Ankle Fracture Fixation

Introduction

• The presentation is case-based, progressing from simple to complex ankle fractures.

• The speaker will share their experience using Acumed implants: plates, Acu-Sinch, and nails.

• The content reflects the speaker's opinions and does not represent Acumed's official views.

About the Speaker: Samuel Ford, MD

• Practices in Charlotte, North Carolina, at Ortho Carolina.

• Residency at Carolinas Medical Center, fellowship in Dallas.

• Takes level one trauma call and manages complex trauma and reconstruction cases.

Defining Complex Ankle Fractures

• Bone-related Factors:

  • Fracture comminution.

  • Segmental fracture patterns.

  • Associated plafond fractures.

  • Marginal joint impaction.

  • Syndesmosis or deltoid ligament injuries.

  • Specific posterior malleolar fracture variants.

• Patient-related Factors (crucial):

  • Age and activity level.

  • Soft tissue condition (most important).

  • Bone quality.

  • Smoking or drug use.

  • Neuropathy and patient trustworthiness/compliance.

  • Life stage considerations.

Simple Ankle Fracture Case

• Patient: 19-year-old healthy male with an ankle twist from wrestling.

• Treatment Decision: Surgical fixation despite some literature suggesting potential for conservative treatment.

• Rationale: Benefits of early mobilization and functional rehabilitation.

• Procedure:

  • Anatomic reduction via standard lateral exposure.

  • Fixation with a simple lateral plate (e.g., ankle three lateral locking plate).

  • Possible lag screw with neutralization plate (standard AO principles).

• Plate Features: Well-contoured, low profile, and stiff.

• Early Weight Bearing: Achieved almost day one.

• Syndesmosis: One suture button (AccuSynch device) placed due to slight external rotation stress positivity, allowing weight-bearing in two weeks.

• Deltoid Ligament: No repair needed due to negative talar tilt.

• Outcome: Expectation of full recovery without complications.

• Plate Selection: Crucial based on fracture characteristics (e.g., stiffness for comminution or segmental injuries).

  • Distal 2.7 clusters, proximal 3.5 (typically used non-locking).

  • Medium malleolus hook plate.

  • Posterior tibia plates with good contour and size appropriateness (3.5 in shaft, 2.7 at the joint).

More Complex Ankle Fracture Case

• Patient: 47-year-old woman who slipped on pine needles.

• Presentation:

  • Reduced in ER (presumed dislocation).

  • Deltoid insufficiency.

  • Thin wafer butterfly fragmentation on the posterior fibular cortex.

• Treatment Strategy: Combines AO principles with locking plate techniques.

• Plan A (AO Principles): Anatomic reduction, compression with lag screw, neutralization plate (questionable early weight bearing due to cortical insufficiency).

• Plan B (Combined Approach): Anatomic reduction, spanning with a locking plate for increased stability.

• Plan C (If Reduction Fails): Plate as reduction tool; distal locking screws to regain length, proximal non-locking screws.

• Procedure:

  • Anatomic reduction achieved distally.

  • Posterior cortical pieces left undisturbed as they didn't aid reduction.

  • Longer plate used to span the segmental injury.

  • Locking plate acts as a load-sharing, fixed-angle device.

  • Lag screw added for extra stability.

  • External rotation stress positivity addressed with two posterolateral to intermediate trajectory AccuCinch devices.

• Weight Bearing: Allowed at four weeks (potentially six to avoid risks).

• Outcome: Patient back to regular activity at four months.

Weber C Level Fracture

• Patient: 34-year-old male, works as an echotech, ankle fracture dislocation.

• Fracture Characteristics: Weber C fibula fracture with possible posterior comminution, small posterior distal tibia fracture.

• Treatment Options:

  • Nailing (spares a larger incision, good for swelling).

  • Open reduction and plating.

• Speaker's Preference: Open reduction and plating due to the need for anatomic reduction, especially distally.

• Intraoperative Technique:

  • Acceptable flexion deformity at the shaft due to fragment fit.

  • Compression screws through the plate.

  • Posterior butterfly fragment addressed with inner fragmentary screws aiming posteriorly.

• Syndesmosis Fixation: Flexible fixation used due to instability on rotation stress.

• Syndesmosis Fixation Trajectory: Posterolateral to intermediate.

  • Centroid View: Internal rotation lateral X-ray aligning fibular shadow in the tibial shadow to target the perpendicular axis of the syndesmosis.

  • Flexible fixation placed along this axis for reduction within the incisura.

• Flexible Fixation Benefits: Lower reoperation rate and better cost-effectiveness compared to rigid fixation.

• Post-operative Care:

  • At seven months, the patient is running 1.5 to 2 miles.

  • Calcification of the postramellitus.

Segmental Fibula Fracture Case

• Patient: 42-year-old healthy engineer, active, ankle twist during whitewater rafting.

