using a plate with a metallic block interposed in the osteotomy plane (Puddu Plate).

Results of Step-Cut Medial Malleolar Osteotomy

Treatment of certain complex ankle pathology, such as a talar body fracture or osteochondral lesion requiring grafting, can necessitate medial malleolar osteotomy for adequate operative exposure. This paper evaluates the step-cut medial malleolar osteotomy for exposure of the ankle joint. Fourteen patients with intra-articular pathology, including talar body fractures or osteochondral lesions necessitating extensive intra-articular exposure had step-cut malleolar osteotomy. The average age of the patients was 37 (range 20-90) years, and the average followup was 8 months. All 14 patients had an uncomplicated intraoperative course, with excellent exposure of the ankle joint. All patients had prompt healing of the osteotomy by 6 weeks after surgery without loss of reduction. None of the patients had pain at the osteotomy site. Step-cut medial malleolar osteotomy is an excellent, reproducible method for extensive exposure of the talar dome.

Ankle Arthrodesis Using Ilizarov Ring Fixators: A Review of 22 Cases

Orthopaedic surgeons are being increasingly confronted with complex ankle problems that cannot be reliably treated by conventional arthrodesis procedures. The Ilizarov technique can be an alternative salvage method in such cases. Twenty-two Ilizarov tibiotalar arthrodeses were retrospectively reviewed. There were 16 men and six women (mean age 49 years). The underlying pathology was infection after internal fixation of ankle or plafond fractures in 16 patients, posttraumatic ankle arthritis in five, and septic arthritis after an infected Achilles tendon repair in one. Five patients had at least one failed previous arthrodesis. Primary iliac crest bone grafting was done in two patients. Proximal tibial lengthening was done in six patients. Twenty-one patients were followed for an average of 29 months. A solid fusion was achieved in all patients by the end of treatment. The external fixation time averaged 27.7 (range 12 to 84) weeks. The mean time spent in a foot frame was 22.3 weeks. Complications occurred in 11 patients, including two nonunions that healed after revision and renewed frame application and four pin track infections. The use of the Ilizarov frame provides a successful salvage method that offers solid bony fusion, optimal leg length, and eradication of infection in complex ankle pathology or failed previous arthrodesis.

Facteurs favorisant l’infection des fractures de cheville opérées

A prospective 1-year audit was carried out on consecutive patients admitted to a district general hospital of the UK with ankle fractures needing open reduction internal fixation in order to analyse the factors affecting infection. Ninety seven percent patients had had their operative procedure within 24 h from the time of injury. Eighty four percent patients were discharged in less than 7 days period from the day of admission. All but one patient received antibiotic prophylaxis in accordance with local microbiology policy guidelines. Four out of 32 patients received therapeutic antibiotics for wound cellulitis/superficial infection. No patient had a deep infection, osteomyelitis or septic arthritis. Complex ankle trauma, post-radiography preliminary reduction of ankle fracture-dislocation in the emergency department, prolonged operating time, delayed surgery, persistent ankle swelling and unsupervised operation were common denominators in four cases with infection in ankle fracture fixation.

Salvage of Complex Ankle Arthropathy and Injury of the Tibial Plafond Utilizing a Posterior Locked Plating Arthrodesis Construct

Salvage of Complex Ankle Arthropathy and Injury of the Tibial Plafond Utilizing a Posterior Locked Plating Arthrodesis Construct

Lower-Limb Reconstruction Utilizing the Reverse Sural Artery Flap???Gastrocnemius Muscle Cuff Technique

The reverse sural artery flap was described in 1992 and has become an acceptable technique of lower-limb reconstruction. In 2001, Al-Qattan introduced the concept of raising the reverse sural artery flap with a gastrocnemius muscle cuff for lower limb reconstruction and used it in 9 cases and noted a dramatic reduction in the ischemic events with this distally based flap technique. In the current paper, 30 consecutive patients with lower-limb defects were operated upon between 2001 and 2004. All patients underwent reconstruction utilizing Al-Qattan's reverse sural artery flap-gastrocnemius muscle cuff technique. The defects were classified into 4 types: open lower and midtibial fractures (n = 9), Achilles tendon defects (n = 6), heel defects exposing the calcaneus (n = 7), and complex ankle and foot defects exposing bone (n = 8). No cases of major vascular compromise were noted. Two diabetic patients had minor complications in the flap: one patient developed mild venous congestion and epidermolysis limited to the distal edge of the flap, and the second patient had a minor delayed wound healing at the most distal part of the flap. Both patients did not require further surgery. No cases of infection, hematoma, or painful neuroma were noted. After a mean follow-up period of 2 years (range 1-4 years), all flaps remained stable and all Achilles tendon repairs remained intact. The results of this series compares favorably with the results of other series in the literature, indicating the versatility and the better blood supply of the reverse sural artery flap when raised with a gastrocnemius muscle cuff. Other technical tips to ensure a successful outcome are also discussed.

