The Posterior Malleolus: Almost Always Fix it BOB ZURA, MD LSU - - PowerPoint PPT Presentation

The Posterior Malleolus: Almost Always Fix it

BOB ZURA, MD LSU HEALTH, NEW ORLEANS OSET 2017 LAS VEGAS

Acknowledge Eric Moghadamian

Disclosures

• Consultant:

– Smith-Nephew – Bioventus – Cardinal Health

Assumption

• Anatomic reduction of the ankle joint and

syndesmosis correlates to better tibio-talar contact pressures and better clinical outcomes.

The Problem

• We are ter

errib ible le at diagnosing and reducing syndesmotic injuries

• It occurs frequently in association with ankle fracture and we

miss them

– Mostly PER injuries

Weening and Bhandari, 2005 Parikenen et al., 2011 JBJS

– But also in SER with no widening on static films:

Syndesmotic Instability in Weber B Ankle Fractures: A Clinical Evaluation Stark, Erik MD; Tornetta, Paul III MD; Creevy, William R MD

Journal of Orthopaedic Trauma 2007

The Problem

• AND even when recognized and treated in an acceptable

manner, we often get it wrong.

– Incidence of malreduction based on CT scan “standard”: >50% – Gardner et al. FAI 27: 788-92, 2006.

• We know this and still don’t get CT’s!

• From January 1, 2004, to December 31, 2006, 107 of 681
• peratively treated ankle fractures (15.7%) had associated

syndesmotic injuries requiring reduction and fixation.

• All patients available at a minimum of 2 years postindex

procedure underwent clinical and radiographic examination, computed tomographic (CT) scanning of both ankles (injured and uninjured)

• functional outcome scoring using the Short Form

Musculoskeletal Assessment and Olerud/Molander questionnaires. The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up Sagi, H. Claude MD; Shah, Anjan R. MD; Sanders, Roy W. MD

Journal of Orthopaedic Trauma Issue: Volume 26(7), July 2012, p 439–443

• Sixty-eight of 107 (63.5%) syndesmotic injuries in 68 patients

were available for follow-up.

• Twenty-seven (39%) were malreduced (rotational or

translational asymmetry) when compared with the contralateral uninjured syndesmotic joint. The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up Sagi, H. Claude MD; Shah, Anjan R. MD; Sanders, Roy W. MD

Journal of Orthopaedic Trauma Issue: Volume 26(7), July 2012, p 439–443

• Fifteen percent of the open syndesmotic reductions were

malreduced on postoperative CT scans, whereas 44% (A/B) of the closed syndesmotic reductions were malreduced on postoperative CT scan (P = 0.11).

• Patients with a malreduced syndesmosis recorded significantly

worse functional outcome scores (P < 0.05) on both the Short Form Musculoskeletal The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up Sagi, H. Claude MD; Shah, Anjan R. MD; Sanders, Roy W. MD

Journal of Orthopaedic Trauma Issue: Volume 26(7), July 2012, p 439–443

http://m8.i.pbase.com/o4/53/688553/1/92037578.lA9AXs4m.neworleans_pano_std.jpg

• At a minimum of 2 years follow-up, patients with malreduced

syndesmotic injuries demonstrated significantly worse functional

• utcome using the Short Form Musculoskeletal Assessment and

Olerud/Molander questionnaires.

• Open reduction of the syndesmosis resulted in a substantially

lower rate of malreduction when evaluated by postoperative CT scan. The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up

Sagi, H. Claude MD; Shah, Anjan R. MD; Sanders, Roy W. MD Journal of Orthopaedic Trauma Issue: Volume 26(7), July 2012, p 439–443

• Based on these findings, we recommend that surgeons not only

perform a direct, open visualization of the syndesmosis during the reduction maneuver, but obtain a postoperative CT scan with comparison to the contralateral extremity as well.

• If the syndesmosis is found to be malreduced, consideration

must be given to revising the osteosynthesis. The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up

Sagi, H. Claude MD; Shah, Anjan R. MD; Sanders, Roy W. MD Journal of Orthopaedic Trauma Issue: Volume 26(7), July 2012, p 439–443

So……

• If there is a posterior malleoulus – why don’t we fix it and get it

anatomic?

Is there an anatomic solution?

Clin Orthop Relat Res. 2006 Jun;447:165-71.

Posterior Malleolus

• The PITFL complex is thought to

contribute the most to stability of the ankle syndesmosis

• 15 consecutive patients with closed PER

Stage 4 ankle fractures involving the posterior malleolus underwent MRI

• 0/15 patients with posterior malleolar

fractures had complete PITFL ruptures

Posterior Malleolus

• Created a simulated PER Stage 4

with posterior malleolus fx

• The fibula was left intact to

simulate rigid fixation of a Weber C fibula fracture.

Posterior Malleolus

• 5 fixation of posterior malleolus

– 70% of intact stiffness

• 5 syndesmotic fixation

– 40% after using a syndesmotic screw.

Posterior Malleolus: Radiographic and Clinical Evidence

• Posterior malleolar fixation vs. open syndesmotic fixation vs.

historic controls with closed reduction

– Direct visualization for syndesmotic stabilization of ankle fractures. Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG.Foot Ankle Int. 2009 May;30(5):419-26 – Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation.Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG.Clin Orthop Relat

• Res. 2009

• Malreductions were significantly reduced in the direct visualization group
• Posterior malleolar reconstruction was the most accurate for syndesmotic reduction
• The tibiofibular clear space was better maintained in PM group compared to the S group
• Patients with PM/PITFL fixation had functional outcomes at least equivalent to those

patients having syndesmotic screw fixation alone

Posterior Malleolus: Radiographic and Clinical Evidence

As a result……

• Lower threshold to image and

address posterior malleolus

Approaches to Posterior Malleolus

Posterior Malleolus

Percutaneous Rx

Approach (prone) FHL Peroneals

post op

Thank You!