Review Question - QID 3810

This patient presents with malunion after sustaining a bimalleolar ankle fracture. Surgical treatment options consist of osteotomy for deformity correction with internal fixation (joint preserving) versus fusion (joint sacrificing) with the primary determinant being the amount of ankle arthritis present.

When treating ankle malunions, the decision to perform deformity correction and preserve the joint versus fusing the joint is dependent on signs of progressive, advanced tibiotalar arthritis on radiographs.

Yablon and Leach followed 26 patients following corrective fibular osteotomy following malunion and noted excellent results at a mean follow-up of 7 years. All but 3 returned to preinjury level of activity and had desired outcomes following deformity correction.

Reidsma et al. prospectively followed 57 patients with a minimum follow-up of 10 years following corrective osteotomy and fixation for ankle fracture malunions. Good to excellent results were obtained for 85% of the cohort. The authors concluded that those ankle fracture malunions with none to minimal arthritic changes should still receive corrective osteotomy to prevent further progression of arthritis.

Yablon et al. following 53 patients for 6-9 months, reported on the importance of anatomic restoration of the lateral malleolus when fixing bimalleolar ankle fractures. With anatomic reduction and fixation, no progression of arthritis was noted with return to function.

Figure A is an AP radiograph of a right ankle fracture malunion.

Incorrect answers:
Answers 1-3, 5: Factors such as age, gender, and degree of deformity are not as important as the presence of advanced arthritis that may suggest requiring a joint sacrificing fusion procedure. The date of injury may portend a poor outcome (the longer from the date of injury/subsequent malunion), but is not the most important factor in deciding between corrective osteotomy versus fusion.