Clinical analysis of full-repair strategy under small incision for closed Lauge-Hansen pronation-external rotation type <b>Ⅳ</b> ankle fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Heng ¹ , CHEN Yu ² , YI Zhuojun ¹ ,  ZHANG Hui ²

1. Department of Orthopaedics, Mianyang Central Hospital, Mianyang Sichuan, 621000, P.R.China;
2. Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

ZHANG Hui, Email: caesarzh@163.com

Keywords：

Ankle fracture; small incision; full repair; pronation-external rotation; internal fixation; open reduction

DOI：

10.7507/1002-1892.201911024

Video：

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Objective To investigate the safety, feasibility, and efficacy of full repair strategy under small incision in the treatment of closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture.Methods The clinical data of 57 patients with closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture treated by full repair strategy (fracture, ligament, and cartilage repair) under small incision between January 2012 and January 2017 were retrospectively analyzed. There were 31 males and 26 females, with an average age of 41.1 years (range, 21-65 years). The causes of injury included traffic accident injury in 33 cases and falling injury in 24 cases. All of them were closed fractures, including 20 cases of medial malleolus fracture, 37 cases of complete medial malleolus but deep and shallow rupture of deltoid ligament. The average time from injury to admission was 9.6 hours (range, 3-34 hours). The quality of reduction of distal tibial articular surface (based on Ketz-Sanders standard), the reduction of tibiofibular syndesmosis (the anterior and posterior distances of distal tibiofibular syndesmosis and the lateral ankle twist angle measured by CT scan at 10 mm above the ankle joint line), and the fracture healing were evaluated. The medial clear space (MCS), tibiofibular clear space (TFCS), and distal fibular tip to lateral process of talus (DFTL) were measured on the X-ray films of ankle points. Before and after operation, the pain and functional improvement of ankle joint were evaluated by visual analogue scale (VAS) score and American Orthopedic Foot and Ankle Association (AOFAS) score, and the activities of ankle dorsiflexion and plantar flexion were measured.Results Three cases with osteochondral lesions of the talus were found during operation and all were treated with microfracture techniques. Tournament paralysis occurred in 2 cases after anesthesia. The surgical incisions healed by first intention in all patients. All the 57 patients were followed up 24-84 months, with an average of 38.6 months. All patients achieved bone healing without bone nonunion and malunion at 12 months after operation. The reduction quality of distal tibial articular surface was excellent in 56 cases and good in 1 case at 3 months after operation, the excellent and good rate was 100%. There was no significant difference in the MCS, TFCS, DFTL, anterior distance of distal tibiofibular syndesmosis, posterior distance of distal tibiofibular syndesmosis, and lateral ankle twist angle between the affected and healthy sides at 12 months after operation (P>0.05). At last follow-up, the VAS score, AOFAS score, ankle dorsiflexion and plantar flexion activities of the affected side were significantly improved when compared with preoperative ones (P<0.05). Compared with the healthy side, there was no significant difference in ankle dorsiflexion and plantar flexion activities (P>0.05).Conclusion Full-repair strategy under small incisions for the treatment of Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture is effective and safe. It can not only reduce wound complications, but also improve the quality of joint reduction of the ankle joint and distal tibiofibular syndesmosis. Full repair of ligaments and cartilage can improve the internal fixation strength and joint stability of the ankle joint.

Citation： YANG Heng, CHEN Yu, YI Zhuojun, ZHANG Hui. Clinical analysis of full-repair strategy under small incision for closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(6): 730-736. doi: 10.7507/1002-1892.201911024 Copy

