Master Techniques in Orthopaedic Surgery: The Foot and Ankle

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PART IX Trauma

TABLE 43.1 Technical Pearls

• Position the patient in the supine position. The ipsilateral hip can be elevated using a bump to provide easier access to the lateral fibula. This position will afford the ability to evaluate and manage injuries arthroscopically. • Place a thigh tourniquet to avoid challenges of fracture reduction from the Achilles complex being contracted from a calf tourniquet. In addition, the tourniquet may allow for better visualization during arthroscopic work. • Use a low pressure automated system (25-35 mm Hg) or gravity flow to minimize fluid extravasation into potentially compromised soft tissues. • Arthroscopically evaluate and address cartilage injuries and loose bodies that may prevent adequate reduction. • When addressing the syndesmosis, the surgeon should evaluate with the drive-through sign. If the shaver passes easily, the drive-through sign is positive, and further fixation of the syndesmosis is indicated. After syndesmotic fixation, perform the drive-through test again. If the drive-through sign is again positive, the test should raise suspicion that the syndesmosis or fixation is inadequate. • Do not forget to directly visualize the deltoid ligament complex arthroscopically to rule out a deltoid injury. • Monitor total arthroscopic time to minimize fluid extravasation in the surrounding soft tissues to prevent wound complications. RESULTS AND COMPLICATIONS Open reduction and internal fixation (ORIF) affords orthopedic surgeons the ability to directly visu alize and treat intra-articular injury during the time of ankle fracture fixation. It allows for assess ment of intra-articular reduction, and the ability to address concomitant injuries often missed on plain radiographs. Chen et al conducted a systematic review of adult patients undergoing ORIF for ankle fractures and reported that the most common concomitant injuries included chondral lesions (63.3%), deltoid ligament injuries (60.9%), and syndesmotic injuries (77.9%). 16 Hintermann et al conducted a prospective study in 288 patients and reported a 79% rate of articular injury with associ ated ankle fractures. 3 In addition, previous studies have also demonstrated an increase in the diag nostic effectiveness when utilizing arthroscopy in the evaluation of associated syndesmotic injuries particularly when compared with standard radiographs. 12,15 Loren and Ferkel reported a rate of 45.8% of syndesmotic disruption when evaluating ankle fractures arthroscopically. 17 Several studies have attempted to compare traditional ORIF with ORIF. Thordarson et al conducted a prospectively randomized trial evaluating ankle fractures treated with and without arthroscopy. The authors concluded that there was no difference in SF-36 scores or lower extremity scores between the two groups and that in the short term, the addition of arthroscopy did not appear to negatively impact patient outcomes. 2 A systematic review by Gonzalez et al identified ankle arthroscopy as a tool in treating intra-articular lesions associated with ankle fractures but demonstrated that the literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF. 18 In addition, there had been few prospective randomized controlled studies compar ing these two operative techniques demonstrating that ORIF improves clinical outcomes over tradi tional ORIF, and therefore, further research is needed to determine the benefits clinically. • Soft tissue swelling and fracture displacement can make identification of landmarks and arthroscopic portal location difficult. • Be cautious of anatomy when establishing arthroscopic portals. Commonly injured structures include the following: ⚬ ⚬ Anteromedial portal: tibialis anterior and saphenous nerve/vein ⚬ ⚬ Anterolateral portal: intermediate dorsal cutaneous branch of the superficial peroneal nerve • Perform the drive-through sign with minimal force to avoid cartilage injury to the medial malleolus and the medial talar dome. • Limit débridement of anterior synovial tissue to limit bleeding that may obstruct visualization. • If using a well-leg holder and noninvasive distraction, ensure that when the extremity is resting on the operative table, it is adequately positioned for the reduction and fixation portion of the case. TABLE 43.2 Common Pitfalls

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