OBJECTIVE: To investigate the clinical efficacy of closed reduction percutaneous positioning screw internal fixation in the treatment of post-rotation-internal ankle fractures. METHODS: A retrospective analysis of 14 cases of post-rotation-adduction ankle fractures treated with this technique from October 2010 to April 2014. All 14 cases were fixed with “Guanshu-like” closed reduction percutaneous positioning screws. RESULTS: Fourteen patients were completely followed up for 12-48 months, with a mean score of (95±3.2) according to the Baird-Jackson scale, with 11 excellent cases, 3 good cases, and no and poor cases. CONCLUSION: Closed reduction percutaneous positioning screw internal fixation is simple, reliable and an effective method for the treatment of post-rotation-internal ankle fractures. Wang Wei, Department of Bone and Joint, Xiaoshan Hospital, Zhejiang, China
Keywords: ankle; internal fixation of fracture; surgical method
Discussion of surgical problems about closed reduction and percutaneous locking screw fixation for the treatment of ankle fractures (Supination-Adduction II°) WANG Wei*,Bi Dawei,YE Jiakuan, ZHONG Liang,HONG Junyi. Department of Orthopaedics, Zhejang-XiaoshanHospital,Hangzhou311200,Zhejiang,China
ABSTRACT Objective: To discuss the clinical effect of closed reduction and percutaneous lockating screw fixation for the treatment of ankle fractures (Supination-Adduction II°).Methods: Retrospective analysis 14 treatment cases using CRCS from October 2010 to April 2014, 9 males and 5 females, aged 19-65 years, mean 28 years. While 14 cases are used “off book ” closed reduction and percutaneous lockating screw fixation. For complete results of 14 patients followed up for 12-48 months, according to Baird-Jackson scoring average (95 ± 3.2) points, excellent in 11 cases, good in 3 cases, no poor cases.Conclusion: Closed reduction and cannulated screw fixation is simple to operate, is reliable to fixation – an effective method for ankle fractures(SA II°).
Keywords: Ankle; Internal Fixation; Surgical Methods
Ankle fractures are characterized by an “open book” displacement of the anterior aspect of the ankle (see Figure 1). The fracture is characterized by an “open book-like” separation and displacement of the anterior aspect of the ankle (see Figure 1). From October 2010 to April 2014, we used this technique to treat 14 cases of posterior-internal ankle fractures, and achieved satisfactory results, as reported below.
1 Clinical data
There were 14 cases in this group, 9 males and 5 females; age ranged from 19 to 65 years old, with an average of 28 years old. Causes of injury: 4 cases of fall from height, 8 cases of fall from electric bicycle, 2 cases of sprain from stairs. The fractures were all post-rotation-adduction type (SA-II°) injuries according to the Lauge-Hansen typology, including 4 cases of external ankle avulsion fractures, 8 cases of lateral ankle ligament injuries, and 2 cases of undetected lateral structural injuries. There were also 9 cases with medial talar subluxation, 3 cases with talar osteochondral injury, and 2 cases with embedded fractures of the medial ankle shoulder. Combined medical diseases: 3 cases with hypertension, 1 case with diabetes mellitus, 1 case with mental disorder, and 2 cases with severe osteoporosis. All cases were operated electively, and the average time from injury to operation was 5 days.
2 Treatment methods
2.1 Preoperative preparation After admission, those with severe internal ankle dislocation or talus subluxation were immediately repaired by manipulation (see the procedure of closed manipulation for details), followed by braking with a plaster rest. Routine preoperative laboratory and imaging examinations were performed to detect combined injuries and concealed injuries. Medication was administered to control pain and swelling. Actively manage and control medical comorbidities and exclude contraindications to surgery.
2.2 Surgical method Continuous epidural anesthesia is usually used. After successful anesthesia, the patient is placed in a supine position with a sandbag under the affected hip, and the field is routinely disinfected and towels are laid. The operator holds the heel of the foot with one hand and places the big fish interval on the inner ankle with the other hand, pulls forward and rotates the affected foot while applying lateral squeezing pressure to the inner ankle, dorsally extends the ankle joint to 90°, resets the fractured end of the inner ankle (does the shut book-like), and maintains the resetting by clamping with a ball-shaped two-point resetting forceps. Mortis position fluoroscopy was performed to determine that the distal tibial subchondral bone line continuity was restored and the medial joint cavity width was equal to that between the talus and the distal tibia. We borrowed the geometric concept and divided the medial ankle into four nail placement quadrants, A, B, C, and D. Quadrants A and D were selected as nail placement quadrants, and two screws were inserted (see Figure 1). After positioning the nail entry point, an incision of about 0.5 cm in length was made along the skin pattern to reach the periosteum, and the subcutaneous tissue was separated slightly with a small mosquito clamp, and the guide pin was inserted with a slow-speed drill. In severe osteoporosis, washers were added to avoid screwing into the bone cortex during compression. In this group, there were 4 cases with I° external ankle avulsion fracture, 3 of which had large bone masses, and we also fixed them with incision and repositioning “8” wire kerf pins, while 1 case had a small bone mass, and we fixed it with incision and metal anchor suture. After the fixation was satisfactory, the C-arm machine was used again for frontal and lateral fluoroscopy to check the screw length and assess the repositioning, and the images were stored, printed and archived. The guide pins were removed, rinsed, and the small percutaneous incision was finely sutured. An elastic bandage is applied with pressure.
