Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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T HE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2008 · VOLUME 90-A · SUPPLEMENT 2, PART 1 · JBJS.ORG
FIG. 9
The talocrural angle after indirect reduction of the affected side (left) is within 1° of the normal side (right), providing an objective measure
of fibular length and congruence of the mortise 4 .
plate. If fibular length is restored
with this technique, screws must
be placed into the distal fragment
or length will be lost once the
Kirschner wire (or manual traction)
is removed.
If fibular length cannot be
restored with use of this method,
then the last option is to fix the
plate to the distal fragment of the
fibula and use an articulated
compression-distraction device
proximally to push the fibula out
to length. When this is done, a
clamp must be used to hold the
plate to the bone proximally or
the tensioning device will lift it
off the bone. Once length is restored
in this way, the proximal
screws can be inserted in the
plate. The downside to this technique
is the additional exposure
required to use the articulated
compression-distraction device.
However, without restoration of
fibular length, proper ankle mechanics
will not be reestablished.
Care should be taken to maintain
as much soft-tissue integrity of
the fracture fragments as possible
to preserve healing potential.
This outrigger method is simple
and predictable but is rarely
needed.
POSTOPERATIVE MANAGEMENT
Postoperatively, patients who
have a stable syndesmosis are
kept non-weight-bearing for six
weeks, but, in compliant pa-
tients, active and passive motion
is permitted as soon as the
wounds are healed. If syndesmotic
screws are required,
weight-bearing is deferred for
twelve weeks. Active and passive
motion is begun at four weeks in
compliant patients. After twelve
weeks, patients are offered syndesmotic
screw removal. If the
patient chooses to have the hardware
removed, it is removed
prior to the commencement of
any weight-bearing. If the patient
elects not to have the screw removed,
he or she is told that the
screw(s) will either loosen or
break at some point in the future
and the patient is unlikely to
know when that happens.