Treatment of malunion in ankle fractures

Abstract

Malunions are fractured bones that have healed in pathological positions. This leads to nonphysiological load transfer. Clinical symptoms at the ankle may include swelling, pain and impaired function. Lateral, posterolateral or posteromedial subluxation of the talus will be visible on the radiographs. Surgical correction may be indicated if the malunion is symptomatic. Different osteotomies have been described, but the goal of surgery will always be the reduction and retention of the subluxed talus in an effort to recreate stable conditions. Eighty percent of patients show good results with significant pain reduction in mid-term follow-up studies. Ankle arthrodesis after corrective osteotomy is rarely necessary.

Comparison of Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Fixation for Medial Malleolus Fractures

“…Malunion of the MM typically occurs setting of a bi- or tri-malleolar ankle injury. 26 , 27 Because of the anatomy of the ankle, malalignment of the MM is associated with coronal shift of the talus and concomitant malalignment or shortening of the fibula. Furthermore, there may be significant ankle malunion related to the fibula and talar shift without malunion of the MM component.…”

Operative Treatment of the Malunited Fibula Fracture

“…These images must be taken under load to most accurately assess for any talar subluxation. 18 Mortise malreduction should be suspected with an increase of the medial clear space >4 mm and an increase in tibiofibular clear space. 3 Most fibular malunions exhibit shortening due to external rotation.…”

“…9 Multiple studies have shown that the time from initial injury to reconstructive surgery does not influence the final outcome in patients, but given the pathologic load transfer with a malunited ankle, it is recommended to perform operative correction as soon as possible. 9,12,17,18 Although fibular osteotomy and reconstruction is unable to repair existing arthritis if present, the goal of surgery is to re-create a more anatomic ankle configuration with the hope of limiting the progression of post-traumatic arthritis. At 4-year follow-up, Weber et al noted that 3 of 6 (50%) patients treated with fibular osteotomy, each of whom had degenerative changes in the preoperative imaging, had slight progression of arthritic changes.…”

“…9 Multiple studies have shown that the time from initial injury to reconstructive surgery does not influence the final outcome in patients, but given the pathologic load transfer with a malunited ankle, it is recommended to perform operative correction as soon as possible. 9,12,17,18…”

Realignment Surgery for Malunited Ankle Fracture

“…Therefore, supramalleolar osteotomy has gained increasing popularity for treatment of posttraumatic ankle arthritis. The key issues in the treatment of osteotomies are the reduction and retention of the subluxated talus and the fixation of the osteotomized malleoli in their anatomical positions. Results after healed osteotomies are generally good, with 80% of patients reporting significant pain reduction and improved ankle function.…”