Arthroscopy After Ankle Fracture

Fig. 2.1

(a) Arthroscopic view of distal tibiofibular joint in a left ankle with medial mortise widening on preoperative radiographs. (b) Widening of the syndesmosis is demonstrated when external rotation force is applied to the ankle confirming injury to the syndesmosis and the need to stabilize the distal tibiofibular joint, in this case with syndesmosis screw placement

If an acute osteochondral fragment is noted, the surgeon must decide whether internal fixation or debridement is the appropriate treatment. In general, anterolateral acute osteochondral lesions of the talus have the highest likelihood of having sufficient size and quality of bone to justify internal fixation. If this type of lesion is encountered, internal fixation can be performed arthroscopically or via a small anterolateral arthrotomy approach. If it is elected to debride an osteochondral lesion, then the major fragments are removed using loose body forceps, and the articular cartilage at the periphery is debrided back to well-attached cartilage with perpendicular margins. The base then is stimulated by curettage, abrasion, or microfracture.

If the procedure is being performed for a Maisonneuve injury, it is important to assess the medial gutter for tearing of the deltoid ligament and possible impingement of torn deltoid fibers that could impair anatomic reduction. Torn fibers should be debrided using a shaver, and the ability to anatomically reduce the medial disruption can be assessed arthroscopically.

If there is a suspected syndesmosis injury, then it is important to carefully assess the distal tibiofibular joint arthroscopically. Abnormal motion at the tibiofibular joint can be detected by observing the joint as an external rotation force is applied to the ankle joint which will usually cause the joint to visibly spread and then reduce into anatomic position as an internal rotation force is applied (Fig. 2.2).

Fig. 2.2

(a) This patient presented for treatment of a distal fibula fracture accompanied by widening of the medial mortise which had been neglected for 6 weeks. Initial arthroscopic evaluation of this left ankle demonstrated a loose osteochondral fragment which was removed using a loose body forceps. (b) Arthroscopic view of the medial gutter with the medial malleolus on the left and the deltoid below after debridement of clot and debris from the medial gutter. (c) Arthroscopic view of lateral malleolus fracture at the level of the joint after debridement of clot and debris. Fixation of the lateral malleolus was then performed using a plate and screws along with a syndesmosis screw to stabilize the distal tibiofibular joint

When arthroscopy is performed in conjunction with internal fixation of an intra-articular fracture of the tibia, such as a medial malleolar fracture or tibial plafond fracture, the fluoroscope is useful as the fracture is temporarily fixed with smooth Kirschner wires. The articular cartilage is anatomically reduced using arthroscopic guidance and major fragments are held with the Kirschner wires. After confirming good position, fixation is performed using cannulated screws.

This type of minimally invasive arthroscopic-assisted internal fixation is particularly useful when soft tissue damage makes open exposures more problematic, because of the risk of poor soft tissue healing and infection (Fig. 2.3).

Fig. 2.3

A 65-year-old obese, diabetic female sustained a bimalleolar ankle fracture with significant soft tissue injury. (a) Anteroposterior, lateral, and mortise radiographs show the bimalleolar ankle fracture with displacement of the medial malleolar fragment along with slight shortening and rotation of the fibular fracture. (b) Photographs of the patient’s leg document the severity of soft tissue injury which includes severe swelling with fracture blisters. The treating physician felt that the combination of the soft tissue injury and underlying medical factors including diabetes increased the likelihood of postoperative complications including infection and wound healing and therefore opted to utilize a minimally invasive arthroscopic-assisted approach in treating this patient. (c) Intraoperative photograph documenting injury to the syndesmosis. Fibula at right, tibia at upper left, and talus at lower left in this left ankle. (d) Intraoperative photograph showing injury to the posterior tibiofibular ligament. (e) Intraoperative photograph showing the displaced medial malleolar fracture. (f) Intraoperative photograph documenting accurate reduction of the medial malleolar fracture. Provisional fixation was then obtained using smooth K-wires under fluoroscopic guidance, and then screws were utilized to achieve final fixation. (g–h) Radiographs show final fixation which includes screw fixation of the medial malleolus, percutaneous intramedullary fixation of the lateral malleolus, and screw stabilization of the syndesmosis. The fractures healed uneventfully, and there were no wound healing complications (This case was contributed by Dr. Alastair Younger, Vancouver, BC, Canada)

When arthroscopy is performed for evaluation of chronic pain after ankle fracture, either in the case of a fracture treated nonoperatively or a fracture treated with open reduction and internal fixation, the procedure is performed in a similar fashion. It is however easier because soft tissue injuries including swelling, possible fracture blisters, and acute injury to the muscle, tendon, or capsule are absent. The same setup with noninvasive distraction and use of a three-portal technique is recommended. In cases where significant adhesions cause painful limitation of range of motion, initial visualization may be difficult. Careful insertion of the arthroscope and shaver will allow initial debridement with creation of a working space. This minimizes the potential for injury to the articular surfaces or inadvertent penetration of the anterior capsule with the potential for injury to the anterior neurovascular structures or tendons during further debridement.

2.7 Conclusions

Arthroscopy of acute ankle fractures is gaining acceptance as a valuable tool for identifying and treating pathology. Identification of intra-articular pathology may allow a more accurate prognosis regarding the outcome of ankle fractures. Arthroscopic examination at the time of open reduction and internal fixation allows the diagnosis and treatment of otherwise unrecognized intra-articular pathology, which may decrease early postoperative complications and improve long-term outcomes. With many potential benefits and minimally increased risks, arthroscopy of acute ankle fractures should be seriously considered in operative cases.

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