FILIPPOCASTOLDI, ROBERTOROSSI, ANTONGIULIOMARMOTTI, RAINERODELDIN, PAOLO
ROSSI
Introduction
Soccer is the most popular game in Europe. It accounts for 28.9% of exercise- related injuries. However, malleolar fractures are relatively infrequent in soc- cer players [1, 2]. Malleolar fractures generally result from rotational forces and rarely involve the horizontal articular surface of the distal tibia and fibu- la. Most foot and ankle injuries are the consequence of foul play involving direct contact with the injured ankle. Player-to-player contact has been reported to be a contributory factor in 44–74% of soccer injuries [2, 3], with a higher incidence for weight-bearing limb lesions, resulting in ankle sprains or fractures (39%), compared with non-weight-bearing limbs (23%) [2].
The immediate goals of malleolar fracture treatment are to restore overall limb alignment, reconstruct the articular surface with early reduction, and obtain early ankle mobilisation, avoiding major complications. The ability to achieve these objectives is a function of the severity of fracture and associat- ed soft-tissue injuries. In order to determine proper treatment for these injuries, it is essential to classify the fractures: the Danis-Weber/AO and Lauge-Hansen classification systems [4, 5] based on mechanism of injury and fracture pattern are the most widely used.
Initial Evaluation
Clinical examination and radiographic evaluation form the basis of treatment for ankle fractures. A careful neurovascular examination is mandatory, and special attention should be paid to soft-tissue status, noticing wounds, ecchy- mosis, blistering, skin tension, and massive swelling. The standard radi- ographic evaluation includes anteroposterior, lateral, and mortise views (Fig.
1). Great attention must be paid to some parameters, such as tibiofibular clear space, tibiofibular overlap (Fig. 2a), medial (tibiotalar) clear space (Fig. 2b),
tibiofibular line, talar subluxation, and talar tilt (Fig. 2c, d). Computed tomog- raphy (CT) is required only in cases of severe displacement or impaction of the tibial weight-bearing articular surface.
Classification
The two most widely used classification systems are the Danis-Weber/AO and the Lauge-Hansen [4, 5], the former based on the level of fibular fracture, the latter on the mechanism of injury. Both systems have poor inter-observer and intra-observer reliability. Further more, associated soft-tissue injuries are not adequately considered, and in this is their limit. A third system has been recently developed by the Orthopaedic Trauma Association (OTA). However, its reliability and usefulness in decision making and prognosis is yet to be evaluated [6].
Timing of Surgery
Many Authors have expressed the opinion that malleolar fractures can be safely treated surgically within a short, early window (from 4 to 48 h) when the swelling is from haematoma rather than oedema; but no convincing evi- dence exists that early surgery is safe or beneficial [7]. Although it is undoubt- Fig. 1.Normal ankle mor- tise view
a
b c
d
Fig. 2 a-d.a X-ray appearance of the syndesmotic relationship. b Normal medial clear space must be
< 4 mm. c, d Talar malalignment is clear if a talar subluxation or a talar tilt is present
ANTEROPOSTERIOR VIEW
edly true that surgery has to be postponed in the presence of soft-tissue injuries (intra-dermal oedema, fracture blisters, subcutaneous oedema), it seems a reasonable early surgical treatment for soccer players. Indeed, the initial swelling is due generally to haematoma formation, and early open reduction internal fixation (ORIF) techniques allow primary closure without tension of the surgical wound, releasing this haematoma.
Treatment Options
The goals of surgical treatment are to reduce the joint surface, restore axial alignment, and obtain enough stability of the distal tibia to allow for early motion of the ankle joint, meanwhile avoiding complications that could severely compromise the outcome.
Isolated Malleolar Fractures
Tip avulsions or small transverse lateral malleolar fractures below the joint are treated non-operatively. In several studies, the outcome of anatomic reduction and internal fixation of lateral malleolar fractures with up to 3 mm of displacement [8] was similar to that of non-surgical treatment. This find- ing suggests that injuries associated with up to 3 mm of displacement can be addressed by conservative treatment, provided that anatomic reduction of the talus is achieved. In these cases, a short-leg weight-bearing cast or a func- tional fracture brace should be applied, usually for 4–6 weeks. However, fol- lowing AO principles of early motion in fracture healing, the indication for operative treatment in soccer players is primary to obtain early ankle mobil- isation, even in absence of weight bearing. Isolated medial malleolar fracture is a rare entity: It is usually associated with soft-tissue injury or other malle- olar fractures. When faced with this injury, the same principles of lateral malleolar fracture treatment are applied.
Bi-Malleolar Fractures
Bi-malleolar fractures involve both peroneal and tibial malleolus or lateral malleolus with accompanying disruption of the deltoid ligament complex.
Although it has been reported that 80–91% of ankle traumas in soccer play- ers involve the lateral compartments [9, 10], it must be considered that the medial side of the foot is frequently used for passing, shooting, and tapping the ball so that the ankle is exposed to extremes of plantar flexion, dorsiflex- ion, inversion, or pronated foot position. Therefore, soccer players might be more subjected to medial injuries than the general sporting population.
