The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons
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Treatment of the posterior malleolus has been debated among orthopedic surgeons. Most orthopedic surgeons will fix the posterior malleolus if it is larger than 25% to 30% of the distal articular surface. The most common method of fixation of the posterior malleolus is by indirect reduction and anteroposterior screws. ⋯ There were 2 cases of 2 mm or more of articular surface displacement at the final follow-up visit (1 patient had 2-mm displacement noted in the immediate postoperative period and 1 patient had adequate reduction in the beginning but was displaced with additional follow-up). The posterolateral approach to the ankle is a useful tool to treat certain cases of posterior malleolus fracture. It allows good visualization and stable fixation of the posterior malleolus.
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Arthroscopic arthrodesis of the ankle has several advantages compared with open arthrodesis, including a smaller skin incision, less damage to the soft tissue around the joint, a lower risk of skin necrosis and infection, a lower incidence of postoperative infection and swelling, and better preservation of the contour of the surface of the joint, which maintains a larger contact area between the talus and tibia. We successfully performed arthroscopic arthrodesis of the tibiotalocalcaneal joints with intramedullary nails with fins in 9 ankles of 8 patients. Solid fusion was attained in all cases, except for 1 case of nonunion at the subtalar joint. ⋯ The fixation was strong, even in the case of poor bone quality, such as occurs in rheumatoid arthritis. The intramedullary nails with fins allowed for appropriate compression for bone consolidation without loss of rotational stability. Arthroscopic tibiotalocalcaneal arthrodesis, a less-invasive technique than conventional open surgery, is effective treatment, especially in patients with poor skin conditions secondary to diseases such as rheumatoid arthritis and diabetes mellitus.
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Comparative Study
The radiographic fate of the syndesmosis after trans-syndesmotic screw removal in displaced ankle fractures.
The purpose of this study was to evaluate the radiographic changes of the tibiofibular position and the ankle mortise after removal of trans-syndesmotic fixation to determine if there is loss or maintenance of correction. In addition, the effect of the type of rotational injury, early weight bearing, and the number of trans-syndesmotic screws used on the integrity of the inferior tibiofibular articulation or ankle mortise after screw removal were evaluated. An analysis was conducted of 86 patients, with an unstable rotational ankle fracture requiring open reduction with syndesmosis screw stabilization. ⋯ Tibiofibular diastasis is commonplace upon removal of the syndesmotic hardware, but the ankle mortise remains unchanged. Based on the radiographic criteria described in this study, the postoperative change in medial clear space or tibiofibular diastasis has no bearing on fracture type, deltoid injury, or the use of 1 or 2 cortical screws. As such, other unknown mechanisms affecting the integrity of the syndesmosis after screw removal are in place.
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Management of a dislocated ankle fracture can be challenging because of instability of the ankle mortise, a compromised soft tissue envelope, and the potential neurovascular compromise. Every effort should be made to quickly and efficiently relocate the disrupted ankle joint. ⋯ An alternative to conscious sedation is the hematoma block, or an intra-articular local anesthetic injection in the ankle joint and the associated fracture hematoma. The hematoma block offers a comparable amount of analgesia to conscious sedation without the additional cardiovascular risk, hospital cost, and procedure time.
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Case Reports
Bilateral os subtibiale and talocalcaneal coalitions in a college soccer player: a case report.
An os subtibiale is an accessory bone separated from the distal medial tibia proper. Subtalar tarsal coalition is a failure of joint formation between the talus and calcaneus during hindfoot maturation. The patient in this case report has large bilateral os subtibiale and subtalar coalitions, which were undiagnosed throughout his soccer career until recently when he began having anteriorlateral ankle pain. ⋯ This report will hopefully alert clinicians about these 2 rare anatomic findings and encourage them to use caution when evaluating suspected fractures of the medial malleolus that could be functional os subtibiale ossicles. In addition, we hope to shed some light on the complicated coupling of motion between the ankle and subtalar joint. These may have developed together to allow more normal coupled motion between the ankle and subtalar joint in this high-level college soccer player, and may be relevant to future reports or research in this area.