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JOURNALOF ORTHOPAEDIC

TRAUMA

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OFFICIAL JOURNAL OF

Belgian Orthopaedic Trauma Association

Canadian Orthopaedic Trauma Society

Foundation for Orthopedic Trauma

International Society for Fracture Repair

The Japanese Society for Fracture Repair

Orthopaedic Trauma Association

AOTrauma North America

Special Case Report Series

CASE REPORTS

Sponsorship provided by Smith & Nephew, Inc.

Treatment of Unstable Ankle Fractures Using ContouredDistal Fibula Locking Plates

Brigham Au, MD

Summary: The treatment of unstable ankle fractures is a com-mon problem for orthopedic surgeons. Multiple components inthe treatment of unstable ankle fractures remain controversial.Optimal fixation strategies in neuropathic and osteoporoticpatients are not presently well defined. Techniques and implantscontinue to evolve in an effort to solve these controversies.Anatomically contoured distal fibula plates offer the biome-chanical advantage of polyaxial locked fixation with a lowerprofile than previous implants to mitigate concerns with woundcomplications. This case demonstrates the use of a contoureddistal fibula small fragment locking plate in the treatment of anunstable bimalleolar ankle fracture.

Key Words: ankle fracture, syndesmosis, locking fixation

INTRODUCTIONAnkle fractures are a common injury treated by orthopedic

surgeons,1 and the incidence of geriatric and osteoporotic anklefractures is increasing.2 Preoperative evaluation, intraoperativedecision making, and postoperative treatment continue to evolve.There are many concepts in the treatment of ankle fractures that arecurrently debated, but the 2main concepts that are always present inthe decision-making algorithm are congruity and stability of thejoint.3,4 The goal of nonoperative or operative treatment for anklefractures is restoration of function by restoring articular congruity

and stability to allow early rehabilitation. The following case dem-onstrates the use of a contoured distal fibula small fragment lockingplate for an unstable ankle fracture.

CASE

History of Present IllnessThe patient is a 40-year-old woman who presented 6 days after

falling on wet cement. The patient was unable to bear weight andwas using crutches, but had not been treated by a physician. She isobese, has hypertension, has not had surgery previously, takesmedication for her hypertension, and does not smoke.

Clinical FindingsOn examination of the left ankle, the patient had non–

wrinkleable skin, ecchymosis, and tenderness to palpation of herankle. Her vascular and gross neurologic examinations were nor-mal; motor examination was intact but limited because of pain. Leftankle AP,mortise, and lateral filmswere obtained in the emergencydepartment, demonstrating a bimalleolar ankle fracture (Figs. 1A–C). The ankle was immobilized in a splint, and the patient wasdischarged home for elevation. No deep vein thrombosis pro-phylaxis was given pre- or postoperatively. Several days later, thepatient presented as planned to the day surgery unit and was foundto have skin amenable to operative fixation.

Surgical TechniqueThe patient was identified in the preoperative holding area, and

a regional block was performed. The patient was taken to theoperating room, and general anesthesia and intravenous antibioticswere administered. The patient was positioned in the right lateraldecubitus position to facilitate posterior malleolar exposure.

The limb was exsanguinated and tourniquet inflated. A postero-lateral incision was used. A sharp dissection down to the deepfascia was performed, and then an anterior flap was createdsuperficial to the peroneals. The fibula fracture was identified,

From the TMI Sports Medicine & Orthopedic Surgery, Arlington, TX.

Invited Lecturer/Speakers Bureau, Smith and Nephew.

Reprints: Brigham Au, MD, TMI Sports Medicine & Orthopedic Surgery,3533 Matlock Rd, Arlington, TX 76015 (e-mail: bau@tmisportsmed.com).

The views and opinions expressed in this case report are those of theauthors and do not necessarily reflect the views of the editors of Journalof Orthopaedic Trauma or Smith & Nephew, Inc.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

DOI: 10.1097/BOT.0000000000001350

J Orthop Trauma � 2018 www.jorthotrauma.com e1

mobilized, and reduced with clamps. A 2.7-mm lag screw bytechnique was placed and clamps were removed.

The interval between the peroneals and the gastroc–soleuscomplex was identified, and blunt dissection was performeddown to the flexor hallucis longus muscle belly. The fascia wasincised to allow mobilization and medial retraction of the flexorhallucis longus muscle. The periosteum was intact and incisedsharply to allow reduction of the posterior malleolus. Corticalreads were used to reduce the posterior malleolus, and a wire wasplaced under fluoroscopic guidance for a 4.0-mm cannulatedscrew.5 Once the screw was placed across the posterior malleolusfracture, attention was returned to the fibula.

A 3.5-mm distal fibula small fragment locking plate was used inthe neutralization mode with 2 cortical screws placed proximal tothe lag screw, and 3 unicortical locking screws placed distal to thelag screw.

The syndesmosis was found to be stable on cotton test, butunstable on external rotation and Candal–Couto tests.6,7 Afteranatomic reduction of the syndesmosis, it was stabilized witha tricortical 3.5-mm position screw under fluoroscopic guidance.Intraoperative fluoroscopic views demonstrated restoration of theankle mortise and articular surface (Figs. 2A–C).

A standard layered closure was performed; a dry dressing andwell-padded posterior splint with stirrup were applied. The patientwas discharged without complication from the day surgery unit.

Postoperative CourseThe patient was seen in the clinic at 2 weeks. Her pain was

controlled with Tylenol #3. She complained of numbness when thefoot was dependent for prolonged periods of time. She had beencompliant with weight-bearing restrictions. The sutures wereremoved and range of motion was initiated with a 3D boot.

