The next one, we're going to have Dr. Mignacci come up and talk about ankle fractures and some of the controversies within that realm. Good morning, everyone. Thank you for having me. I am Sarah Limignacci-Coxsett, and I am happy to be here today and hiding from Cleveland, so this is awesome. So no disclosures related to this talk. So when I was asked to give this talk, you know, it was controversies and ankle fractures, so I tried to pare down kind of the things that I thought would be interesting to talk about. So first, we're going to discuss rotational ankle fractures, what they are, you know, what we see, and then I kind of picked out four controversies that I thought we could talk about. So the first is, how do we stress a lateral malleolus fracture? How do we fix this in dysmosis? When do you fix the posterior malleolus, and how do you approach the deltoid ligament and should you? So when we talk about rotational ankle fractures, we're typically talking about malleolar fractures. So these are your typical either isolated malleolar fractures or bimal or trimal fractures. We are not talking about pilon fractures today. Those are the smashy, high-energy, you know, distal tibia fractures with articular involvement. Those are a different beast, different animal. So we're really talking about rotational injuries. And so these are incredibly common, you know, the stats that I found, 187 per 100,000 adults per year. And really, isolated malleolus fractures are the most common at 70%. We also see about 20% bimalleolar fractures and only 7% trimalleolar fractures. So obviously, just like any traumatic injury, we want to start with examining the foot and the ankle. So you want to note the presence of wounds. Obviously an open fracture, you need to address appropriately with antibiotics and usually taking them to the operating room in the appropriate amount of time. Always looking for skin tenting. Usually in the emergency room, if there's something tenting the skin, you want to reduce the ankle as quickly as possible, splint it to make sure we take the pressure off the skin. The longer an ankle is left dislocated, especially that medial skin, because 98% of these are dislocated laterally, you're going to get tenting of that medial tibia on that skin. And originally, at the initial outset, it's okay, but then, you know, when I see these patients a week, two weeks later, you know, they start to get necrosis of that medial skin, and they can actually get wounds there, and it can be really problematic. So timely reduction is incredibly important. And then for swelling and fracture blisters, this tends to dictate when we take patients to the operating room. So if someone has reasonable swelling with good skin wrinkles and no fracture blisters, they're ready for the operating room. If they're still very swollen, you know, that glassy skin that you see, that, you know, there are no skin wrinkles, you want to wait to operate on those. And then obviously, a good neurovascular exam. And so this is obviously not ankle fractures, but just reviewing our standard imaging of the ankle. So we have our AP, our mortis, and our lateral, which we need to get in an ankle fracture situation as well, because it's going to give us lots of information. And we use a couple classifications. I think the Weber classification is the easiest, and we tend to use this quite a bit, where our Weber A fracture is either infrasyndesmotic or below the level of the plafond, where Weber B is at the level of the plafond or syndesmotic, and then Weber C is above the level of the plafond. This system's great for descriptive, right? If you tell anyone you have a Weber C ankle fracture, they know exactly what you're talking about. It doesn't tell you a lot about, you know, necessarily the medial side of the ankle. Also doesn't tell you how you may want to approach this in the operating room. And then the Loggie Hansen classification is definitely more detailed, and there's a lot of different steps, but really what it does is it indicates not only the deforming forces, but how you're going to reduce. So if it was a supination, external rotation, you know, you typically have to do the opposite. So you have to internally rotate and pronate to get the ankle back and reduce it. You know, the first word talks about supination, talks about the position of the foot, and then the second word, external rotation, internal rotation, abduction, adduction, discusses the force that was directed on the foot. There's a little bit of controversy about this in terms of reproducibility, but it is still classic, and we still use this on a regular basis. The interesting thing about this classification is that, you know, it goes in stages, and we're going to zone in on the supination, external rotation ones today, but, you know, that kind of implies the level of injury, and it applies, you know, what needs to be fixed and the stability of the ankle. So how do we decide if a malleolar fracture needs to be treated or not, operated on or not? They're all