Endoscopic-Assisted Fibula Reduction With Full Percutaneous Fixation of Ankle Fracture Dislocation

Abstract

Ankle fracture is one of the most commonly encountered fractures. Open reduction and internal fixation is the gold standard of treatment. However, minimally invasive fixation of ankle fracture is gaining popularity among foot and ankle surgeons as the result of recent advances in ankle arthroscopic techniques. Despite this, there are limited reports on endoscopic assessment of fibula fracture. In this Technical Note, we describe an endoscopic-assisted fibula reduction with full percutaneous fixation of ankle fracture dislocation. Patients with noncomminuted fibula fracture or poor soft-tissue condition may be more indicated for minimally invasive ankle fracture fixation. This technique can provide better visualization of fibula fracture during percutaneous fixation and may result in less soft-tissue trauma.

Fig 1

Injury plain radiographs. (A) Anteroposterior view. (B) Lateral view. The radiographs show a Lauge-Hansen supination-external rotation type facture dislocation of the right ankle. Immediate closed reduction is performed. The reduction in tibiofibular overlapping (∗) signifies syndesmosis injury.

Fig 2

Computed tomography (CT) 3-dimensional reconstruction after closed reduction. (A) Anterior view. (B) Posterior view. A CT scan is performed after close reduction. In this instance, it shows a Weber B fracture distal fibula and a posterior malleolus fracture (∗). The fibula fracture is noncomminuted.

Fig 3

Positioning of patient. The patient is placed in a floppy lateral position with a sandbag under the operative leg to reduce the natural external rotation. A pneumatic thigh tourniquet (arrow) is used to provide a bloodless surgical view.

Fig 4

Portal sites are marked as purple cross around the fibula and the screw trajectories are shown as 3 purple lines across the fracture line. The portal sites are marked under fluoroscopic guidance. The DA portal is located over the distal end of fracture line and the PP portal is located over the proximal end of fracture line. The AP portal is marked at the middle of the fracture line. (AP, accessory portal; DA, distal anterior portal; PP, proximal posterior portal.)

Fig 5

Endoscopic image of fibula fracture. Patient is in floppy lateral position. Proximal posterior (PA) portal is the viewing portal and distal anterior (DA) portal is the working portal. A 2.9 mm arthroscopic shaver is used to clear the hematoma to expose the fracture gap for reduction. The fracture gap in labelled in the image.

Fig 6

Endoscopic image of fibula fracture after reduction. Patient is in floppy lateral position. Distal anterior (DA) portal is the viewing portal. The fracture gap after reduction is assessed under endoscopy along the fracture. The proximal fragment is over the top of the view and the distal fragment is at the bottom. The fracture gap in labelled in the image.

Fig 7

Radiographs after fracture fixation. (A) AP view. (B) Mortise view. (C) Lateral view. The intraoperative fluoroscopic images showed a congruent ankle joint and adequate tibiofibular overlapping. The fibula fracture was fixed with 3 lag screws and the syndesmosis is held with TightRope XP (Arthrex, Naples, FL). (AP, accessory portal.)

Fig 8

Early postoperative wound photos. (A) Lateral view. (B) Medial view. The surgical wounds heal with minimal scarring.