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Defect in the lateral malleolus along with lateral ligamentous injury of ankle is rare. It occurs mainly due to resection of distal fibula tumors and severe trauma leading to loss of lateral malleolus. Lateral malleoli has the major contribution in weight transmission to foot and ankle stability. To avoid persistent pain and gait abnormality due to ankle instability, reconstruction of bony defect is inevitable. Methods to address these defects are iliac crest bone grafting, vascular and nonvascular proximal fibula transfer, patella tendon bone graft and allograft. Donor site morbidity, allograft related problems are not rare. Arthrodesis of ankle gives painless stable joint. Arthrodesis can be performed by open and arthroscopic methods. Open method has more soft tissue dissection and too difficult in scenario with previous skin grafting with adherent skin to bone. We managed a case of compound ankle injury with loss of lateral malleolus with loss of lateral ligament in stages, first management of compound crushed ankle followed by arthroscopic ankle arthrodesis. Even after 6 year of follow patient has stable pain less ankle with satisfactory gait.
1. Introduction
Incidence of open ankle injury is around 1.5% of all ankle fractures and usually caused by high energy trauma.
Isolated lateral malleolus fracture with loss of ankle ligament with soft tissue loss due to compound injury is very uncommon. Loss of lateral malleolus along with lateral ankle ligament leads to ankle instability.
Biomechanics of ankle ligament reconstruction: an in vitro comparison of the Brostrom repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique.
Management of this bone defect can be done by reconstruction technique using iliac crest bone grafting, patellar tendon bone grafting, double bundle Achilles Tendon–Bone Allograft, allograft and both vascular and nonvascular fibular head transfer.
Medial malleolus and deltoid ligament reconstruction in open ankle fractures with combination of vascularized fibular head osteo-tendinous flap and free flap transfers.
Donor site morbidity and allograft related complication and address to ligaments are obvious issues. Arthrodesis of the tibiotalar joint is an alternative to address the instability due to bone loss and ligament deficient along with poor soft tissue.
Open arthrodesis in a scenario with previous skin grafting with skin adhered to underlying bone may lead to further soft tissue complication. Arthroscopic ankle arthrodesis is having less chance of subsequent adjacent joint arthritis and soft tissue complication as compare to open method.
We intend to share one case with compound ankle injury with loss lateral malleolus along with ligament injury and skin loss managed by staged procedure external fixation and skin grafting followed by arthroscopic ankle arthrodesis.
2. Case presentation
A 66 year active male presented at casualty with right side Gustilo and Anderson Type III B ankle injury with loss of lateral malleoli and fracture of medial malleolus following run over of vehicle over foot and ankle (Fig. 1a and b). Wound was grossly contaminated with mud, cow dung and grass with wound laterally communicating to ankle joint. After rulling out of injury to all other organ, wound was copiously lavaged with saline at casualty. Patient was operated within six hours of injury, debridement done followed by external fixator (Fig. 1c and d). Plastic surgery intervention with split thickness skin graft was done after seven days. External fixator removed after five weeks and ankle supported by plaster splint. At that time minimal pin tract discharge was persisted which was managed by regular dressing and antibiotic as per the culture and sensitivity. By two months skin was healthy along with all the pin tracts but ankle was unstable (Fig. 2a and b). Patient was unable to bear weight without ankle stop brace. We planned for arthroscopic ankle arthrodesis after discussion with patient about advantage and disadvantage of reconstruction using various techniques. After four months of injury and two months of fixator removal ankle was visualized arthroscopically with anteromedial and anterolateral portals (Fig. 2c). The articular cartilage of lower end tibia and talar dome denuded till subchondral bone was exposed followed by application of charnly's clamp. After eight weeks Charnly's clamp was removed and boot cast was applied. Patient was allowed to bear weight as tolerated with the cast in situ. Cast was removed after 8 weeks and allowed for gradual weight bearing with added support. After 6 months patient had painless stable joint with normal walking. During follow up radiograph there was significant fusion of the ankle joint (Fig. 3a and b). Patient was able to perform all his daily needs without any discomfort till now. He is able to walk 4–5 km daily without any discomfort.
Fig. 1(a,b-radiograph AP and lateral view of Right ankle following trauma), (c,d-radiograph after debridement and external fixtaion).
The sequel of compound loss lateral malleolus along with lateral ligament and soft tissue leads to lateral shift and tilt of talus. This leads to ankle instability and unstable gait which ultimately lead to ankle arthritis.
Management of loss of lateral malleolus can be done using proximal fibula vascular or nonvascular, sliding of middle part of fibula, illiac crest graft, bone patellar tendon graft or allograft.
Medial malleolus and deltoid ligament reconstruction in open ankle fractures with combination of vascularized fibular head osteo-tendinous flap and free flap transfers.
The issue with these technique were donor site morbidity and only bone reconstruction which was not able to address the ankle instability as ligaments also responsible for stability.
Biomechanics of ankle ligament reconstruction: an in vitro comparison of the Brostrom repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique.
Dukhwan et al. address both the bony and ligament issue using double bundle Achilles tendon allograft for a patient with compound loss of lateral malleolus and lateral ligament and reported good results.
The issue with this patient was bone loss, ligament injury and poor soft tissue. Dieckmann et al. conducted a retrospective study patients with tumour of distal fibula where resection of distal fibula and followed by ankle arthrodesis and good result reported.
So ankle arthrodesis is an alternative to address these problem. Although similar functional outcome and stability with arthroscopic and open ankle arthrodesis method, arthroscopic method is preferred over the open as risk of delayed fusion and arthritis of adjacent hind foot joint is less.
Arthroscopic ankle arthrodesis was done after 4 months of injury in our case and good result was reported with no wound problem and ambulation started 8 weeks after arthrodesis initially with support followed by without support.
4. Conclusion
Maintain stability and restore soft tissue in a case of compound ankle injury with loss of lateral malleolus with lateral ligament injury is a challenging. Complication and comorbidity with reconstruction procedure is not uncommon. Arthroscopic ankle arthrodesis may be one of the valid options for managing such cases.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
Biomechanics of ankle ligament reconstruction: an in vitro comparison of the Brostrom repair, Watson-Jones reconstruction, and a new anatomic reconstruction technique.
Medial malleolus and deltoid ligament reconstruction in open ankle fractures with combination of vascularized fibular head osteo-tendinous flap and free flap transfers.
Owing to a Publisher error Declaration of Competing Interest statements were not included in the published versions of the following articles, that appeared in previous issues of Journal of Clinical Orthopaedics and Trauma.
Owing to a Publisher error Declaration of Competing Interest statements were not included in the published versions of the following articles, that appeared in previous issues of Journal of Clinical Orthopaedics and Trauma.
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