treated, but it's whether it's operative or non-operative. So our goal is to keep the talus under the tibia, and so this is the key concept. As long as you can keep the talus under the tibia, you're in a good position. And the reason we care so much about this is because there's been some great study, biomechanical studies, looking at shifting of the talus, and if you shift the talus just one millimeter, you decrease that surface area, increase contact pressures, and down the road, leading to an increased risk of arthritis, and that's what we're really trying to avoid. You know, I tell a lot of my patients, that fibula is going to heal, whether I operate on you or not operate on you. It's not a bone that doesn't heal. It's whether the ankle's stable that decides whether I need to do surgery or not. So let's start with controversy number one, which is the isolated fibula fracture. And as I alluded to, these are typically seen in supination external rotation. These are the ones I'm going to talk about. Weber C fractures, those super syndesmotic ones, those are typically a different injury pattern that has injuries at the ankle that make them unstable right from the beginning. But as you can see, this is the stages of a supination external rotation. And so it starts with an injury to the ligaments on the lateral side of the ankle, progresses to that Weber B fibula fracture. Stage three includes a posterior fracture or disruption of the posterior ligament complex. And then on the final stage is either a medial malleolus fracture, so you'd get a typical bimalleolar fracture, or a deltoid ligament injury. And so how do we know the ankle is stable? Well, there's some things we look at. So the medial malleolus provides a lot of stability, the lateral malleolus, obviously, and then the deltoid ligament. If you have intact of any of those things, typically you have a stable ankle. So if you have an isolated fibular fracture, but an intact medial side in both the deltoid and medial malleolus, you have a stable ankle fracture. If it's kind of like one of those two-thirds thing, if you've got two of these out, you're probably not okay. So how do we know if there's a medial-sided injury? So in a bimalleolar fracture, it's obvious. There's a medial malleolar fracture. Game over, unstable injury, it needs surgery. But if it's the deltoid ligament, how can you tell? And so this one's obviously very obvious. There's a lot of medial clear space widening. So this is very clearly an unstable or an SCR4 injury that we would probably recommend surgery for. But sometimes it can be subtle, and sometimes you can't really tell. And so this is another patient where, you know, is it stable or not stable? And this is where the controversy comes in, and there's a lot of studies that have looked at, you know, medial tenderness, well, no, that's not sensitive or specific. Can we get an MRI to tell us if the deltoid's out? Nope, that doesn't really help us either. And we all think it's because there's these different branches of the deltoid ligament, which we'll talk about in a little bit, but the deep and superficial sections of the deltoid, and we really think it's the deep deltoid. So someone can have a superficial deltoid rupture with an SCR4 injury, but have a stable ankle still. And that's why we talk about stress X-rays. So the controversy is how do you stress your ankle? And so do you do an external rotation, which is in the operating or in the fluoro suite? Do you do a gravity stress view, or do you have the patient do weight-bearing X-rays? So there's really no data to support one over the other. Rotation stress view is classic. It's what all the residents do. You know, they go to the X-ray suite, and they get under there, and they externally rotate the ankle. In a clinic setting, you know, if you're not in the emergency room, if you're, you know, someone like me comes to clinic, this is really hard. You know, I can't run out of my clinic and go to an external rotation stress test and come back, you know, I'll be 10 patients behind, and everyone's yelling at me, and it's just not a good day. And you need to help with your X-ray tech as well. And this can be painful. This patient has a broken ankle, so you're now actually pushing on their broken ankle. So patients don't love this. The second is a gravity stress view. So you can see the picture on the top that shows how you set the patient up. You know, you obviously need the lateral side down. The number of stress X-rays I've seen with the medial side down, that doesn't work that way. So you have to have the lateral side down. You let the foot sit free. And the idea is that the foot has this constant gravitational force. You get a mortise view, and you can see that medial clear space widening. It's a little less painful for the patient because you're not, you know, but it's still painful. And then finally, weight-bearing films have gotten a little bit more popular because it actually is in a loaded position. One of the critiques of the gravity stress view