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Ankle Fractures, Minimally Invasive Fixation

 

Candidates for percutaneous fixation of ankle fractures are immunosuppressed patients, patients with severe soft tissue compromise, patients with diabetes, elderly patients, and patients with peripheral vascular disease. These patients may be candidates, especially if reduction of the fracture can be obtained in a closed fashion. Precise anatomic reduction of the fibula, the medial malleolus, and the syndesmosis is important in achieving excellent functional outcome after ankle fracture. The talus must be reduced in the mortise and any lateral talar subluxation is an indication for surgery. Open surgery usually utilizes plates and screws, and even with open surgery, the syndesmosis reduction and fixation may not be perfect (there may be malreductions). Open surgery requires dissection of the traumatized soft tissue. Wound complications and infection may occur, especially in certain groups of patients. Surgery is better than conservative treatment especially if it is done properly and after the soft tissue condition improves. Sometimes the soft tissue condition does not improve or it takes longer time than usual to improve. I always thought, that if we do fixation of the ankle percutaneously, we may reduce the incidence of infection and soft tissue complications for these patients. For the last several years, I have used percutaneous fixation of ankle fractures starting with the fibula to try to achieve the fibular length utilizing the currently used landmarks. Then we use cannulated screws (4.5 or 6.5 mm cancellous screws). We use 6.5 mm cancellous screws if the bone is very osteoporotic and if the canal is wide. We try to preserve the soft tissue envelope and decrease the potential risk of infection. You will pass the guide wire percutaneously across the fibular fracture and use fluoroscopy to confirm a good standing point and good reduction of the fibular fracture. The screw is inserted over the guide wire and then the screw is passed across the fracture while the fibular length is maintained. The fracture is kept in a reduced position with the manual reduction techniques. After fixing the lateral malleolus, we attempt to fix the medial malleolus. We use reduction clamps applied percutaneously and the screws are inserted over guide wires percutaneously, which is also fluoroscopically guided. Partially threaded cannulated screws are used. Sometimes I will use three screws in some cases. Fixing the medial malleolus is not as easy as fixing the lateral malleolus. Sometimes I fix the medial malleolus first if the fibula is comminuted and if I think I am going to have trouble in obtaining reduction of the fibula fracture and in obtaining the length of the fibula. In these cases, fixing the medial malleolus first will help you obtain the proper length of the fibula. Sometimes we accept a small area of imperfection in the medial malleolus. The best cases for the percutaneous screws are the cases that do not have a medial malleolar fracture. If there is a medial malleolar fracture present, then you will try not to accept more than 2mm step-off. If you cannot obtain the reduction of the medial malleolus, either you open the fracture and reduce it or you delay opening of the fracture until the soft tissue condition improves significantly. After fixation of the lateral side and the medial side, then the syndesmotic injury is treated with reduction and fixation. The reduction is achieved by a reduction clamp to close and reduce the syndesmosis. The guide wire is used, cannulated screws are inserted over the guide wire, and the reduction clamp is removed. Sometimes I use several syndesmotic screws and sometimes I use them converging or crossing each other (used for strength). Fluoroscopy is always used to show the appropriate reduction and fixation of the syndesmosis.
 

Author
Nabil Ebraheim, MD

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