Date: Thursday, June 05, 2003 8:46 PM
Subject: Pain 6 mos s/p ankle fx
Requesting your opinion on a case...
40 year old male had injury to ankle on 22-11-2002 and was treated with POP cast which was removed on 27-1-2003 and then gradual mobilisation of the ankle. Has come with deformity of the ankle and pain on walking for about 200 meters. Can do with one tablet of a Brufen a day if he does not walk much. Examination ankle has deformity, no localised tenderness or abnormal mobility. ROM PF 30 DF 5-10 Inversion and eversion strains are not painful. DP, PT palpable and no neurological deficit. Patient is not a known diabetic. X-ray attached.
Kindly suggest how to proceed and what are the tricks to achieve reduction during surgery.
with kind regards
Dr Harpal Singh Selhi
Lecturer, Dept Of Orth. Surgery.
Model Town, Ludhiana-141002 Punjab, India
Date: Sun, 8 Jun 2003 10:26:23 -0400
From: James Carr
Check his fasting sugars, his VDRL, and his Hb A1C. This sure sounds like a neuropathic ankle. With regards to tips, open both medially and laterally. Try to recreate the fibula fracture, and use a push pull plate/screw to regain length. I wouldn't argue with a snydesmotic screw given the deltoid rupture. Some have tried a suture of the deltoid to its bony origin using a mitek suture. If he's a diabetic, he goes into a bent knee long leg cast for 6 weeks.
James B. Carr, MD
Palmetto Health Orthopedics
Date: Sun, 8 Jun 2003 12:05:56 EDT
This is a case of malunion after cast treatment of a distal fibula fracture with lateral translation of the talus by 1 cm. The syndesmotic and deltoid ligaments are presumably incompetent.
The prognosis is considered poor with low likelihood of good ankle function currently (confirmed by limited painful ambulation of 200 m) and high likelihood of progressive degenerative arthritis of the ankle.
The most commonly recommended treatment is fibular osteotomy of Weber and reduction of the talus beneath the tibial plafond with fixation. Reasonable success reported.
Critics have labelled this a two stage ankle fusion, thinking the die is cast.
This particular case is 6 months post injury which makes it early enough that articular degeneration is not already so severe as to totally doom osteotomy and reduction.
This particular case seems to have more radiographic deformity than symptoms further raising the concern about neuropathic ankle (from undiagnosed diabetes or other etiologies). Neuropathic ankle certainly worsens the ultimate prognosis for all treatments and increases the likelihood of eventual fusion. However, aggressive reconstructionists have reported success with osteotomy even with diabetes.