Weber B Ankle Fracture: “To Scope or Not To Scope... or Just Fix the Bone!” Robert B. Anderson, MD OrthoCarolina Titletown Sports Medicine
Disclosures Consulting: Amniox, Diamond Orthopaedic Royalties: DJO, WMT, Arthrex, Zimmer Biomet
Arthroscopy and Ankle Fractures = you don’t know what you’ll find
Arthroscopy and Ankle Fractures = Great Diagnostic Tool • Allows careful and direct evaluation of articular injury – Chondral surfaces, ligament/capsular structures • Allows debridement of capsular and intrarticular ligament tears, removal of debris • May facilitate reduction and verify stable fixation
Ankle Fractures and Intra-articular Lesions – Hintermann 1999 Clinical Results • 288 acute ankle fractures • Weber A (14); B (198); C (76) • Articular lesions- 79.2% – Talus- 69.4%; Fibula- 45%; Tibia- 46% • No outcome data
Ankle Fractures and Intra-articular Lesions Ferkel et al, 2000 • 47 acute ankle fractures • No preoperative osteochondral lesions • Age 36 years (12-77) • Time to surgery- 7 days avg
Ankle Fractures and Intra-articular Lesions – Ferkel 2000 Clinical Results • Chondromalacia- 19% • Traumatic articular surface lesions- 62% • Free fragments- 28% • 19 talus lesions- 15 medial, 4 lateral No outcome data available
Ankle Fractures and The Scope?
Recent Literature of Scope with Ankle Fractures • Arthroscopy 2015 – Systematic review – Only 2 prospective studies – 63% chondral injuries – 60% Deltoid injury – >70% with syndesmotic injury – No “true” functional outcomes – just incidence
Ankle Fractures and The Scope?
Ankle Fractures and the Scope • Is there improved outcome with arthroscopic-assisted techniques? – Not sure!!! Literature does not support • What is the downside? – Cost!! • Scope often reimburses more than ORIF – Complications??
Arthroscopy is not Benign • Iatrogenic chondral injury • Iatrogenic nerve injury • Sinus tract
Arthroscopy is not Benign
Arthroscopy and Ankle Fractures • There is an advantage – Medico-legal • I use in all elite athletes – Document chondral injury in case they don’t do well with ORIF – Identification and assist with treatment/postop plan • Need for primary cartilage allograft? • Weightbearing/ROM determination However – it is not prognostic…
So... Weber B Ankle Fractures • Arthroscopy should not be the priority but an adjuvant • Fixing the fracture correctly #1 priority – this is prognostic! – Avoid malunion/nonunion • Restoring length and rotation mandatory • Addressing ligament injuries #2 – Avoid chronic subtle instability and secondary chondral injury
Fix the Fracture Correctly - #1 • Anatomic Reduction and Rigid Fixation Mandatory!
Fix the Fracture Correctly - #1 • Percutaneous fixation – Beware!!! – Some advocate for Weber B/C fractures – Rationale • Decreased wound issues • May allow for earlier surgery • Facilitates early rehab – High risk of subtle displacement – Especially rotatory/shortening
Abundant Literature = Avoid fibular shortening and malrotation Saltzmann et al, 2005: fibular malunion leading cause of ankle arthritis...
If you treat it, treat it…
If you treat it, treat it…
#2: Not Just the Fracture – Think Ligaments (Syndesmosis/Deltoid) • Supination-External Rotation (Not just Weber C) • Weber B – bone + ligament – 20% of syndesmotic injuries (Weening, JOT, 2005) – 33% incidence of syndesmotic injury (Jenkinson, JOT 2005)
NFL Study – Cadaver/Computer Modeling • External Rotation of the foot around the tibia – Ligaments rupture in series – a continuum – Altered by addition of DF/eversion – Fibula may fail prior to PITFL
NFL Ankle Injury Research • Injury modeling of the external rotation injury mechanism – Superficial deltoid frequently involved – AITFL > PITFL
Why is Joint Reduction Important? • 1mm of lateral displacement of the talus results in 42% reduction in tibiotalar contact (Ramsey and Hamilton, 1976) • Chissel and Jones, JBJS, 1995 – threshold of 1.5mm diastasis with worsening results with increasing malreduction/diastasis • Weening and Bondari, JOT, 2005 – “ the only significant predictor of functional outcome was reduction of the syndesmosis ”
Fixing Weber B/C Fractures • Intra-operative stress radiographs should be performed after “anatomic” fixation of the fibula
Injury Patterns – Weber B/C • Address associated ligament instability – Syndesmosis – Deltoid complex • Avoid chronic instability and risk of chondral wear Syndesmotic Fixation
Need to Manage the Bone and Ligament Issues Deltoid Fixation
Need to Manage the Bone and Ligament Issues Deltoid Fixation
If not certain about adequacy of reduction and fixation open it! Syndesmosis and Deltoid Complex
My Paradigm Shift… • I started opening the medial side on all Weber C (and Maissoneuve fractures) and some Weber B in 2004 – Found superficial deltoid avulsion amenable to direct repair • Primarily young (18-36 y/o) male athletes • Minimal morbidity; quicker RTP
Acute deltoid complex avulsion off of the medial malleolus an under-recognized injury in athletes Medial * = bare medial malleolus * = deltoid complex avulsion * *
You Can’t Appreciate this with a Scope! Fix the Bone Anatomically; Assess and Stabilize the Ligaments = Improved RTP and Outcome!
Thank You
References: 1 . Hintermann B, Valderrabano V, Boss A, Trouillier HH, Dick W. Medial ankle instability: an exploratory, prospective study of fifty-two cases. Am J Sports Med. 2004;32(1):183-190. 2. Campbell KJ, Michalski MP, Wilson KJ, et al. The ligament anatomy of the deltoid complex of the ankle: a qualitative and quantitative anatomical study. J Bone Joint Surg Am. 2014;96(8):e62. 3. Zeegers AV, van der Werken C. Rupture of the deltoid ligament in ankle fractures: should it be repaired? Injury. 1989;20(1):39-41. 4. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries: diagnosis and management. Foot Ankle Clin. 2006;11(3):625-637. 5. Jeong MS, Choi YS, Kim YJ, et al. Deltoid ligament in acute ankle injury: MR imaging analysis. Skeletal Radiol. 2014;43(5):655-663.
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