The use of circular wire external fixation in the treatment of salvage ankle arthrodesis

The authors retrospectively reviewed their experience with circular wire external fixation in the treatment of salvage ankle arthrodesis during the past 9 years. The results of 43 cases in a difficult patient population are presented with an average follow-up of 27.0 months. Thirty-three patients (80.5%) went on to achieve a solid fusion or stable pseudarthrosis. A minimum of a 4-ring frame construct was applied for an average of 96.1 days. The major complication rate was 51.2%, including 3 below-knee amputations (7.3%), 7 unstable nonunions (17.1%), 7 cases of osteomyelitis and/or deep-space infection (16.3%), 3 malunions (7.3%), and 2 tibial stress fractures (4.7%). The incidence of complications occurred similarly in patients with Charcot arthropathy, failed total ankle arthroplasty, septic fusion, posttraumatic deformity, or avascular necrosis of the talus, whereas it was relatively higher in patients who were diabetics, smokers, or had an increased body mass index. In addition, the incidence of a nonunion tended to increase with longer follow-up, suggesting that early presumption of a solid union may be erroneous. Based on our defined criteria of a stable, well-aligned fusion without severe pain or activity restrictions, 28 patients (68.3%) had a good result. Circular wire external fixation can be a viable treatment for complex ankle salvage pathology; however, it is difficult to predict the prospects of success or failure.

Ankle and foot injuries: analysis of MDCT findings.

The purpose of our study was to assess MDCT findings and the advantages of MDCT compared with radiography in patients referred to a level 1 trauma center for diagnostic evaluation of acute ankle and foot trauma. During a period of 37 months, 388 patients underwent MDCT of the ankle and foot due to an acute trauma. Imaging studies (MDCT and radiography) were retrospectively reevaluated with respect to fracture location, fracture type, and mechanism of injury, and findings from the primary radiographs of the ankle and foot were compared with MDCT findings. Of the 388 patients, 344 (89%) had one or more fractures in the ankle or foot. A total of 517 fractures were found in all anatomic regions: ankle, calcaneus, talus, midfoot, and forefoot. The three most common occult fractures in the ankle not detected on primary radiography were isolated fractures of the posterior and medial malleolus and Tillaux fractures. The calcaneus was the most commonly fractured bone, and the sensitivity of radiography in the detection of calcaneal fractures was 87%. The sensitivity of radiography in the detection of talar fractures was 78%, whereas it was only 25-33% in the detection of midfoot fractures. A Lisfranc fracture-dislocation was not detected on primary radiography in five (24%) of 21 cases. The three main injury mechanisms were falling from a height (164 patients [48%]), a simple fall (68 patients [20%]), and a traffic accident (47 patients [14%]). In patients with injuries from high-energy polytrauma and in those with complex ankle and foot fractures, the sensitivity of radiography is only moderate to poor; in these cases, MDCT is recommended as the primary imaging technique.

Concomitant traumatic rupture of the tibialis posterior tendon with a closed complex ankle fracture: An uncommon injury, which can easily be overlooked

A complete traumatic rupture of the tibialis posterior tendon is described. A high index of suspicion should be observed in patients with pronation-external rotation type of injury, resulting into a complex ankle fracture dislocation. An eversion attitude under anaesthesia should raise a suspicion. After completing osteosynthesis, a diligent search should be made to confirm or exclude the adjacent tendon injuries. Timely recognition of the concurrent tendon rupture and primary surgical repair prevents tibialis posterior tendon related long-term functional impairments.

Textbook of Bunion Surgery

Dr. Sigvard T. Hansen is a world authority on highenergy multi-trauma and internal fixation. Relatively early in his career, Dr. Hansen broke ranks with his peers and developed some astonishing protocols for dealing with these severe orthopedic injuries, protocols that have been expanded and universally adopted today. He has successfully married these interests to his intrigue with the complexity of foot and ankle surgery such that his focus is on restoring anatomy and function. His position in a respected tertiary care center has attracted a plethora of foot and ankle problems, from relatively difficult deformities and post-traumatic reconstruction to repairing surgical disasters. This book, then, reflects the culmination of 30 years of experience; a universal interest in foot and ankle biomechanics, pathology, and reconstruction, regardless of the source of the information; a steady stream of interested visitors, scholars, and students; and above all, patient feedback. Clearly, it is the sharing of one person’s philosophy, principles, approaches, and techniques deemed successful, as the information is often expressed in the first person. After expressing his principles of surgery for the foot and ankle in the first chapter, the author divides the bulk of his textbook into three sections: trauma, reconstruction, and an “atlas” of surgical techniques. The author’s approaches to even the most difficult types of foot and ankle trauma are presented simply and clearly. The reconstruction section is a series of unique perspectives on such challenging areas as post-traumatic and degenerative problems, progressive flatfoot, the dysfunctional forefoot, the diabetic Charcot foot, and surgical revisions. Many useful and sometimes pioneering ideas are described. The final section on surgical techniques takes the surgeon directly to the operating table. Not only are the procedures clearly described and illustrated, but they are sprinkled with some of the author’s reasoning as well. Refreshing is the simplicity and clarity of the illustrations for the often complex subjects presented. Most consist of anatomical line drawings, simple yet adequately labeled, that are supported by radiographs and associated studies. Unfortunately, there are very few clinical photographs and fewer intraoperative surgical field photographs. Despite these relatively minor deficiencies, this single-author textbook rises above its contemporaries, providing a great deal of useful information for the experienced foot and ankle surgeon, food for thought for specialty residents, and insights into complex foot and ankle problems for students. This book will be a valuable reference for years to come. Stephen J. Miller, DPM

