Malunited subluxed ankle injury

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george therthanath

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Feb 7, 2012, 5:55:27 AM2/7/12
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Friends,

This 61 year old diabetic lady was seen by me today. She had an ankle injury 3 months ago which was treated non-operatively in cast and by traditional splinting. Now she is unable to bear weight and ambulate. 

My dilemma is whether to do osteocleisis and fixation in as anatomical position as possible or to go for arthrodesis straight away? If we decide on osteocleisis, what are the problems and tips to overcome the same. If arthrodesis how to go about the same?

Thanks in advance.

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Dr. T. I. George,
(Dr George T Ittoop),
Sr Specialist, Orthopaedics,
Ibra Regional Hospital,
PO Box no: 437,
Postal code 400.
North Sharquia Region,
Sultanate of Oman.
Cell phone no: 968 95825197

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Felix Albers

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Feb 7, 2012, 6:24:11 AM2/7/12
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Hello,

Difficult decision. Not much personal experience with this. But I guess that with a osteoclasis and late reduction she won´t be pain free either and you will eventually need to proceed with arthrodesis. Being a diabetic patient, I guess that one surgical agression is enough.

I would suggest an arthrodesis or talectomy (preserving some motion).

Felix




2012/2/7 george therthanath <drtig...@gmail.com>

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Myles Clough

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Feb 8, 2012, 2:05:21 PM2/8/12
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I would hasten to disclaim any special expertise in this area but my arm was twisted to respond - and in general I think that more of us should respond to these types of questions.

Further clinical information
is she insulin dependent and how many years has she been diabetic? Any other significant co morbidities? Pre-injury level of function and expectations of treatment - eg is she expecting to return to heavy activity eg agriculture, cleaning, standing or walking long periods.
any signs of diabetic neuropathy or circulatory impairment?

Further investigation
is the subluxation reducible? Can you do a lateral xray with the ankle forwardly stressed into the anatomical position?
CT scan if available. This would show you the extent of healing and therefore the ease with which you could mobilize the fracture fragments. A 3D CT reconstruction would allow you to understand the exact anatomy of the fracture and the ways you would have to approach it and free it up.

Management
I agree with Dr Albers that it is desirable to do only one operation. Since she has pain, my guess is that there already is extensive damage to the tibio/talar joint surfaces and that if you opened the joint with the intention of reducing and fixing the fracture you would back off and go to plan B (arthrodesis) when you see what the joint looks like. However, most likely you will have to mobilize and even fix the fracture fragments in order to centre the talus under the tibial and fuse it. So my thought is that you would have to do a posterior approach to mobilize the posterior malleolus and an antero lateral approach to take down the fibula and do the fusion (or fixation). I suppose that if you were widely exposing the ankle joint to do a fusion (eg by fibular osteotomy) you might be able to get an osteotome into the bone at the step between the plafond and the posterior malleolus fragment to mobilize the fragment; but I have no experience with that and wonder if it would be mobile even after you broke down the callus. I would position the patient so you can expose the back of the tibia if you need to.
If she has evidence of neuropathy then the prospect of a severe problem (Charcot foot) post fusion is worrying. Pre-operative counselling for the patient and family may be quite complex!

Literature
I did a 2 PubMed searchs (URLs =
http://www.ncbi.nlm.nih.gov/pubmed?term=((%22Fractures,%20Malunited%22[Mesh])%20AND%20(%22Ankle%20Injuries%22[Mesh])%20OR%20%22Ankle%20Joint/surgery%22[Mesh]) 
and came up with the following - from the first 20 in each search. There is probably a lot more and you may wish to follow some of the related citations links.
Hintermann B, Barg A, Knupp M.
J Bone Joint Surg Br. 2011 Oct;93(10):1367-72.
Related citations
Wukich DK.
Foot Ankle Int. 2011 Sep;32(9):924; author reply 924. No abstract available.
PMID:
 
22097173
 
[PubMed - indexed for MEDLINE]
Jehan S, Shakeel M, Bing AJ, Hill SO.
Acta Orthop Belg. 2011 Oct;77(5):644-51. Review.
PMID:
 
22187841
 
[PubMed - indexed for MEDLINE]
Klein SE, Putnam RM, McCormick JJ, Johnson JE.
Foot Ankle Int. 2011 Jul;32(7):686-92.
PMID:
 
