Advances in the Surgical Management of Ankle Fractures

Abstract

Ankle fractures are one of the most common injuries treated by orthopedic surgeons worldwide. However, operative indications, techniques, and reported outcomes following operative fixation vary widely in the literature. This evidence-based review focuses on recent advances in the operative management of ankle fractures including arthroscopic-assisted surgery, deltoid ligament complex repair, expanded indications for posterior malleolus fixation, fibula intramedullary nailing, and dynamic syndesmosis repair.

Level of evidence: Level V, expert opinion.

Keywords: TightRope; ankle arthroscopy; deltoid ligament repair; fibula nail; posterior malleolus; syndesmosis.

Figure 1.

(A) Anteroposterior and (B) lateral radiographs of a 24-year-old woman who sustained a closed, right trimalleolar ankle fracture-dislocation after a fall from height. (C) Intraoperative arthroscopy prior to fracture fixation shows a large full-thickness talar osteochondral lesion (OCL), (D) cartilaginous loose bodies from the OCL, and (E) syndesmotic disruption (yellow arrow) not seen on preoperative radiographs.

Figure 2.

(A) Ankle arthroscopy setup for the same patient as shown in Figure 1 using a thigh holder, noninvasive ankle strap, and distractor connected to the foot of the bed. Distraction can be applied to the ankle using manual traction through the L-shaped bar, fine-tuned traction through the hand turn knob, or by slowly lowering the foot of the bed. (B) Anteromedial and anterolateral portals to visualize the entire ankle joint surface using a 2.7-mm scope. (C) Direct visualization of the posterior malleolus fracture with probe in the fracture site to assist with debridement followed by (D) visualization of the articular reduction after screw fixation.

Figure 3.

(A) Preoperative anteroposterior radiograph of a 19-year-old woman who sustained a closed, right fibula fracture with large medial clear space widening. (B) Arthroscopy demonstrated medial gutter hematoma and deltoid disruption (red arrow). (C) A small, curvilinear incision was made over the medial gutter and the deltoid ligament complex was found to be avulsed off the anterior aspect of the medial malleolus (asterisk). (D) Double-loaded 3-mm suture anchors (Suturetak, Arthrex Inc) were placed in the medial malleolus followed by (E) repair of the deltoid ligament using multiple horizontal mattress sutures back to bone.

Figure 4.

(A) Lateral radiograph of a 25-year-old man who sustained a bimalleolar ankle fracture with unstable posterior dislocation after a slide tackle injury. (B) Axial computed tomography cuts demonstrate a posterior rim fracture and distal fibula fracture (C) better seen on 3-dimensional reconstructed imaging. (D) A posterolateral approach was performed and the unstable posterior rim fracture was fixed using a 5-hole 2-mm plate to prevent persistent posterior joint subluxation along with a posterolateral fibula plate as seen on anteroposterior and (E) lateral intraoperative radiographs.

Figure 5.

(A) Lateral radiograph of a 30-year-old woman who sustained a posterior malleolus fracture after a motor vehicle accident. (B) Axial computed tomography cuts show posterolateral and posteromedial fracture fragments with interposed articular comminution (C) confirmed on 3-dimensional reconstructed imaging. (D) A posterolateral approach was used to access both fragments that were fixed using two 2.4-mm buttress plates (E) followed by syndesmotic fixation using a 4-hole 1/3 tubular plate with 2 divergent TightRopes.

Figure 6.

(A) Anteroposterior and (B) lateral radiographs of a 65-year-old woman with diabetes who fell down a flight of stairs sustaining an open bimalleolar ankle fracture-dislocation with lateral soft tissue compromise and medial malleolar comminution. (C) Fixation was achieved using a 3×130-mm fibular nail (FibuLock, Arthrex Inc) along with 2.4-mm medial buttress plate, 3-mm cannulated lag screws, and a TightRope through the nail as seen on anteroposterior and (D) lateral intraoperative radiographs.

Figure 7.

(A) Anteroposterior tibia radiograph of a 40-year-old man who sustained a ground-level fall with resultant right displaced, midshaft fibula fracture with (B) significant syndesmotic and medial clear space widening that is better seen on anteroposterior ankle radiograph. (C) The fibula shaft fracture was fixed using a lag screw and neutralization plate to ensure proper fibula length, alignment, and rotation and to assist with anatomic syndesmotic fixation. (D) A 2-hole buttress plate was used distally with 2 divergent TightRopes for syndesmotic fixation as seen on anteroposterior and (E) lateral postoperative radiographs. The superficial deltoid ligament complex was found to be avulsed off of the anterior aspect of the medial malleolus and flipped into the medial gutter. Therefore, the deltoid ligament was repaired directly back to bone using two 3-mm suture anchors before final tightening of the TightRopes.