1.	Lamontagne J, Blachut PA, Broekhuyse HM, et al. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma, 2002, 16(7): 498-502.
2.	Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int, 2001, 22(8): 642-648.
3.	Ovaska MT, Mäkinen TJ, Madanat R, et al. Predictors of poor outcomes following deep infection after internal fixation of ankle fractures. Injury, 2013, 44(7): 1002-1006.
4.	SooHoo NF, Krenek L, Eagan MJ, et al. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg (Am), 2009, 91(5): 1042-1049.
5.	Ntalos D, Rupprecht M, Grossterlinden LG, et al. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function-Clinical study and MRI evaluation. Injury, 2018, 49(6): 1220-1227.
6.	Ovaska MT, Mäkinen TJ, Madanat R, et al. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop, 2014, 38(1): 83-88.
7.	Walsh AS, Sinclair V, Watmough P, et al. Ankle fractures: Getting it right first time. Foot (Edinb), 2018, 34: 48-52.
8.	Hess F, Sommer C. Minimally invasive plate osteosynthesis of the distal fibula with the locking compression plate: first experience of 20 cases. J Orthop Trauma, 2011, 25(2): 110-115.
9.	Krenk DE, Molinero KG, Mascarenhas L, et al. Results of minimally invasive distal fibular plate osteosynthesis. J Trauma, 2009, 66(2): 570-575.
10.	Chiang CC, Tzeng YH, Lin CC, et al. Minimally invasive versus open distal fibular plating for AO/OTA 44-B ankle fractures. Foot Ankle Int, 2016, 37(6): 611-619.
11.	Chiang CC, Tzeng YH, Jeff Lin CF, et al. Arthroscopic reduction and minimally invasive surgery in supination-external rotation ankle fractures: A comparative study with open reduction. Arthroscopy, 2019, 35(9): 2671-2683.
12.	Gonzalez TA, Macaulay AA, Ehrlichman LK, et al. Arthroscopically assisted versus standard open reduction and internal fixation techniques for the acute ankle fracture. Foot Ankle Int, 2016, 37(5): 554-562.
13.	Lee S, Lin J, Hamid KS, et al. Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg, 2019, 27(14): e648-e658.
14.	Johnson JP, Vopat BG, Blankenhorn B. Use of a pin distractor as an aid for fixation of pronation-external rotation fibular fractures. Orthopedics, 2017, 40(1): e192-e194.
15.	Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
16.	Lepojärvi S, Niinimäki J, Pakarinen H, et al. Response to “Letter regarding: rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography”. Foot Ankle Int, 2016, 37(10): 1152-1153.
17.	Panchbhavi VK, Gurbani BN, Mason CB, et al. Radiographic assessment of fibular length variance: The case for “fibula minus”. J Foot Ankle Surg, 2018, 57(1): 91-94.
18.	Metitiri O, Ghorbanhoseini M, Zurakowski D, et al. Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int, 2017, 38(4): 443-451.
19.	Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 1997, 18(3): 187-188.
20.	Boszczyk A, Fudalej M, Kwapisz S, et al. Ankle fracture-Correlation of Lauge-Hansen classification and patient reported fracture mechanism. Forensic Sci Int, 2018, 282: 94-100.
21.	Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg (Br), 2000, 82(3): 345-351.
22.	Smeeing DPJ, Briet JP, van Kessel CS, et al. Factors associated with wound-and implant-related complications after surgical treatment of ankle fractures. J Foot Ankle Surg, 2018, 57(5): 942-947.
23.	Cedell CA. Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand, 1967, (Suppl 110): 113+.
24.	Warner SJ, Fabricant PD, Garner MR, et al. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures. J Bone Joint Surg (Am), 2015, 97(23): 1935-1944.
25.	Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma, 2012, 26(7): 439-443.
26.	Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
27.	孙振辉, 陈宇, 张晖, 等. 解剖路径骨-韧带修复技术在旋前型踝关节骨折中的临床应用研究. 中国修复重建外科杂志, 2019, 33(11): 1351-1357.
28.	Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg (Am), 1976, 58(3): 356-357.
29.	Thordarson DB, Motamed S, Hedman T, et al. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg (Am), 1997, 79(12): 1809-1815.
30.	Valderrabano V, Hintermann B, Horisberger M, et al. Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med, 2006, 34(4): 612-620.
31.	Ray R, Koohnejad N, Clement ND, et al. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot Ankle Surg, 2019, 25(2): 180-185.
32.	Wu Y, He QF, Lai LP, et al. Functional outcome of pronation-external rotation-Weber C ankle fractures with supracollicular medial malleolar fracture treated with or without syndesmotic screws: A retrospective comparative cohort study. Chin Med J (Engl), 2018, 131(21): 2551-2557.

