Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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Arthroscopic-Assisted Open Reduction and Internal Fixation Ankle

Arianna L. Gianakos, Stephanie Maestre, Niall Smyth, and Amiethab Aiyer

INTRODUCTION Ankle fractures are common injuries in the adult population traditionally managed with open reduc tion and internal fixation (ORIF) when displacement is present. Although clinical outcomes fol lowing ankle ORIF have been favorable, previous studies have demonstrated residual symptoms as a result of various intra-articular pathologies including chondral defects or ligamentous injury. 1,2 Studies have found a prevalence of intra-articular lesions in patients sustaining an ankle fracture between 20% and 79%. 3,4 In addition, up to 55% of ankle fractures may have a resultant loose body that cannot be addressed with standard open management. 5 The use of arthroscopy to assist in the evaluation and management of ankle surgical fixation has gained increased attention (see Video 43.1). Arthroscopy-assisted ORIF affords the orthopedic surgeon the ability to directly visualize and potentially address intra-articular injuries without formal arthrotomy. 4 In addition, formal lavage and débridement of the ankle joint can also be performed, which may help improve postoperative range of motion (ROM) and expedite return to activity. 6 This chapter will provide an overview for the use of ORIF in the surgical management of ankle fractures. The authors’ surgical technique will be described, and this article will provide technical tips and tricks for success. INDICATIONS AND CONTRAINDICATIONS ORIF is indicated when direct visualization of the articular surface may be warranted. Visualization of the talus is often limited when performing ORIF for most ankle fractures. ORIF is useful when there is concomitant pathology that can be addressed at the time of surgery. This includes patients with an osteo chondral lesion or an osteochondral fracture of the talus that can be microfractured or fixed. In addition, ORIF is useful in patients who have a loose body affording the ability to remove the loose fragments. Lastly, ORIF can improve the evaluation of ligamentous injury, particularly that of the syndesmosis, which can then be addressed and fixed concomitantly. ORIF can afford direct visualization of chondral injury as well assess the integrity of the syndesmosis and deltoid ligament complex. ORIF can also be useful in determining whether there is an impaction injury of the medial malleolus not evident on plain radiographs, particularly with supination adduction injuries or any shear injuries through the medial malleolus from talar inversion and axial loading. Relative contraindications to arthroscopy may include open injury, vascular injury, and a poor soft tissue envelope limiting the ability to establish portal sites as well as increasing the risks related to fluid extravasation and potential compartment syndrome.

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PREOPERATIVE PLANNING Soft Tissue Status

The clinical examination of the patient is crucial for preoperative planning. The integrity of the soft tissues around the ankle, particularly around the portal sites is critical in determining whether arthroscopy can be performed. Potential anterolateral portal injury to the superficial peroneal nerve branches is an important consideration.

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