Date: Thu, 12 Dec 2002 22:20:08 -0600

Subject: Ankle Subluxation

Advise on patient that presented today.:

42 yo s/p trimalleolar ankle fx 3 mos ago and left subluxated for 2 days prior to ORIF. ORIF of fibular shaft, medial malleolus and perc screws of posterior malleolus all look healed w/ decent reduction. Not a big surprise, but she has a 4x2 cm antero-medial wound to bone where her ankle was subluxated. This needs a local debridement and flap closure. Her mortise view looks well reduced, but the talus is 50% anterior translated and subluxated on the lateral view. Acutely these fxs w/ ligamentous instablity can be managed w/ an ex fix as well as ORIF. At three months, it will be more difficult to attain and maintain reduction. Anyone w/ similar experience?

Bill Obremskey

Reply at: Orthopaedic Trauma Association forum

Date: Fri, 13 Dec 2002 00:21:01 -0500

From: Bill Burman

Any xrays? See recent discussion

Bill Burman, MD
HWB Foundation

Date: Fri, 13 Dec 2002 09:19:07 -0500

From: James Carr


I have had a few over the years that were fortunately picked up within the first few weeks, and reduced. The problem as you pointed out is the ATF is gone, allowing the ankle to go out front. Someone casts them holding the foot up by the big toe, and out it goes - usually with some plantar flexion. The one case I had that presented late occurred in a head injured patient. At 4 months, it reduced partially with an open reduction despite using transfixing pins in the talus and tibia + mechanical compression (I think I used an A-O ex fix with the compression attachment). In retrospect, I think the mortise had closed down, narrowing the gap for the talus to fit into. If I had it to do over, I think I would have released the syndesmosis (using a laminar spreader to push the fibula outwards), vs performing a fibular osteotomy. The ligaments should heal if the talus is brought back under the tibia and held 6 weeks or so. I also wonder if a tensioned wire fixator with gradual compression could achieve the same thing.

Just some thoughts - let us know how it turns out.

Jim Carr

Date: Fri, 13 Dec 2002 14:02:13 -0600

From: Obremskey, William T


Thanks. I am considering the Ilizarov to correct her anterior subluxation and plantar flexion over time. I would prefer to do it all at once. It may be difficult. I'll let you know.


Date: Mon, 23 Dec 2002 17:37:39 -0600

From: Obremskey, William T

The 41 yo woman who was 3 mos s/p ankle ORIF who has persistent anterior subluxation. I do not think that a fibular malunion contributed in this case, but the subluxation was due to ligamentous injury and splinting her anteriorly subluxated.

She also has a medial wound due to delayed ORIF w/ subluxated ankle.

Attached are xrays.




I released her anterior capsule through medial wound (see flouro ), did TAL percutaneously, released some posterior capsule through medial wound as well and placed medial monolateral ex fix.

I will hold her for 6 weeks and now need to get medial soft tissue coverage.

Bill Obremskey

Date: Thu, 26 Dec 2002 10:31:24 -0500

From: James Carr

I think the ankle looks good, and should do well now that you have placed the talus under the tibia once again.

James B. Carr, MD
Palmetto Health Orthopedics