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Posterior Ankle Arthroscopic Fracture Reduction with Internal Fixation

March 01, 2017

Contributors: Alicia Unangst, BS, DO; Cody Englert; Kevin D Martin, DO, FAAOS; Kevin D Martin, DO, FAAOS

The leg is positioned with the ankle off the end of the surgical table in a neutral position, allowing maximum surgical access and creating room for the C-arm to facilitate optimal fluoroscopic views. A thigh tourniquet is applied before placing the patient in the prone position. The anatomic structures are identified and marked. The external positioning arm provides traction for positioning and fracture reduction as needed. The posteromedial and posterolateral portals are established, and the 4.0-mm camera is placed into the posteromedial portal. Before reduction, the fracture hematoma is evacuated with the use of an arthroscopic shaver. The hematoma is further cleaned after fracture reduction and before internal fixation. After fracture hematoma evacuation, any loose bodies are identified and removed with the use of an arthroscopic grasper. After the fracture is identified, a third portal is created approximately 2 to 3 cm proximal to the posterolateral portal. The portal must be established via the nick-and-spread technique to prevent sural nerve injury. A bone pusher or elevator is used for reduction. A 1.25-mm cannulated guidewire is inserted in the posterolateral portal. The position and angle is assessed arthroscopically and via fluoroscopy. A second guidewire is placed in the accessory portal. The more proximal positioning allows for creation of an axilla, preventing proximal migration of the fragment as the distal screws are tightened. Finally, the arthroscope is moved to the posterolateral portal, and a third guidewire is placed in the posteromedial portal. Direct arthroscopic visualization should be maintained throughout reduction to ensure optimal anatomic reduction. The fracture is reduced to a nearly anatomic position, with some plastic deformation remaining along the posterolaterally impacted area. After the guidewires are in place, a 3.5-mm cannulated drill is used to create a gliding hole through the near cortex of bone. Next, 3.5-mm cannulated titanium screws are placed over the guidewires and into the fragment. The use of washers is optional, depending on bone quality and the amount of biomechanical compression desired. These screws allow for near anatomic reduction and provide maximum biomechanical strength in the posterior to anterior position. After reduction of posterior pathology, the fibula is addressed in the standard fashion. Reduction of the fibula is improved secondary to preservation of the posteroinferior tibiofibular ligament. Sagittal CT scans obtained at 6 weeks postoperatively should demonstrate near anatomic reduction with good bone healing. After this is confirmed, flatfoot weight bearing is initiated and progressively increased over the next 4 weeks.

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