• Fracture Characteristics: Segmental fibula fracture.

• Treatment Goal: Activity restoration with appropriate fibula alignment.

• Treatment Strategy: Locking plate construct is essential.

  • Lag screws alone are insufficient.

  • Avoiding multiple small plates and screws to preserve bone vascularity.

• Technique:

  • Clamps used to restore length and alignment.

  • K-wires used for temporary reduction.

    • Proximal K-wires: Anterior to posterior for proximal fragment reduction.

    • Distal K-wires: Lateral to medial out to medial skin (posterolateral to intermediate trajectory) to accommodate plate placement.

  • Locking screws distally, non-locking screws proximally.

  • Stiff Plate Spanning.

• Posterior Malleolus Management: Percutaneous screw compression preferred over open reduction and internal fixation (ORIF).

  • Wire placed percutaneously from anteromedial to posterolateral, then a screw inserted from posterolateral to anteromedial.

  • Referenced paper by Max Mikulski on safe zone for screw placement relative to the syndesmosis.

• Additional Fixation: Acu-Sinch devices along the centroid axis.

• Deltoid Ligament Repair: Necessary due to open talor tilt.

• Outcome: Patient ran five miles the day before a 3.5-month follow-up visit.

  • Aggressive dorsiflexion at two weeks encouraged.

• Acu-Sinch Function: Micromotion (rotational and translational) of the fibula relative to the tibia indicating syndesmosis stability.

Ankle Fracture with Comorbidities

• Patient: 35-year-old female with lupus, on mycophenolate and hydroxychloroquine (immunosuppressants), increasing infection risk, ankle twist on inflatable slide.

• Treatment Strategy: Prioritize minimizing infection risk.

• Fibular Nail: Selected due to good bone quality and the need to minimize soft tissue disruption.

• Surgical Technique:

  • Closed reduction through a 2 cm posterolateral incision.

  • Fluoroscopic guidance.

  • Confirmation of congruence to lateral shoulder.

  • Guidewire inserted into the fibula.

    • Avoiding medial placement (joint violation) and lateral placement (lateral wall breach).

  • Nail insertion with attention to position relative to the syndesmosis.

  • Centroid technique again is used.

• Syndesmosis Fixation: Flexible fixation to stabilize posterior mouth fracture.

• Medial Malleolus Fixation: Two screws provide good bite and compression.

• Outcomes:

  • Minimal incision length (2 cm).

  • Acceptable Weber B reduction.

Fibular Nail Details

• Advantages: MIS option, adaptable length and width, headless hexalobe screws.

• Proximal Locking: Available for spanning segmental injuries.

• Compatibility: Works with AcuSinch Knotless (note: proximal syndesmosis hole is threaded, requiring consideration with knotless suture buttons).

Posterior Malleolus Fracture Case

• Patient: 72-year-old healthy male, fall down the stairs, talus driven out the back of the distal tibia.

• Fracture Characteristics:

  • Medial malleolus fracture (anterior colliculus only).

  • Standard Weber B fibula fracture.

  • Large posterior malleolus fragment.

• Imaging: CT scan rules out marginal impaction of the distal tibial plafond.

• Treatment Principles:

  • Posterior approach for direct reduction.

  • Good anti-glide plating.

  • Precontoured plates offering better fit.

• Patient Positioning: Prone position with knee flexion.

• Fixation Technique:

  • Apex screw placement and metaphysis screw.

    • Ball spike to compress at the joint.

• Additional Plate Features: locking swap out options used and Cortical screws aid reduction.

• Fibular Fixation: Posterolateral fibula plate.

• Medial Malleolus Fixation: Small anteromedial incision for direct reduction and screw placement.

• Outcomes:

  • At six months, some soreness and swelling with exercise but back to exercising.

  • Limited dorsiflexion loss (5-10 degrees) despite early dorsiflexion exercises.

  • Heterotopic bone formation.

Pilon Fracture Case

• Patient: 32-year-old female, fall down the steps, smokes and vapes.

• Initial Management: Aspirin for DVT prophylaxis, CT scan required.

• Fracture Characteristics:

  • Median malleolus is in four pieces.

  • Marginal impaction along the lateral joint surface of the tibial plafond.

  • Fractional line where the reduction order matters.

• Key Principle: Reduce posterior medial tibia before posterolateral.

• Surgical Approach: Posterolateral and large medial exposure.

  • Anterior leading edge of the posterior tip sheath exposure.

  • Posteromedial Anti Galli.

• Reduction Sequence: Posteromedial fragment first, then posterolateral fragment.

• Fixation Strategy: Posteromedial anti-glide plate, then a posterolateral fixation. At this point, only a tubular or Anti-glide for the fibula is needed.

• Outcomes:

  • At six weeks, the patient has ankle dorsiflexion to 10 degrees.

  • Slow filling in of the comminuted anterior margin of the mutable illness (but stable).