2.3 Postoperative management Postoperatively, the affected ankle is braked and elevated in a neutral position. After resuscitation from anesthesia, axial flexion and extension exercises of the ankle joint can be started as soon as pain is tolerated. On the second postoperative day, the patient could wear a brace and go down to the ground for partial weight-bearing activities as far as the affected ankle could tolerate. Postoperatively, Chinese herbal medicine was used to tonify the liver and kidney, regulate qi and blood, and strengthen tendons and bones, together with western medicine to reduce swelling, antibacterial drugs to prevent incisional infection, and multimodal analgesia.
3 Treatment results
3.1 Efficacy assessment criteria The Baird-Jackson ankle joint scoring grade system was used [1]. The rating system included 7 items including pain, ankle stability, walking ability, running ability, working ability, ankle range of motion, radiological findings, etc. The highest rating value was 100. 96-100 was considered excellent, 91-95 was considered good, 81-90 was considered acceptable, and 0-80 was considered poor.
3.2 Results of efficacy assessment A total of 14 cases in this group had stage I healing of the incision and no endophytic fixation failure. According to the Baird-Jackson ankle score, the mean postoperative score of 14 cases was (95±3.2), excellent in 11 cases, good in 3 cases, and no and poor cases.
4 Discussion
4.1 Mechanism and characteristics of fracture displacement When this type of fracture occurs, the talus is displaced medially and strikes the medial ankle, resulting in an oblique or near-vertical fracture of the medial ankle, which starts from the anterior aspect of the medial ankle and then goes to the posterior aspect of the medial ankle, which is an “open book-like” injury. This can be judged from the fact that in some cases, the anterior fracture of the medial ankle lifts off, while the posterior cortical bone of the medial ankle remains continuous. In rotational ankle fractures, the stability of the ankle joint is determined by the damage to the medial structures [2], therefore, an anatomical repositioning of the medial ankle must be achieved.
4.2 Effective repositioning and fixation of the fracture After closed manipulation of this type of fracture, if the fracture has a tendency to re-displace, the repositioning can be maintained by clamping and fixation with a ball-shaped two-point repositioning forceps. The medial teeth of the resetting forceps can be clamped at the geometric center of the medial ankle, and the lateral teeth of the resetting forceps can be placed at the bony prominence above the lateral ankle. According to the characteristics of this type of fracture and fracture line alignment, the nail entry point should be selected as close to the anterior aspect of the medial ankle as possible, i.e., within the A and D quadrants. The direction of screw placement can be either two perpendicular to the fracture line or one perpendicular to the fracture line and the other oblique upward to resist shear stress, which is the application of the “tension band principle” to ankle fractures (see Figure 1).
4.3 Management of lateral structural injuries When this type of fracture occurs, both avulsion fractures and lateral ligament injuries can occur in the lateral ankle. For displaced external ankle fractures, “8” tension band wire internal fixation or metal suture anchor nail fixation can be chosen. In cases of non-displaced lateral ankle fractures or lateral ligament injuries, postoperative assisted cast or brace braking is an option to delay weight bearing. If patients with lateral ligament injuries present with distant instability of the lateral ankle structures, lateral ligament reconstruction is feasible. Clinically, some patients have only a more vertical fracture of the medial ankle without injury to the lateral structures of the ankle, probably because the patient’s lateral ligaments are very lax, allowing the talus to invert and subluxate medially against the medial ankle resulting in a fracture without combined injury to the lateral structures [3].
4.4 Management of other structural injuries and postoperative rehabilitation In cases with embedded fractures of the medial ankle shoulder, prying and bone grafting are required to support the fracture while fixing the ankle joint [4]. In case of osteochondral injury of the talus, it can be left untreated in stage I. In the long term, it should be repaired by arthroscopic microfracture or autologous cartilage graft according to individual needs. Postoperative elevation of the affected limb can reduce the probability of wound complications. Braking the affected ankle in a neutral position can prevent the development of clubfoot and Achilles tendon contracture. Protective postoperative flexion and extension exercises can effectively prevent joint stiffness, reduce edema and improve patients’ confidence in recovery. According to the clinical follow-up images, patients were instructed to gradually transition to full weight-bearing activities.
In conclusion, the use of closed reduction percutaneous hollow nailing for the treatment of posterior-adduction ankle fractures requires consideration of the “open book” displacement of the internal ankle fracture, and “closed book” reduction combined with positioning screw fixation based on the tension band principle to ensure the effective reduction and strong internal fixation of the fracture. In order to ensure the effective repositioning and strong internal fixation of the fracture. At the same time, we must solve the problems of structural damage of the external ankle, embedded fracture of the internal ankle shoulder and cartilage surface damage of the talus to ensure the stability and integrity of the internal and external joints and reduce the incidence of traumatic arthritis of the ankle joint.
References
1. 2. 3, Wang JJ, Zhang JC, Yu GR Foot and Ankle Surgery People’s Health Press, 2006,134. 4, Gui J Liu [ Wu XB Luo CF Translated Principles of AO in the treatment of fractures 2nd edition, Shanghai Science and Technology Press, 2010,660. accompanying figure. 1a 1b 1c 1d 1e 1f Figure 1 Patient, female, 29 years old, left ankle fracture (Lauge-Hansen II°) caused by a fall on a battery-operated bicycle.1a, 1b, 1c, preoperative CT and reconstruction.1d, preoperative CT template delineating the four nail placement quadrants A, B, C, and D.1e, 1f, at week 4 postoperatively, front and lateral DR films showed bone scab growth at the fracture end, no screw withdrawal, normal ankle motion, and no pain.