APPLICATIONS OF RING FIXATORS IN COMPLEX FOOT AND ANKLE TRAUMA

There is a growing base of literature that supports the use of external ring fixators in the treatment of complex foot and ankle fractures. Clinical studies that determine definitively the optimal treatment for particular injuries are absent. Small wire ring fixators have a growing role in allowing the stabilization of complex skeletal injuries with a minimum of iatrogenic soft tissue injury. Ring fixators should be considered in the algorithm of treatment of complex lower extremity fractures with associated significant soft tissue injury. One of the cornerstones of trauma management is the preservation of reconstructive options after injury. As interest in ankle arthroplasty increases and experience broadens, such options may be available to patients who sustain severe tibial plafond or talus fractures. It is imperative that hindfoot alignment and height be maintained and infection avoided so that reconstructive osteotomy, arthrodesis, and arthroplasty remain as options for patients who sustain severe trauma.

Protection and performance effects of ankle bracing.

We investigated the protection afforded to ankle ligaments by ankle supports and the extent to which these were associated with a diminution of motor performance. Eleven volunteers were subjected to a 10 degrees tilt in four directions (inversion, eversion, plantar flexion and dorsiflexion) on a rocking platform. Three-dimensional videography was used to record complex ankle kinematics. The prophylactic ankle supports used were a semi-rigid brace, a lace-up cloth brace, and taping. The ankle supports provided similar initial protection against acute ligamentous inversion sprains. The semi-rigid ankle brace produced a smaller restriction of plantar flexion-dorsiflexion movement than either the lace-up cloth brace or taping.

Management of simple and complex ankle fractures

Ankle fractures constitute a considerable part of the trauma surgeon's workload. Although many injuries are straightforward, a high proportion merit surgical intervention. Decision-making depends on recognition of the fracture pattern and its associated ligament injuries. An understanding of the mechanism of injury helps fracture diagnosis as this enables prediction of damaged structures. Fractures in the elderly present difficulties in dealing with poor bone quality, but by modification of technique satisfactory results may be obtained. The mechanism and management of ankle fractures is discussed including current controversies, open fractures and post-traumatic osteoarthritis.

Management of simple and complex ankle fractures

Management of simple and complex ankle fractures

Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases.

To analyze the results of 45 patients after ankle arthrodesis in the presence of joint infection. Arthrodesis was performed with two compression screws and an anterior plate in 29 patients and with two compression screws only in 16 patients. In all patients, additional stabilization with external fixation was used. In 29 patients, isolated fusion of the ankle joint was performed; in 13 patients, the ankle and subtalar joints were fused, and in 3 patients, isolated arthrodesis of the subtalar joint was performed. In 39 of 45 patients (86.6%), solid fusion was obtained. Nonunions occurred in 6 patients (13.4%). A below-knee amputation was necessary for one patient. Full weight-bearing was achieved after 21.6 weeks on average. Thirty-two patients returned to work after 35.5 weeks on average. Five of the six patients with failed ankle fusion needed special shoes; in one patient, a below-knee amputation was performed. A total of 33.3% of failed ankle fusions were associated with systemic disorders such as diabetes mellitus, and other concomitant diseases compromising local arterial blood supply and proprioception. Our results prove that limb salvage is possible even in complex ankle and subtalar pathology by thorough fusion by using a number of different techniques.

Expanding the use of the ankle distractor in the treatment of complex ankle fractures.

Use of the ankle distractor with ankle arthroscopy is well known to allow improved evaluation of the intraarticular surfaces. A less common application of the ankle distractor is for the treatment of complex ankle fractures. We evaluated the use of the ankle distractor in the treatment of six patients with ankle trauma. Five of these cases involved comminuted intraarticular fractures of the distal tibia, and one case involved a malunion of an ankle fracture with widening of the mortise. In each case, the ankle distractor increased the exposure of the ankle joint and allowed better access for fracture fragment reduction. There were no complications associated with the use of the distractor. The technique of using the ankle distractor in these situations is described.

Surgical Treatment of Foot and Ankle Trauma: Use of Indirect Reduction Techniques

A useful intraoperative technique to aid the surgical treatment of complex foot and ankle trauma is described. With mechanical distraction to help obtain bony reduction and improve exposure, it can be used in the acute or reconstructive situation. Indications and a step by step technique are outlined.

Management of Complex Ankle Fractures in Athletes

Outcome from complex ankle fractures depends on the severity of the injury, the accuracy of the reduction, and the institution of soft-tissue rehabilitation. The timing of surgery must take into consideration the degree of soft-tissue swelling and the overall condition of the patient. Good operative technique is vital in preventing complications, restoring anatomic relationships, and obtaining rigid stability. In order to diminish time away from sports, the rehabilitation phase should overlap the healing phase.