Extraperiosteal plating without grafting effective for pronation-abduction ankle fractures

The fixation techniques preserve the periosteum normally stripped by traditional subperiosteal plating techniques.

Extraperiosteal plating performed without bone grafting can effectively reduce and stabilize pronation-abduction ankle fractures, according to a study by surgeons in Boston. The technique also provides fracture reduction without stripping the periosteum, the study authors noted.

"Traditional subperiosteal plating techniques strip the remaining soft tissue from the fracture, making the fragments extremely difficult to align and stabilize with a lateral plate, which has led some authors to recommend bone grafting for comminuted fractures," they wrote.

"Extraperiosteal fixation techniques, which preserve the periosteum and indirectly reduce comminution, have been used for the treatment of other long bones," they wrote.

Jodi Siegel, MD, and colleague Paul Tornetta, MD, both of the Boston University Medical Center, evaluated their outcomes using extraperiosteal fixation in 31 consecutive patients treated at a mean age of 44 years. All cases had unstable, closed pronation-abduction ankle fractures, according to the study, published in the American edition of the Journal of Bone and Joint Surgery.

The study included 19 bimalleolar fractures classified as Orthopaedic Trauma Association (OTA) type 44C2.2 and 12 lateral malleolar fractures with an associated deltoid ligament injury, which were classified as OTA type 44C2.1. The operating surgeon used only medial-side fixation in 18 patients and placed syndesmotic screws in 23 patients, according to the study.

"In all cases, the fibular fracture extended to within 2 cm of the tibiotalar joint, precluding the use of syndesmotic fixation only," the authors noted. Fibular fixation required an average of 16 minutes, they added.

"Immediately postoperatively, all patients had a well-aligned mortise on the fractured side as compared with the normal side on the basis of measurements of the medial, superior, lateral and syndesmotic spaces, the position of the fibula on the lateral view, and the talocrural angle," the authors reported.

In addition, all fibular fractures had healed without evidence of displacement within 10 weeks postop, they said.

Among 20 patients with a minimum of 2 years follow-up, the American Orthopaedic Foot and Ankle Society score averaged 82 points at latest follow-up. Regarding range of motion, dorsiflexion averaged 13° and plantar flexion contracture averaged 31°, according to the study.

Only one patient had fixed plantar flexion contracture of 5°, the authors noted.

For more information:
Siegel J, Tornetta P. Extraperiosteal plating of pronation-abduction ankle fractures. J Bone Joint Surg Am. 2007;89-A:276-281.