2/23/2018 FIBULAR & SYNDESMOSIS MALUNIONS MICHAEL P. CLARE, MD FLORIDA ORTHOPAEDIC INSTITUTE TAMPA, FL USA MORTISE INHERENTLY UNSTABLE ∅ LATERAL MALLEOLUS ∅ ACTS AS BUTTRESS / POST ∅ RESIST LATERAL TRANSLATION OF TALUS MORTISE INHERENTLY UNSTABLE ∅ POSTERIOR MALLEOLUS ∅ RESIST POSTERIOR TRANSLATION OF TALUS 1 2/23/2018 MORTISE INHERENTLY UNSTABLE ∅ MEDIAL MALLEOLUS / ANTERIOR COLLICULUS ∅ SUPERFICIAL P A DELTOID LIGAMENT ∅ ROLE IN RESISTING EXTERNAL ROTATION OF TALUS MORTISE INHERENTLY UNSTABLE ∅ MEDIAL MALLEOLUS / POSTERIOR COLLICULUS ∅ DEEP DELTOID LIGAMENT P A ∅ 1° STATIC STABILIZER ∅ RESIST EXTERNAL ROTATION OF TALUS WHY IS THIS IMPORTANT ? ∅ ANKLE JOINT SUBJECT TO ENORMOUS FORCES OVER RELATIVELY SMALL SURFACE AREA OF CONTACT THE BIG SHOW 7’0” 400# 2 2/23/2018 WHY IS THIS IMPORTANT ? ∅ RAMSEY & HAMILTON: JBJS 58-A, 1976 ∅ 1MM LATERAL TRANSLATION OF TALUS: 42% REDUCTION IN SURFACE CONTACT AREA ∅ 2MM LATERAL TRANSLATION OF TALUS: 64% REDUCTION IN SURFACE CONTACT AREA ∅ DECREASED CONTACT AREA: ABNORMAL DISTRIBUTION OF JOINT STRESSES: ARTHRITIS WHY IS THIS IMPORTANT ? ∅ THORDARSON, ET AL.: JBJS 79-A, 1997 ∅ FIBULAR DISPLX: 2 MM SHORTENING OR LATERAL SHIFT ∅ EXTERNAL ROTATION >5 ∅ INCREASED CONTACT FORCES ON ANKLE JNT: PREDISPOSE TO ANKLE ARTHRITIS WHY IS THIS IMPORTANT ? ∅ RAPID DETERIORATION ∅ POST-TRAUMATIC ANKLE ARTHRITIS 3 2/23/2018 CORONAL PLANE ALIGNMENT ∅ PERFECT SYMMETRY BETWEEN MEDIAL & LATERAL CLEAR SPACE CORONAL PLANE ALIGNMENT ∅ FIBULAR LENGTH ∅ “SHENTON’S LINE” ∅ TALOFIBULAR SYMMETRY ∅ “DIME SIGN” RESTORATION OF FIBULAR LENGTH/ROTATION IS CRITICAL ∅ TALOFIBULAR SYMMETRY ∅ LATERAL COLUMN OF TALAR BODY IN LINE WITH POSTERIOR INCISURA 4 2/23/2018 INDIRECT “PUSH-PULL” ∅ SECURE PLATE TO DISTAL FRAGMENT ∅ CORTICAL SCREW OUTSIDE PLATE (+ 4MM) ∅ LAMINAR SPREADER BETWEEN SCREW & PLATE ∅ PROXIMAL FRAGMENT SECURED WITH CLAMP INDIRECT “PUSH-PULL” ∅ PLATE MUST SIT JUST ANTERIOR TO POSTEROLATERAL RIM OF DISTAL FRAGMENT TO RESTORE ROTATION TIBIAL TUBERCLE TO FOOT AXIS ∅ ROTATIONAL ALIGNMENT ∅ ALMOST ALWAYS ALIGNS WITH 2ND RAY ∅ EXCEPTION: EXTERNAL TIBIAL TORSION 5 2/23/2018 FIBULA USUALLY SHORTENED &/OR EXTERNALLY ROTATED TIBIAL TUBERCLE TO FOOT AXIS ∅ OFTEN MEDIAL TO 1ST RAY TIBIAL TUBERCLE TO FOOT AXIS ∅ TALUS FOLLOWS FIBULA ∅ FIBULA EXTERNALLY ROTATED RELATIVE TO DISTAL TIBIA 6 2/23/2018 STANDING XR ESSENTIAL ∅ DETERMINE ORIGINAL FX PATTERN ∅ ASSESS FIBULAR