Arthroscopy and Management of Ankle Fractures

Arthroscopy and Management of Ankle Fractures

Beat Hintemann

Despite having adequate open reduction and internal fixation, ankle fractures may still be associated with poor clinical outcomes (1, 2, 3 and 4). Residual problems such as chronic pain, arthrofibrosis, recurrent swelling, and perceived instability continue to occur unpredictably after ankle fractures. The cause of such poor outcomes is unclear, yet may be related to occult articular trauma (5, 6, 7 and 8). The use of arthroscopy allowed comprehensive evaluation of the pattern and extent of articular injury associated with acute ankle fractures (9, 10, 11 and 12).


The operative procedure is performed under general, spinal, or epidural anesthesia. The patient is positioned supine with a padded bolster placed under the ipsilateral pelvis. The knee is flexed to about 70° using the knee holder, which allows the foot to hang free. No distraction device is used for the ankle. Following sterile preparation, surface anatomy is carefully outlined. In the swollen ankle, more care is necessary to delineate the important structures. To avoid iatrogenic lesions of the soft tissues and articular cartilage, the joint is first inflated with saline, and the portals are created by blunt dissection. The anterior approach at the lateral border of the anterior tibial tendon is used to insert the 4.5- or 2.7-mm, 30° arthroscope. If necessary, accessory anteromedial or anterolateral portals are used for the insertion of instruments. After having copiously irrigated the joint, the joint is inspected systematically (13).

Arthroscopic Assessment

Chondral lesions are carefully assessed with regard to extent and severity, and graded as described by Outerbridge (14). Unstable chondral flaps are debrided, and free osteochondral fragments are removed. Articular surface lesions and intra-articular ligament integrity and syndesmosis stability are evaluated (Fig. 91.1).

Arthroscopic Reduction and Internal Fixation

The use of arthroscopic reduction and internal fixation (ARIF) is surgeon dependent. Reported indications for ARIF include transchondral talar dome fracture, talar fracture, low-grade fracture of the distal tibia, syndesmotic disruption, malleolar fracture, and chronic pain following definitive management of fracture about the ankle. Among the potential benefits are less extensive exposure, preservation of blood supply, and improved visualization of the pathology.

Percutaneous manipulation of fracture fragments under direct visualization is performed using fluoroscopy as needed. If arthroscopically assisted reduction of the medial malleolus or distal tibia fracture is successful, cannulated screw fixation under fluoroscopy control is undertaken without open exposure of the fracture site. If the fracture morphology precludes arthroscopic reduction, open reduction and fixation (ORIF) are then performed. This is typically the case for a fracture of the fibula.

Postoperative Care

Postoperatively, the ankle is routinely immobilized in a posterior splint until swelling-down and safe wound-healing. Thereafter, the patients are kept in a cast or a walker for a minimum of 6 weeks following surgery with a period of 4 to 6 weeks of partial weight-bearing immobilization, and additional 2 or more weeks of weight-bearing immobilization.

Jul 22, 2016 | Posted by in ORTHOPEDIC | Comments Off on Arthroscopy and Management of Ankle Fractures

Full access? Get Clinical Tree

Get Clinical Tree app for offline access