Treatment strategies for complex ankle fractures-current developments summarized in a narrative review

Abstract

Background and objective: Ankle fractures occur frequently in patients throughout all ages. Due to the many pitfalls associated with their treatment, complex ankle and especially tibial pilon fractures remain a challenge for surgeons. As there is still need for improvement in treating complex ankle fractures and treatment options are steadily increasing this review aims to summarize current practice and aims to highlight current developments by reviewing the literature.

Methods: We conducted a thorough search of PubMed database in December 2022 to identify relevant articles on complex ankle and tibial pilon fractures. Articles in English and German were included in this study.

Key contents and findings: Complication rates, especially wound infection are still high, emphasizing the need for careful preoperative planning. Soft tissue management is crucial to reduce complication rates and will often dictate the treatment plan utilized. Open reduction and internal fixation (ORIF) remains the treatment of choice. Nevertheless, in select cases alternative methods such as external fixation, tibiotalocalcaneal nailing or conservative treatment need to be considered as well. Furthermore, additional treatment options such as arthroscopically assisted surgery might help to improve functional outcome after complex ankle fractures. The incidence of complex ankle fractures in geriatric patients keeps rising with our aging population. This group of patients demands particular care and further high-quality studies are needed to warrant best results.

Conclusions: However, more randomized controlled trials are need in order to enhance evidence of newly developed treatment options.

Keywords: Complex ankle fractures; osteosynthesis; soft tissue management.

Figure 1

Preoperative CT scan: a large posterolateral, an anterolateral and anteromedial column can be identified; (A) coronal plane; (B) sagittal plane; (C,D) axial plane.

Figure 2

Intraoperative clinical pictures of the posterolateral approach used: (A) marking of surgical incisions between the achilles tendon and the fibula; (B) splitting of the superficial fascia; (C) visualization of the dorsal tibial rim, the forceps point to the posterior syndesmosis. (D) Reduction and fixation of the posterior malleolus with a cannulated 4.0 spongiosa screw; (E) closing of the posterior fascia, before approaching the fibular fracture; (F) depiction of the fibula fracture before reduction.

Figure 3

Intraoperative fluoroscopy: (A) lateral view; (B) mortise view.

Figure 4

Clinical pictures of the distal tibia approach via the anteromedial approach. (A) Full view of the fracture site utilizing the anteromedial approach, the tibialis anterior tendon is held to the lateral side with a Langenbeck hook; (B) reduction with temporary clamps; (C) fixation of the distal tibia using an anatomically precontoured, polyaxial locking plate (2.7/3.5 mm).

Figure 5

Intraoperative fluoroscopy after finalizing open reduction and fixation of the complex ankle fracture: (A) mortise view; (B) lateral view.

Figure 6

Preoperative radiographs and CT scan. (A) A.P.-view prior to reduction; (B) lateral view prior to reduction; (C) lateral view of the CT scan after temporary spanning with EF; (D) axial view after temporary spanning with EF. EF, external fixation; A.P., antero-posterior.

Figure 7

Postoperative radiographs: (A) A.P.-view; (B) CT in lateral view of reduced articular surface; (C) CT in axial view of reduced fracture. A.P., antero-posterior.