Ankle Trauma: Does arthroscopy really make a difference? - - PowerPoint PPT Presentation

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Feb 17, 2023 140 likes •527 views

Ankle Trauma: Does arthroscopy really make a difference? Disclosure BESPA Owner Extremity Medical Consultant Nextremity Consultant Types of Ankle Fractures Historical Malleolar Lateral, Medial, Posterior

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Ankle Trauma: Does arthroscopy really make a difference?

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Disclosure

BESPA – Owner
Extremity Medical – Consultant
Nextremity – Consultant

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Types of Ankle Fractures ‐ Historical

Malleolar
Lateral, Medial, Posterior
Bi/Trimalleolar
Pilon
Salter Harris
Tillaux
Nondisplaced
Displaced
If you can see a fracture line it is

displaced

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Mechanism of Injury

Low energy
Twisting
Direct blow
Fall
High Energy
MVA
Fall from height

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Complexity

How did the fracture occur
Severity of displacement at time
f injury
Was the joint loaded?
Pressing brake pedal
Stepped off the curb
Impaction injury
Soft tissue impingement

preventing reduction

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Cartilage injury

Was the mechanism of injury sufficient

to cause cartilage injury

Shearing
Medial talar shoulder on inversion injury
Central talar dome lesion on eversion due

to scraping on lateral tibia

Deltoid injury or medial malleolar fracture
Impaction
Fall from height
Brake pedal
Anterior/Posterior Tibia

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Modalities

X‐ray
Bony anatomy
Alignment
CT
Identify more subtle fracture lines
Analyze the complexity of the fracture
Loose bone fragments
MRI
Cartilage injury
Ligamentous injury
Soft tissue interposition

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Rationale for AORIF

80% of malleolar fractures have a chondral injury
AO – fractures are reduced to restore articular congruity
Articular incongruity in the ankle is not well tolerated
Treatment of osteochondral lesions is often delayed
What damage is being caused by this delay
Impingement – decreased ROM
Additional cartilage damage

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Fracture types ameniable to AORIF

Medial malleolar
Posterior malleolar
Tillaux
Triplane
Tibial Plafond

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Timing

No surgery prior to 6 days
Let soft tissue heal and bleeding to subside
Ideal window is between 6‐12 days
Contradindications
Compromised soft tissue envelope
Excessive swelling +/‐ blisters
Arthroscopy fluid will extravasate into soft tissue ‐LR
Open fractures

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AORIF technique

4.0 mm 30 degree arthroscope
Fluid – gravity to 30 mmHg
Aggressive shaver
Slotted shaver
Reduction instruments
K‐wires
Cannulated screws

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Anterior portals

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Distraction – limit if possible

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Posteriomedial portal

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Fluoroscopy capability

Loose Body
Location of fracture
Reduction evaluation
Hardware placement

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Bone fragments

Resist excising unless

completely loose

Maybe hinged by cartilage
Reduce and prelinarily

fixate

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Cartilage tears

Should this be excised?
Will it heal itself?
How unstable is it?
Excise if unstable or loose

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Microfracture

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Arthroscopy Journal

Fibula fracture is

extraarticular and fixated first

Camera inserted to

verify reduction of medial malleolus fragment

Cartilage evaluated

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Questions

Does the body absorb the cartilage fragments
Native ability of bone to heal
Does fluid pressures hamper healing
What is the definition of a good/excellent outcome?

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64 y/o male – DOI 4 weeks ago

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CT Scan

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Scope images

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Scope Images

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Scope Images

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Post Op

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