At 6 weeks, the patient was seen in the clinic for routine follow-up. She was compliant with weight-bearing restrictions and hadinitiated range of motion exercises.

At 10 weeks, weight-bearing was initiated. Weight-bearingradiographs taken at 3 months showed maintained reduction of theankle mortise and no sign of fixation failure (Figs. 3A–C). Thepatient then began weight-bearing in a 3D boot and working withphysical therapy.

OutcomeThe patient did not follow up at her 6-month appointment

because of financial reasons. Inquiry over the phone was made, andthe patient had returned to full activity and returned to work by 4months.

DISCUSSIONSurgical management of ankle fractures is variable from

surgeon to surgeon because of the wide variety of injury patternsand options available for fixation. An area that deserves furtherinvestigation is the use of distal fibula small fragment lockingplates. Biomechanical studies suggest that there is an advantageto using locking distal fibula plates.8 However, locking platesused in distal fibula fractures have shown a higher level ofwound complications.9,10 Two recent retrospective studies oflocking versus nonlocking fixation for distal fibula fracturesshow no difference in wound complications.11,12 The new gen-eration of contoured locking plates with a lower profile maymitigate wound complications while still providing superiorbiomechanical advantages in patients with osteoporosis anddiabetes.

Biomechanical studies have not translated directly into supe-rior clinical outcomes. The same retrospective study showing no

FIGURE 1. Left ankle AP, mortise, and lateral films obtained in the emergency department, demonstrating a bimalleolar ankle fracture(A, B, and C).

Au

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difference in wound complications also showed no difference inclinical outcomes.11 However, selection bias may have resulted insimilar results because the locking plate group had more diabeticand elderly patients. Another retrospective study aimed specificallyat clinical and radiographic outcomes showed no differencebetween a locking one-third tubular and anatomical distal fibulalocking plate.13 A wide variety of fixation strategies, fixation op-tions, and postoperative protocols makes it difficult to compare 1

type of plate with another, resulting in a variety of outcomes re-ported in the literature.

CONCLUSIONNew contoured, distal fibula locking plates may provide a bio-

mechanical advantage over previous generations of locking plates.Future randomized studies are needed to elucidate the clinical

FIGURE 3. Weight-bearing radiographs taken at 3 months, showing maintained reduction of the ankle mortise and no sign of fixationfailure (A, B, and C).

FIGURE 2. Intraoperative fluoroscopic views, demonstrating restoration of the ankle mortise and articular surface (A, B, C).

Contoured Distal Fibula Locking Plates

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advantages and complications seen while using them in unstableankle fractures.

REFERENCES1. Shibuya N, Davis ML, Jupiter DC. Epidemiology of foot and ankle frac-tures in the United States: an analysis of the national trauma data bank(2007 to 2011). J Foot Ankle Surg. 2014;53:606–608.

2. Olsen JR, Hunter J, Baumhauer JF. Osteoporotic ankle fractures. OrthopClin North Am. 2013;44:225–241.

3. Berkes MB, Little MT, Lazaro LE, et al. Articular congruity is associatedwith short-term clinical outcomes of operatively treated SER IV anklefractures. J Bone Joint Surg Am. 2013;95:1769–1775.

4. Sanders DW, Tieszer C, Corbett B, et al. Operative versus nonoperativetreatment of unstable lateral malleolar fractures: a randomized multicentertrial. J Orthop Trauma. 2012;26:129–134.

5. Erdem MN, Erken HY, Burc H, et al. Comparison of lag screw versusbuttress plate fixation of posterior malleolar fractures. Foot Ankle Int.2014;35:1022–1030.

6. Kortekangas TH, Pakarinen HJ, Savola O, et al. Syndesmotic fixation insupination-external rotation ankle fractures: a prospective randomizedstudy. Foot Ankle Int. 2014;35:988–995.

7. Candal-Couto JJ, Burrow D, Bromage S, et al. Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction? Injury.2004;35:814–818.

8. Minihane KP, Lee C, Ahn C, et al. Comparison of lateral locking plate andantiglide plate for fixation of distal fibular fractures in osteoporotic bone:a biomechanical study. J Orthop Trauma. 2006;20:562–566.

9. Schepers T, Van Lieshout EM, De Vries MR, et al. Increased rates ofwound complications with locking plates in distal fibular fractures. Injury.2011;42:1125–1129.

10. Moss L, Kim-Orden M, Ravinsky R, et al. Implant failure rates and costanalysis of contoured locking versus conventional plate fixation of distalfibula fractures. Orthopedics. 2017;40:e1024–e1029.

11. Lyle S, Malik C, Oddy M. Comparison of locking versus nonlockingplates for distal fibula fractures. J Foot Ankle Surg. 2018;57:664–667.

12. Moriarity A, Ellanti P, Mohan K, et al. A comparison of complication ratesbetween locking and non-locking plates in distal fibular fractures. OrthopTraumatol Surg Res. 2018;104:503–506.

13. Bilgetekin YG, Çatma MF, Öztürk A, et al. Comparison of different lockingplate fixation methods in lateral malleolus fractures. Foot Ankle Surg. 2018;1–5.

Read the rest of the JOT Case Reports online on www.jorthotrauma.com. It’s the Grand Rounds series from the Jour-nal of Orthopaedic Trauma, the official journal of the Ortho-paedic Trauma Association.

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