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Physical therapy for ambulation assistance and proprioception training
2%
23/1356
Short leg bracing
1%
12/1356
Revision open reduction and internal fixation with open syndesmosis reduction
84%
1142/1356
Addition of syndesmosis screw from fibula to tibia
11%
151/1356
Open medial ankle ligament reconstruction
16/1356
Select Answer to see Preferred Response
This patient requires revision open reduction and internal fixation of her syndesmosis as post-operative radiographs demonstrate a severely malaligned ankle with obvious syndesmosis widening and fibular shortening. Malalignment following ankle fracture fixation can alter the anatomical axis of the joint, articular congruency, and normal load distribution. This predisposes the patient to the development of chronic pain, functional impairment, and finally early post-traumatic ankle arthritis. Marti et al. retrospectively reviewed the outcomes of 31 patients with malunited ankle fractures who underwent reconstructive osteotomies. The authors found that reconstruction resulted in good or excellent results in the majority of patients. They also note that minor post-traumatic arthritis was not a contraindication to reconstruction. Ramsey et al. evaluated 23 cadaveric ankles using a carbon black transference technique to determine the contact area in the dissected tibiotalar articulations, with the talus in neutral position and displaced one, two, four, and six millimeters laterally. They found that 1 mm of lateral talar displacement resulted in a 42% decrease in tibiotalar contact area. Figure A is a x-ray demonstrating severe malalignment of a bimalleolar ankle fracture following fixation of the fibula and medial malleolus. There is obvious shortening of the fibula and lateral shift and valgus tilt of the talus associated with a disrupted syndesmosis. Incorrect Answers: Answer 1 & 2: Physical therapy and short leg bracing are not indicated at this point as the anatomical malalignment needs to first be addressed via revision surgery. Answer 4: The addition of a syndesmosis screw will not successfully reduce the syndesmosis as it has been chronically malreduced and will require open reduction and debridement prior to syndesmosis screw fixation. Answer 5: Open medial ankle ligament reconstruction is insufficient in isolation to provide mechanical stability to the ankle fractures with syndesmosis disruption.
3.8
(31)
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