Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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139 T HE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2008 · VOLUME 90-A · SUPPLEMENT 2, PART 1 · JBJS.ORG FIG. 2-B Incision and dissection for medial malleolar fixation. The fracture is now reduced and clamped with a bone tenaculum. Note the visualization of the joint while the surgeon is still able to place lag screws perpendicular to the fracture. is not anatomic. If the fibula is not accurately reduced, then the plate must be removed, recon- FIG. 3 Medial malleolar fixation with bicortical lag screws ideally placed parallel to each other and perpendicular to the fracture site. Since the tibia is a curved bone, the screws may appear as though they are not bicortical when in fact they are penetrating the posterior cortex. Bicortical screws increase stability and allow compression across the fracture site. toured, and replaced, with attention to fibular length. If the fibula is anatomically aligned, then the syndesmosis is unstable and needs to be reduced and stabilized as described below. With both medial and lateral stability restored, the syndesmosis must be tested for stability. If the medial injury is ligamentous, the syndesmosis is tested by applying an abduction stress on the foot and evaluating the medial clear space, the syndesmotic space, and residual talar subluxation (Fig. 8-A). If the medial injury is osseous and fixation is in place, then a clamp is placed on the fibula and an abduction stress is applied. If >2 mm of lateral translation occurs at the syndesmotic notch, syndesmotic fixation is indicated. The reduction of the syndesmosis can be accomplished in several ways. Most commonly, we use a large balltipped reduction clamp, which engages a plate hole or screw
140 T HE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2008 · VOLUME 90-A · SUPPLEMENT 2, PART 1 · JBJS.ORG FIG. 4 Intraoperative fluoroscopic image made after preliminary closed reduction. The fibula is out to length as determined by the alignment of the fracture line at the medial cortex. head on the fibula and the anteromedial distal aspect of the tibia. It does not require much force to accurately reduce the syndesmosis, but tightening the clamp too hard can translate the fibula posteriorly. A perfect lateral radiograph to confirm the fibular location and compare it with the normal ankle prevents malreduction as there is no direct visualization of this region. Alternately, direct digital pressure by the surgeon can be used to hold the reduction. In rare cases, the syndesmotic screw can be placed as a lag screw to obtain the reduction, but it must be placed through the plate exactly in the plane perpendicular to the tibiofibular axis and care must be taken not to overtighten it as this will overcontour the plate through the area of fibular comminution. Once the reduction is achieved and is confirmed on the anteroposterior and lateral radiographs, the syndesmotic screws are placed through the plate, which acts as a substitute for the lateral cortex (Fig. 8-B). Typically, syndesmotic fixation is FIG. 5 achieved with one or two fully threaded 3.5-mm cortical position screws (non-lag), placed just proximal to the subchondral bone of the plafond, through the plate, and through three cortices. When there is substantial comminution in the fibula, screws can be placed through the plate and into the tibia to gain additional fixation even if the syndesmosis is stable with a stress examination. This is recommended if more than two screw holes in the plate are not usable because of fibular comminution. Fibular Length Restoring fibular length is one of the most important aspects of this technique. In general, it is not difficult to restore length because of the pure bending mechanism of the injury. Occasionally, however, restoring and confirming fibular length with use of the Intraoperative example of extraperiosteal dissection. The peroneal tendons are visible. The outline of the fibula has been drawn in. There is a rent in the periosteum caused by the initial fracture displacement (red arrow). Weitlaner retractors help to identify the plane between the subcutaneous tissues and the periosteum.
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Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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