and the external rotation stress view are that the patient can plantar flex their foot. And as we all know, the talus is wider anteriorly than posteriorly. And so it can give you this false appearance of a widening of the medial clear space when it's actually just because of the position of the foot. So weight-bearing films put that foot in a loaded neutral position, but patients may not put their full weight on it. So that's where the concern comes with a weight-bearing. And so what I kind of tried to do with each of these controversies is say what my opinion is. Now, obviously, this is my opinion, but so I prefer to do a weight-bearing stress for a lot of reasons. So one is that I like the idea of getting the talus into a neutral position. So I know that I'm looking at a true look of the talus in the mortise. The second is, quite frankly, it's easier for my clinic flow. So if I have a patient that I need a stress view on, I explain it clearly to the patient why I'm doing this. I'm not sending them to torture them. I'm trying to decide if their ankle is stable or not and needs surgery. So I can send them to my x-ray suite and have them come back. And sometimes I actually just have them come back one week later after walking on the ankle in a boot and re-x-ray them. There's actually a couple of good studies that have come out recently that said that's completely acceptable, and it really based on the injury films. So if your injury films show you widening, it's game over at that point. But if it's one of these, eh, it's not really wide, it's not, you know, that's how I like to treat these patients. All right, so controversy number two is syndesmotic fixation. So the syndesmosis, obviously, that area between the tibia and the fibula, and this can be injured in any of our rotational ankle injuries. And there's a couple methods that have been used to fix this. So screws have historically been, you know, the workhorse of this, but newer, flexible suture button fixation has kind of taken off in the last 10 years or so. So again, this is historically how we achieve syndesmotic fixation, and this patient is actually someone that was diabetic, which is why I have three screws there. As you'll see, this is really one of the only situations where I use syndesmotic screws, but we call this the comb because it gives more stability, and, you know, for our diabetic patients who like to ruin ankle fractures really easily. So it's more rigid fixation with a screw, and usually most people will talk about removing those, although that's a controversy all on its own. But there is some concern for malreduction, and there's been quite a few studies that have looked at malreduction after screw placement, and it is quite significant. So suture button fixation is flexible, and so the idea being that you drill a track across the fibula and the tibia after reducing your syndesmosis. The far button flips as you go across, and then you use those sutures to tighten it. It's like a pulley, and that pulls the two bones together. Studies have shown that there's less malreduction. I can say in my own practice, you can actually see the fibula kind of fall into place when you use this fixation method. You don't have to remove these unless there's an issue with them. And again, some more recent studies have actually shown improved functional outcomes with suture button fixation versus screw fixation. And so again, my opinion, I like the suture button construct, except in diabetics. That is a hard no. So you have to put screws in the diabetic. I like them. I think I get a better reduction. I don't have to remove the implants, and so I have gone towards almost all suture button constructs. All right, so the next controversy, the posterior malleolus. So if you go on OrthoBullets, they're going to tell you that you need to fix any posterior malleolus fracture that has greater than 25% of the articular surface is involved. And the idea behind this is, one, it prevents tailor subluxation and that articular incongruity, and the larger fragments tend to be associated with poor outcomes in arthritis. Which makes sense. This really is kind of almost bordering on a pilon variant. It's becoming more of an interarticular fracture. And so one, why is the posterior malleolus important? Well, that's where the syndesmotic ligaments attach to. So the posterior inferior tibiofibular ligament, or PITFL, attaches from the posterior fibula onto the posterior malleolus fragment. And so it's stability of the ankle that we're really worried about. And so some people are now advocating even fixing smaller fractures of the posterior malleolus because that's where the stability comes from. So this argument that it's a hard line of 25% is somewhat going to the wayside and saying, well, no, no, no, we need to be looking at stability of the ankle. And again, there's some biomechanical studies that have said by actually fixing the posterior malleolus fracture versus just fixing the syndesmosis, you get a better fixation and a more stable ankle by