21972763
 
[PubMed - indexed for MEDLINE]
Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ.
Foot Ankle Int. 2011 Feb;32(2):120-30.
PMID:
 
21288410
 
[PubMed - indexed for MEDLINE]
Tornetta P 3rd, Ricci W, Nork S, Collinge C, Steen B.
J Orthop Trauma. 2011 Feb;25(2):123-6.
PMID:
 
21245717
 
[PubMed - indexed for MEDLINE]
Giannini S, Faldini C, Acri F, Leonetti D, Luciani D, Nanni M.
Injury. 2010 Nov;41(11):1208-11. Epub 2010 Oct 8.
PMID:
 
20934697
 
[PubMed - indexed for MEDLINE]
Chiodo CP, Cicchinelli L, Kadakia AR, Schuberth J, Weil L Jr.
Foot Ankle Spec. 2010 Aug;3(4):194-200. No abstract available.
PMID:
 
20664007
 
[PubMed - indexed for MEDLINE]
Reidsma II, Nolte PA, Marti RK, Raaymakers EL.
J Bone Joint Surg Br. 2010 Jan;92(1):66-70.
PMID:
 
20044681
 
[PubMed - indexed for MEDLINE]
Molloy AP, Roche A, Narayan B.
Foot Ankle Clin. 2009 Sep;14(3):563-87. Review.
PMID:
 
19712890
 
[PubMed - indexed for MEDLINE]
Chu A, Weiner L.
J Am Acad Orthop Surg. 2009 Apr;17(4):220-30. Review.
PMID:
 
19307671
 
[PubMed - indexed for MEDLINE]
Borrelli J Jr, Leduc S, Gregush R, Ricci WM.
Clin Orthop Relat Res. 2009 Apr;467(4):1056-63. Epub 2009 Jan 15.
PMID:
 
19145464
 
[PubMed - indexed for MEDLINE] 
Free PMC Article

The Reidsma (2010 JBJS - B) article suggests that there are good results after accurate reconstruction and that 
" Minor post-traumatic arthritis is not a contraindication but rather an indication for reconstructive surgery. We also found that prolonged time to reconstruction is associated negatively with outcome" so if your patient is a good surgical risk and has well controlled diabetes with no diabetic complications that might alter things in favour of an attempt at reconstruction.
 
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george therthanath

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Feb 8, 2012, 2:40:50 PM2/8/12
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Myles,

Thanks for the response though I coerced you to respond. In your natural style you have flooded the reply with citations and thank you very much for the same.

I have already requested for a 3D CT and the same is awaited. Unfortunately the 3D images from our machine is not great but nevertheless hope to get some information from it.
I do understand the importance of counselling the family of all possible complications in such a case and hope to do the same. The task is little delicate since the patient is one of our own hospital staff's mother and there are issues of poor communication in the initial phase of treatment when I was away on a long leave.

There have been a few private communications from few well experienced Orthopods where they said that similar case done by them ended in amputation ( because of some legal issues they did not want to comment on the same through the list).

I do understand that such a patient will be a candidate for only a single surgery as pointed out by Felix.

Once again thanks for the response and I hope to get more responses before I am forced to take the final decision on management.

Dr. T. I. George.

george therthanath

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Feb 9, 2012, 10:41:35 PM2/9/12
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Friends,

I will be seeing this patient again in two days time. Is there any role of using ring fixators for arthrodesis or osteosynthesis considering that this is patients bones will be quite porotic by the time we go in,if we decide to go in?

Thanks for your responses.

Muhammad Amin Chinoy

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Feb 8, 2012, 2:17:57 PM2/8/12
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Myles,

Brilliant, just cannot tell you how much i had missed your input in such cases, with up to date litreature search and results.

Thanks a million

Amin
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Head, Dept of Trauma & Orthopedics
The Indus Hospital,
Korangi Crossing, Karachi- 75190
Pakistan
Tel : +92-21-35112709-17
Fax: +92-21-35112718
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Treasurer, Pakistan Orthopaedic Association 2006-2009

george therthanath

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Feb 19, 2012, 3:09:51 PM2/19/12
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Friends

Thanks for all the inputs. The patient has not returned for further care - told by a reliable source that she is back on indigenous treatment! Will update if and when she returns for treatment.
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