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• W3136993156 abstract "In the event of an acute ankle injury the likelihood of developing post-traumatic arthritis has been documented in the ranges of 65% to 80%. This is significantly higher than in other major joints of the body such as the hip or knee. It is reported that nearly 37% to 53% of patients with advanced or end-stage ankle arthritis have had previous malleolar fractures, with 28% arising from milder injuries such as ankle sprains. Traditional orthopedic teaching suggests that anatomical restoration of the ankle joint following fracture or dislocation may reduce the rate of post-traumatic arthritis. Despite this, post-traumatic arthritis may still develop unpredictably. If present, patients will likely undergo further surgical intervention in the form of ankle arthroplasty, arthrodiastasis or fusion. Typically speaking, low-energy acute ankle injuries such as a syndesmotic injury, simple split plafond, or single malleoli fractures are treated by primary open-reduction with internal fixation with relatively low post-operative complications. In these cases, the soft-tissue envelope and vital anterior and posterior-medial soft-tissue structures can be maintained without sacrificing surgical restoration of the ankle joint. Usually, simple plate and screw constructs are adequate. However, as the complexity and intra-articular involvement of ankle fractures increases, the requirement for sound osseous fixation of these fractures becomes more complicated. High-energy bimalleolar, trimalleolar or pilon type injuries are often coupled with extensive soft-tissue trauma including edema, fracture blisters or open wounds. Surgeons are then tasked with anatomic restoration of complex articular fractures while minimizing further soft-tissue injury. In the attempt to achieve anatomic alignment of the ankle joint extensive hardware and precarious incision placements may be required, further jeopardizing the soft-tissue envelope. Staged fixation is often inevitable, resulting in several insults to the skin envelope over time, with no prognostic reduction of the development of post-traumatic ankle arthritis. Despite ample internal fixation and near or complete anatomic reduction of the ankle joint, I have witnessed that the majority of post-operative high energy ankle fractures go on to develop symptomatic post-traumatic arthritis. These injuries require staged removal of hardware to allow ankle arthroplasty or arthrodesis. Removal of multiple plate/screw constructs in itself can be tedious and demanding on both the surgeon and patient. Obstacles may arise, such as increased operative time, re-opening of previous scar incisions, screw breakage/fragmentation and loss of bone stock. Theoretically, this may place the patient into an adverse position for joint salvage procedures in the future. It has been reported that two major complications of ankle arthroplasty are anterior incision dehiscence and prosthetic subsidence. Therefore, it is quite possible that ankle arthroplasty procedures may benefit from avoidance of overzealous fixation and multiple soft-tissue insults. As such, at face value, it seems reasonable to avoid anteriorly placed surgical incisions when performing fracture fixation in favor of lateral or posterior approaches. Instead, attention should also be focused on maintaining medial and lateral malleolar length and syndesmotic stability while minimizing internal fixation. Surgeons should be aware of limitations in regard to correction of tri-planar distal tibia joint line angular deformities. Correction of joint line angular deformities should be attempted; however, not at the expense of additional internal fixation implantation since nearly all ankle arthroplasty systems allow planar joint resection with even the most severe deformities. It should be noted that similar treatment standards have been implemented for other acute injuries of the lower extremity, such as ankle fragility fractures in the elderly or complex intra-articular calcaneal fractures. Favorable outcomes have been reported in these populations where immediate soft-tissue preservation is maintained and arthrodesis or minimally invasive fixation is performed later. In cases where excessive fixation requiring disruption of the soft-tissue envelope and elimination of metaphyseal and talar bone stock, it seems logical to minimize the amount of internal fixation in the attempt to preserve soft-tissue. Anatomic and secure reduction should be attempted without disadvantaging patients from long-term treatment options such as ankle arthroplasty, fusion or other salvage procedures. Improving overall patient outcomes should be the primary goal. Careful pre-operative planning should be thought out with long-term outcomes being a major focus when selecting a treatment strategy. Clinical outcomes continue to be unfavorable in regard to fixation of high-energy ankle fractures, whereas ankle arthroplasty continues to become the competing gold standard for management of post-traumatic ankle arthritis. Surgeons should ask, “At what point must a paradigm shift in treatment strategy be made in regard to treatment of high-energy intra-articular ankle fractures?” Perhaps we should minimize our fixation with internal fixation in the short-term for a more favorable ankle joint salvage procedure outcome in the long-term. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper." @default.
• W3136993156 created "2021-03-29" @default.
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• W3136993156 date "2021-01-01" @default.
• W3136993156 modified "2023-09-25" @default.
• W3136993156 title "Our fixation with fixation - A theory regarding the management of severe traumatic intra-articular ankle injuries" @default.
• W3136993156 doi "https://doi.org/10.1016/j.fastrc.2021.100004" @default.
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