directly addressing the posterior malleolus fragment. And so this is an example of one that I think there'd be no argument about fixing. That's a pretty large fragment in the joint. You can see that's definitely at least 25%. But also, that's a really big fragment with a step off. And so my method for these, I use a posterior lateral approach, and I usually reduce with some wires. Once I get it reduced, then I think in this one I put a couple cannulated screws to compress down the fracture, and then supported it with a buttress plate. And then proceeded to fix the fibula. But in this one, maybe not. This is a little bit of a smaller fragment. This is also an older patient, so that sometimes plays into my thinking and my plan. And so for this one, once I reduce the fibula, that posterior malleolus fracture actually reduced quite nicely on the lateral x-ray. And so for this one, I supplemented with suture button fixation instead of fixing the piece directly. And so if I have larger fragments, and especially in an ankle that was dislocated, I usually fix it. If it's a small fragment, if there was no dislocation at the time of injury, and it's an older patient, I will likely either just address the syndesmosis or perform a percutaneous fixation. But if I have a younger patient, especially an athletic patient, they had a fracture dislocation, and even if that piece is small, I will often choose a posterior approach and fix, even if it's just putting one screw in that fragment, to actually reduce and fix that fragment. And so our final controversy is looking at deltoid ligament. So we've kind of touched on the deltoid ligament, and this is what makes that SCR fracture a stage two to a stage four, is that you lose your deltoid ligament. And like we said, there's two layers. We have the superficial, which really restrains eversion, and then the deeper strain is external rotation. And so it was kind of interesting putting together this talk and looking at the papers, and when you look, there was actually one case series from the 1980s, 90s, that talked about not fixing the deltoid and said, hey, people do okay. So we kind of moved away from fixing the deltoid. However, when you look, there's been good outcomes reported with either reconstructing the deltoid ligament, repairing the deltoid ligament, or indirectly reducing it, meaning fixing the lateral side and just letting that deltoid scar in. But there's no algorithm or what to do. And so this is where it's really hard, and I think part of why it's hard is because we don't have a great, reliable way of fixing the deltoid. When we talk about valgus ankles, which is a totally different topic, we all say, well, I know I need to fix the ligament, but I don't have a great way of doing it. We have some reconstruction measures that work okay, but they're not great. And so it can be really difficult. And so this was a great, from one of the Yellow Journal, which is the Journal of the American Academy of Orthopaedic Surgery, had a great review article on this. And this was a figure from their article showing that instead of just doing a external rotation stress, we really need to be doing an eversion stress to really assess the deltoid. So this patient obviously had their syndesmosis fixed, and then once they did the eversion stuff, they still showed gapping. And they suggested in this situation, you should consider fixing the deltoid. So I'm not sure. I oscillate between whether I fix the deltoid or whether I don't. It's easy if you have to go medial, meaning that there's something in the joint when you're fixing it and your fibula is not reducing, then I am going to fix the deltoid. If I'm making an incision, I'm fixing the deltoid. But I'm definitely more aggressive now with younger patients. So if I have someone who is younger, definitely athletic, who I'm in the OR fixing a distal fibula fracture, especially if it was one of these big lateral dislocations, I will 100% open and fix the deltoid regardless of the reduction. Perhaps in someone older where I really don't want to make a medial incision for medical reasons, I may just say, hey, I'm not going to do it. So in conclusion, ankle fracture is probably one of the most common things we see. But we still have a lot to figure out. I don't think we've come down to the secret sauce, so to speak, of how to really address these. So how best to approach the syndesmosis? I think this one is pretty much panning out that I think most people will say they use flexible fixation in the suture buttons. What to do with the posterior malleolus, I think less clear than the syndesmosis. But still, I think we're really realizing that that stability comes from that area. And then that deltoid ligament, I think, is still the unicorn that we don't really know what to do with. But maybe fixing it, but we'll have to see if we can get some good long-term studies. So thank you very much.

ankle fractures

treatment controversies

types of ankle fractures

stability criteria

controversies in ankle fracture treatment