Speaker: Critically assess patient factors, radiographs prior to ankle surgery
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KOLOA, Hawaii — In his presentation at Orthopedics Today Hawaii, Derek J. Donegan, MD, MBA, noted that ankle fractures are a big spectrum of injury and how surgeons address an ankle fracture determines how patients will function later.
“It is not always your normal ankle fracture. So when you see these injuries, be critical,” Donegan said. “Is it really a bimalleolar? Is it really a trimalleolar? Don’t assume that every fracture is standard.”
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Donegan noted there are several factors that surgeons should be aware of in ankle injuries prior to going into the OR, including patient bone quality and posterior pilon variants. Surgeons should be sure to critically assess patient radiographs, according to Donegan. He added preoperative CT scans have been shown to change operative planning about 25% of the time, with the most common changes including medial malleolar fixation, posterior malleolar fixation and occult Chaput plafond fracture.
Indicated by an articular surface greater than 30%, articular incongruity and joint instability, Donegan noted posterior malleolus fractures can lead to significant instability due to ligamentous attachments and poor outcomes if not addressed.
“If you’re going to fix [a posterior malleolus fracture], how do you get there? The ankle tolerates multiple approaches. Going posterior lateral and posterior medial is completely reasonable,” Donegan said. “If you are going to get there, think about fixing them with buttress-type fixation, if you can. Using plates and screws, I think, is a significant construct that allows for these people to restore their anatomy nicely.”
Reduction and appropriate fixation of the posterior malleolus provide a good joint, reconstitute the ligaments and realign the tibiofibular joint, according to Donegan. He added fixing the posterior malleolus decreases the need for syndesmotic fixation and improves long-term outcomes.
“So, consider fixing them. It is going to add to your stability and it’s going to give patients a nice functional outcome in their ankle long term,” Donegan said.
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Donegan DJ. Complex ankle injuries requiring syndesmotic fixation: Fix even small posterior malleolus if there is one and call it a day. Presented at: Orthopedics Today Hawaii; Jan. 8-12, 2023; Koloa, Hawaii.
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