Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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135 COPYRIGHT © 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Extraperiosteal Plating of Pronation- Abduction Ankle Fractures Surgical Technique By Jodi Siegel, MD, and Paul Tornetta III, MD Investigation performed at the Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 276-81, February 2007 ABSTRACT FROM THE ORIGINAL ARTICLE BACKGROUND: Pronation-abduction ankle fractures frequently are associated with substantial lateral comminution and have been reported to be associated with the highest rates of nonunion among indirect ankle fractures. The purpose of the present study was to report the technique for and outcomes of extraperiosteal plating in a series of patients with pronation-abduction ankle fractures. METHODS: Thirty-one consecutive patients with an unstable comminuted pronation-abduction ankle fracture were managed with extraperiosteal plating of the fibular fracture. The average age of the patients was forty-four years. There were nineteen bimalleolar and twelve lateral malleolar fractures with an associated deltoid ligament injury. No attempt to reduce the comminuted fragments was made as this area was spanned by the plate. The patients were evaluated functionally (with use of the American Orthopaedic Foot and Ankle Society score), radiographically, and clinically (with range-of-motion testing). RESULTS: Immediate postoperative and final follow-up radiographs showed that all patients had a well-aligned ankle mortise on the fractured side as compared with the normal side on the basis of standardized measurements. All fractures healed without displacement. At a minimum of two years after the injury, the average American Orthopaedic Foot and Ankle Society score (available for twenty-one patients) was 82. The range of motion averaged 13° of dorsiflexion and 31° of plantar flexion, with one patient not achieving dorsiflexion to neutral. There were no deep infections, and one patient had an area of superficial skin breakdown that healed without operative intervention. CONCLUSIONS: Extraperiosteal plating of pronation-abduction ankle fractures is an effective method of stabilization that leads to predictable union of the fibular fracture. The results of this procedure are at least as good as those of other techniques of open reduction and internal fixation of the ankle, although specific results for pronation-abduction injuries have not been previously reported, to our knowledge. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION:“Extraperiosteal Plating of Pronation-Abduction Ankle Fractures” (2007;89:276-81). DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. A video supplement to this article developed by the American Academy of Orthopaedic Surgeons and JBJS is available at the JBJS web site, www.jbjs.org. To obtain a copy of the video, contact the AAOS at 800-626-6726 or go to their web site, www.aaos.org, and click on Educational Resources Catalog J Bone Joint Surg Am. 2008;90 Suppl 2 (Part 1):135-44 • doi:10.2106/JBJS.G.01138
136 T HE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2008 · VOLUME 90-A · SUPPLEMENT 2, PART 1 · JBJS.ORG INTRODUCTION The Lauge-Hansen ankle fracture classification system correlates the radiographic features of a fracture with the mechanism of injury, defining which forces to counter in order to reduce and surgically stabilize a fracture 1 . The deforming force in pronation-abduction fractures is translational rather than rotational, with the medial structures failing first, under tension, and the fibula fracturing last. This typically results in FIG. 1 a transverse fracture line approximately 5 cm proximal to the joint with lateral comminution, consistent with bending failure (Fig. 1). With the use of an extraperiosteal approach, the soft-tissue attachments to the fracture fragments are preserved, which maintains blood flow to promote healing and aids in obtaining the reduction. SURGICAL TECHNIQUE The patient is placed supine on a standard operating-room table, with a small bump under the ipsilateral hip so the knee is straight up and down. No tourniquet is utilized. If the ankle fracture is bimalleolar and the medial malleolar fracture pattern is supracollicular, it is reduced and fixed as the first step in the procedure. This aids in the reduction because the deep deltoid ligament, the strongest portion of the ligament, which attaches to the posterior colliculus and the intercollicular groove, is attached to the dis- A bimalleolar stage-3 pronation-abduction ankle fracture showing lateral comminution with bending failure of the fibula after an abduction stress.
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Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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