The severity of the fractures often depends on the mode of injury. Another major determining risk factor is the weight-bearing status of the limb at the time of the incident. Hence, the fracture pattern must be understood and clas- sified according to the mode of injury (i.e., supination–external rotation frac- tures) before deciding the proper treatment [2]. Surgical treatment is recom- mended for evident instability or articular incongruity and is less straight- forward than for isolated malleolar fractures. Furthermore, because of acute and chronic instability of the ankle as a common complication of this injury, surgical repair in soccer players is mandatory.
Anatomically, medial structures have a pivotal role in ankle stability while lateral malleolus determines the talar position by means of contact with the lateral facet of the talus. During the reduction procedure, the talus follows faithfully the lateral malleolus; for this reason, in bi-malleolar fractures, it is fundamental to obtain anatomical reduction of the fibula, and in that, restor- ing physiological motion in both planes [11].
On the other hand, medial reconstruction restores normal coronal plane motion [11]. Injury to the superficial portion of the deltoid ligament does not always cause instability; on the contrary, a complete rupture associated with a lateral fracture severely compromises ankle stability so that surgical recon- struction is required for a better clinical result. Nevertheless, the deep deltoid ligament usually ruptures in its mid-substance, and it is difficult or impossi- ble to fully restore. So the real amount of stability after surgical repair is not known by the surgeon unless post-operative stress x-rays are obtained [12].
For all these reasons, bi-malleolar fracture in a soccer player’s ankle should be surgically addressed with reconstructive procedures and internal fixation.
Tri-Malleolar (Cotton) Fractures
Tri-malleolar fractures include a lateral malleolar fracture; a triangular frac- ture of the posterolateral corner of the tibial plafond, most of the time dis- placed; and a horizontal or oblique fracture of the medial malleolus.
Sometimes, the medial malleolus may be intact with a tear of the deltoid lig- ament. Tri-malleolar fractures always require ORIF when more than 25% of the posterior articular surface is involved or the fracture is displaced more than 2 mm [12]. Because of the high level of fracture instability, treatment results are not as predictable as in bi-malleolar fractures.
In facing these complex injuries, particular attention must be paid to restore the length and alignment of the fibula, as it plays a major role in sta- bilising the talus in the ankle joint complex. Moreover, any medial compart- ment injury (i.e. deltoid ligament rupture) has to be properly repaired.
Injuries of the Syndesmosis
It is essential that the syndesmosis be anatomically reduced. The syndesmo- sis will be stable if medial and lateral ligament complexes are anatomically restored; stabilisation of the syndesmosis may be initially accomplished by repairing ruptured ligaments and by fixing the associated fractures of the fibula, avulsed tubercles, and medial malleolus [6, 12]. Whether any further fixation is necessary depends strictly on the stability of the syndesmosis once the fibular length has been restored, the fibula fixed, and the medial side reconstructed. The answer to this controversial orthopaedic dilemma can be found intra-operatively using a simple hook test or taking stress x-rays in external rotation of the ankle: Widening of medial joint space by more than 2 mm suggests residual syndesmotic instability (Fig. 3).
Fixation is usually accomplished by one or two screws inserted in the fibu- la 3–4 cm above the level of the ankle joint perpendicular to the tibiofibular joint, allowing primary stability for ligament healing. The syndesmotic screw (cortical or malleolar screw) is a positioning screw used to hold and not com- press the syndesmosis. The foot is placed in dorsiflexion to bring the widest portion of the talus into the mortise [13–15]. There are also discussions as to whether one or two tibial cortices have to be engaged by the screw threads;
drilling the lateral tibial cortex only allows loosening of the screw rather than breaking if movement occurs. Instead, if the fibular fracture is so high that its direct fixation is not possible (i.e. Maisonneuve injury), then both tibial cor- tices should be engaged in order to increase intrinsic stability of the con- struct. When to remove the screw remains controversial. We advocate removal before weight bearing to restore the physiological movement of the fibula and prevent fatigue failure of the screw.
Injuries of the Medial Collateral Ligament
An isolated lateral malleolar fracture associated with a medial collateral liga- ment injury is equivalent to bi-malleolar fracture. Anatomical reduction of the lateral malleolus restores the medial anatomy and allows medial ligamen- tous structures to heal without the need for operative repair. Surgical indica- tion is mandatory if medial clear space is widened by more than 2 mm after reduction of the fibula or the reduction of the fibula is blocked by interpos- ing tissues (deltoid fibres, posterior tibial tendon).
Reconstruction of the deep deltoid ligament, as stated above, could be dif- ficult because of its transverse position under the malleolus, short length, and the difficulty in getting sutures to hold in the remnant of a ruptured ligament.
Keep in mind the possibility of interposition of the deltoid ligament or oth- ers soft tissue (posterior tibialis tendon).
Fig. 3 a-d.a,b AP and lateral view of a tri-malleolar fracture with subluxation of the talus.
c, dPostoperative x-rays: no screws in the syndesmosis were required
a b
c d
Complications
There are several complications affecting the outcome of the treatment of ankle fractures. These are in common with other articular fractures such as osteochondral fracture, malunion, non-union, wound problems (4–5% and that of secondary surgery, 5%) [6, 7], and post-surgical infection (1–2% for unstable ankle fractures). Loss of motion, degenerative arthritis (greater in the soccer population [16, 17]), development of anterior bone impingement secondary to damage of articular cartilage, and repetitive kicking of the ball, are peculiar, although not exclusive, of a soccer population. Any one of these requires an individualised treatment considering the circumstances, the per- sonality of the fracture, and the athlete.
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