LENGTH STANDING XR ESSENTIAL ∅ LOOK FOR ASYMMETRY WITHIN MORTISE ∅ ASSESS LATERAL TALAR BODY TO INCISURA CT SCAN ∅ FOR JOINT SUBLUXATION / LARGER POSTERIOR MALLEOLAR FRAGMENTS 7 2/23/2018 CT SCAN ∅ ASSESS JOINT SALVAGEABILITY BILATERAL CT SCAN ∅ USEFUL FOR SUBTLE CASES SHORT FIBULA ∅ RE-CREATE ORIGINAL FX LINE ∅ ALLOWS RESTORATION OF LENGTH & ROTATION 8 2/23/2018 CASE 1 ∅ 19M ∅ COLLEGE BASEBALL PLAYER ∅ INJURY SLIDING INTO 2ND BASE ∅ UNABLE TO BEAR WEIGHT INJURY FILMS: P-ER 4 ORIF DONE ELSEWHERE 9 2/23/2018 4 MONTHS POST-OP ∅ "MY ANKLE IS ROLLING IN" CT SCAN 10 2/23/2018 CASE 1 ∅ PURE EXTERNAL ROTATION MALUNION THRU SYNDESMOSIS ∅ FIBULAR LENGTH RESTORED ∅ SOFT TISSUE INTERPOSITION IN SYNDESMOSIS / MEDIAL CLEAR SPACE? HWR / MEDIAL ARTHROTOMY 11 2/23/2018 SYNDESMOSIS DEBRIDEMENT REDUCTION CLAMP / K-WIRE REVISION FIXATION 12 2/23/2018 ROTATIONAL AXIS RESTORED 2 YEARS POST REVISION ORIF CASE 2 ∅ 32M / PROFESSIONAL CHEF ∅ FELL DOWN STAIRS ∅ P-ER 4 PATTERN ∅ ORIF DONE ELSEWHERE 13 2/23/2018 3 MONTHS POST-OP ∅ PAIN WITH WEIGHTBEARING ∅ "MY FOOT TURNS OUTWARD" COMPENSATORY INTERNAL ROTATION OF LEG CASE 2 ∅ EXTERNAL ROTATION MALUNION OF FIBULA & SYNDESMOSIS ∅ FIBULA SHORT / EXTERNALLY ROTATED ∅ INSUFFICIENT LENGTH OF PLATE ∅ TIBIOFIBULAR SYNOSTOSIS CASE 2 ∅ HARDWARE REMOVAL ∅ SYNOSTOSIS TAKEDOWN ∅ SYNDESMOSIS DEBRIDEMENT ∅ MEDIAL CLEAR SPACE DEBRIDEMENT 14 2/23/2018 CASE 2 ∅ PUSH-PULL / LAMINAR SPREADER ∅ REVISION ORIF FIBULA ∅ OPEN REDUCTION OF SYNDESMOSIS ∅ REVISION ORIF SYNDESMOSIS REVISION FIXATION CASE 3 ∅ 67 YR OLD OBESE FEMALE / S/P FALL 15 2/23/2018 ORIF DONE ELSEWHERE ORIF DONE ELSEWHERE (AGAIN) CASE 3 ∅ SHORTENING / EXTERNAL ROTATION MALUNION OF FIBULA & SYNDESMOSIS ∅ FIBULAR LENGTH NOT CLOSE ∅ MORTISE GROSSLY MALALIGNED ∅ INSUFFICIENT LENGTH OF PLATE 16 2/23/2018 CASE 3 ∅ HARDWARE REMOVAL ∅ NONUNION MOBILIZATION ∅ MEDIAL CLEAR SPACE DEBRIDEMENT ∅ PUSH-PULL / LAMINAR SPREADER ∅ REVISION ORIF ANKLE/SYNDESMOSIS NU TAKEDOWN / REVISION ORIF 2 YEARS POST REVISION ORIF 17 2/23/2018 SUMMARY ∅ LOOK CRITICALLY AT RADIOGRAPHS ∅ DETERMINE JOINT SALGAEABILITY ∅ DETERMINE ORIGINAL FX PATTERN SUMMARY ∅ ASSESS FIBULAR LENGTH ∅ ASYMMETRY OF MORTISE / TALAR BODY TO FIBULAR INCISURA ∅ TIBIAL TUBERCLE TO FOOT AXIS SUMMARY ∅ MUST STRIVE FOR PERFECT SYMMETRY OF ANKLE MORTISE ∅ RE-CREATE ORIGINAL FX LINES ∅ INDIRECT PUSH-PULL: RESTORATION OF FIBULAR LENGTH / ROTATION 18 2/23/2018 19.