1. Lamontagne J, Blachut PA, Broekhuyse HM, et al. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma, 2002, 16(7): 498-502.
2. Höiness P, Engebretsen L, Strömsöe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int, 2001, 22(8): 642-648.
3. Ovaska MT, Mäkinen TJ, Madanat R, et al. Predictors of poor outcomes following deep infection after internal fixation of ankle fractures. Injury, 2013, 44(7): 1002-1006.
4. SooHoo NF, Krenek L, Eagan MJ, et al. Complication rates following open reduction and internal fixation of ankle fractures. J Bone Joint Surg (Am), 2009, 91(5): 1042-1049.
5. Ntalos D, Rupprecht M, Grossterlinden LG, et al. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function-Clinical study and MRI evaluation. Injury, 2018, 49(6): 1220-1227.
6. Ovaska MT, Mäkinen TJ, Madanat R, et al. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop, 2014, 38(1): 83-88.
7. Walsh AS, Sinclair V, Watmough P, et al. Ankle fractures: Getting it right first time. Foot (Edinb), 2018, 34: 48-52.
8. Hess F, Sommer C. Minimally invasive plate osteosynthesis of the distal fibula with the locking compression plate: first experience of 20 cases. J Orthop Trauma, 2011, 25(2): 110-115.
9. Krenk DE, Molinero KG, Mascarenhas L, et al. Results of minimally invasive distal fibular plate osteosynthesis. J Trauma, 2009, 66(2): 570-575.
10. Chiang CC, Tzeng YH, Lin CC, et al. Minimally invasive versus open distal fibular plating for AO/OTA 44-B ankle fractures. Foot Ankle Int, 2016, 37(6): 611-619.
11. Chiang CC, Tzeng YH, Jeff Lin CF, et al. Arthroscopic reduction and minimally invasive surgery in supination-external rotation ankle fractures: A comparative study with open reduction. Arthroscopy, 2019, 35(9): 2671-2683.
12. Gonzalez TA, Macaulay AA, Ehrlichman LK, et al. Arthroscopically assisted versus standard open reduction and internal fixation techniques for the acute ankle fracture. Foot Ankle Int, 2016, 37(5): 554-562.
13. Lee S, Lin J, Hamid KS, et al. Deltoid ligament rupture in ankle fracture: diagnosis and management. J Am Acad Orthop Surg, 2019, 27(14): e648-e658.
14. Johnson JP, Vopat BG, Blankenhorn B. Use of a pin distractor as an aid for fixation of pronation-external rotation fibular fractures. Orthopedics, 2017, 40(1): e192-e194.
15. Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
16. Lepojärvi S, Niinimäki J, Pakarinen H, et al. Response to “Letter regarding: rotational dynamics of the normal distal tibiofibular joint with weight-bearing computed tomography”. Foot Ankle Int, 2016, 37(10): 1152-1153.
17. Panchbhavi VK, Gurbani BN, Mason CB, et al. Radiographic assessment of fibular length variance: The case for “fibula minus”. J Foot Ankle Surg, 2018, 57(1): 91-94.
18. Metitiri O, Ghorbanhoseini M, Zurakowski D, et al. Accuracy and measurement error of the medial clear space of the ankle. Foot Ankle Int, 2017, 38(4): 443-451.
19. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int, 1997, 18(3): 187-188.
20. Boszczyk A, Fudalej M, Kwapisz S, et al. Ankle fracture-Correlation of Lauge-Hansen classification and patient reported fracture mechanism. Forensic Sci Int, 2018, 282: 94-100.
21. Hintermann B, Regazzoni P, Lampert C, et al. Arthroscopic findings in acute fractures of the ankle. J Bone Joint Surg (Br), 2000, 82(3): 345-351.
22. Smeeing DPJ, Briet JP, van Kessel CS, et al. Factors associated with wound-and implant-related complications after surgical treatment of ankle fractures. J Foot Ankle Surg, 2018, 57(5): 942-947.
23. Cedell CA. Supination-outward rotation injuries of the ankle. A clinical and roentgenological study with special reference to the operative treatment. Acta Orthop Scand, 1967, (Suppl 110): 113+.
24. Warner SJ, Fabricant PD, Garner MR, et al. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures. J Bone Joint Surg (Am), 2015, 97(23): 1935-1944.
25. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma, 2012, 26(7): 439-443.
26. Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev, 2018, 3(1): 24-29.
27. 孙振辉, 陈宇, 张晖, 等. 解剖路径骨-韧带修复技术在旋前型踝关节骨折中的临床应用研究. 中国修复重建外科杂志, 2019, 33(11): 1351-1357.
28. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg (Am), 1976, 58(3): 356-357.
29. Thordarson DB, Motamed S, Hedman T, et al. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg (Am), 1997, 79(12): 1809-1815.
30. Valderrabano V, Hintermann B, Horisberger M, et al. Ligamentous posttraumatic ankle osteoarthritis. Am J Sports Med, 2006, 34(4): 612-620.
31. Ray R, Koohnejad N, Clement ND, et al. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot Ankle Surg, 2019, 25(2): 180-185.
32. Wu Y, He QF, Lai LP, et al. Functional outcome of pronation-external rotation-Weber C ankle fractures with supracollicular medial malleolar fracture treated with or without syndesmotic screws: A retrospective comparative cohort study. Chin Med J (Engl), 2018, 131(21): 2551-2557.

Chinese Journal of Reparative and Reconstructive Surgery

Clinical analysis of full-repair strategy under small incision for closed Lauge-Hansen pronation-external rotation type Ⅳ ankle fracture

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