Weber B Ankle Fracture: To Scope or Not To Scope... or Just Fix the - - PowerPoint PPT Presentation

Weber B Ankle Fracture: “To Scope or Not To Scope...

• r Just Fix the Bone!”

Robert B. Anderson, MD

OrthoCarolina Titletown Sports Medicine

Disclosures

Consulting: Amniox, Diamond Orthopaedic Royalties: DJO, WMT, Arthrex, Zimmer Biomet

Arthroscopy and Ankle Fractures = you don’t know what you’ll find

Arthroscopy and Ankle Fractures = Great Diagnostic Tool

• Allows careful and direct

evaluation of articular injury – Chondral surfaces, ligament/capsular structures

• Allows debridement of capsular

and intrarticular ligament tears, removal of debris

• May facilitate reduction and verify

stable fixation

Ankle Fractures and Intra-articular Lesions – Hintermann 1999

Clinical Results

• 288 acute ankle fractures
• Weber A (14); B (198); C (76)
• Articular lesions- 79.2%

– Talus- 69.4%; Fibula- 45%; Tibia- 46%

• No outcome data

Ankle Fractures and Intra-articular Lesions

Ferkel et al, 2000

• 47 acute ankle fractures
• No preoperative osteochondral lesions
• Age 36 years (12-77)
• Time to surgery- 7 days avg

Ankle Fractures and Intra-articular Lesions – Ferkel 2000

Clinical Results

• Chondromalacia- 19%
• Traumatic articular surface lesions- 62%
• Free fragments- 28%
• 19 talus lesions- 15 medial, 4 lateral

No outcome data available

Ankle Fractures and The Scope?

Recent Literature of Scope with Ankle Fractures

• Arthroscopy 2015

– Systematic review – Only 2 prospective studies – 63% chondral injuries – 60% Deltoid injury – >70% with syndesmotic injury – No “true” functional outcomes – just incidence

Ankle Fractures and The Scope?

Ankle Fractures and the Scope

• Is there improved outcome with

arthroscopic-assisted techniques?

– Not sure!!! Literature does not support

• What is the downside?

– Cost!!

• Scope often reimburses more than ORIF

– Complications??

Arthroscopy is not Benign

• Iatrogenic chondral injury
• Iatrogenic nerve injury
• Sinus tract

Arthroscopy is not Benign

Arthroscopy and Ankle Fractures

• There is an advantage

– Medico-legal

• I use in all elite athletes

– Document chondral injury in case they don’t do well with ORIF

– Identification and assist with treatment/postop plan

• Need for primary cartilage allograft?
• Weightbearing/ROM determination

However – it is not prognostic…

So... Weber B Ankle Fractures

• Arthroscopy should not be the priority but

an adjuvant

• Fixing the fracture correctly #1 priority –

this is prognostic!

– Avoid malunion/nonunion

• Restoring length and rotation mandatory
• Addressing ligament injuries #2

– Avoid chronic subtle instability and secondary chondral injury

Fix the Fracture Correctly - #1

• Anatomic Reduction and Rigid Fixation

Mandatory!

Fix the Fracture Correctly - #1

• Percutaneous fixation – Beware!!!

– Some advocate for Weber B/C fractures – Rationale

• Decreased wound issues
• May allow for earlier surgery
• Facilitates early rehab

– High risk of subtle displacement

– Especially rotatory/shortening

Abundant Literature = Avoid fibular shortening and malrotation

Saltzmann et al, 2005: fibular malunion leading cause of ankle arthritis...

If you treat it, treat it…

If you treat it, treat it…

#2: Not Just the Fracture – Think Ligaments (Syndesmosis/Deltoid)

• Supination-External Rotation

(Not just Weber C)

• Weber B – bone + ligament

– 20% of syndesmotic injuries (Weening, JOT, 2005) – 33% incidence of syndesmotic injury (Jenkinson, JOT 2005)

NFL Study – Cadaver/Computer Modeling

• External Rotation of the

foot around the tibia

– Ligaments rupture in series – a continuum – Altered by addition of DF/eversion – Fibula may fail prior to PITFL

NFL Ankle Injury Research

• Injury modeling of the external rotation

injury mechanism

– Superficial deltoid frequently involved – AITFL > PITFL

Why is Joint Reduction Important?

• 1mm of lateral displacement of the talus

results in 42% reduction in tibiotalar contact (Ramsey and Hamilton, 1976)

• Chissel and Jones, JBJS, 1995 – threshold
• f 1.5mm diastasis with worsening results

with increasing malreduction/diastasis

• Weening and Bondari, JOT, 2005 – “the
• nly significant predictor of functional
• utcome was reduction of the syndesmosis”

Fixing Weber B/C Fractures

• Intra-operative

stress radiographs should be performed after “anatomic” fixation

• f the fibula

Injury Patterns – Weber B/C

• Address associated

ligament instability

– Syndesmosis – Deltoid complex

• Avoid chronic

instability and risk

• f chondral wear

Syndesmotic Fixation

Need to Manage the Bone and Ligament Issues

Deltoid Fixation

Need to Manage the Bone and Ligament Issues

Deltoid Fixation

If not certain about adequacy of reduction and fixation open it!

Syndesmosis and Deltoid Complex

My Paradigm Shift…

• I started opening the medial side
• n all Weber C (and

Maissoneuve fractures) and some Weber B in 2004

– Found superficial deltoid avulsion amenable to direct repair

• Primarily young (18-36 y/o)

male athletes

• Minimal morbidity; quicker RTP

Acute deltoid complex avulsion off of the medial malleolus an under-recognized injury in athletes

* = bare medial malleolus = deltoid complex avulsion

* * *

Medial

You Can’t Appreciate this with a Scope!

Fix the Bone Anatomically; Assess and Stabilize the Ligaments = Improved RTP and Outcome!

Thank You

References:

• 1. Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W. Medial ankle

instability: an exploratory, prospective study of fifty-two cases. Am J Sports

• Med. 2004;32(1):183-190.
• 2. Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy of the

deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014;96(8):e62.

• 3. Zeegers AV, van der Werken C. Rupture of the deltoid ligament in ankle

fractures: should it be repaired? Injury. 1989;20(1):39-41.

• 4. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis

and management. Foot Ankle Clin. 2006;11(3):625-637.

• 5. Jeong MS, Choi YS, Kim YJ, et al. Deltoid ligament in acute ankle injury: MR

imaging analysis. Skeletal Radiol. 2014;43(5):655-663.