Stefan Rammelt1, Jan Bartoníček2, Tim Schepers3, Livia Kroker4. 1. University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany. stefan.rammelt@uniklinikum-dresden.de. 2. Orthopedic Department of First Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic. 3. Trauma Unit, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands. 4. University Center of Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
Abstract
OBJECTIVE: The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. INDICATIONS: Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. CONTRAINDICATIONS: Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. SURGICAL TECHNIQUE: Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3). POSTOPERATIVE MANAGEMENT: Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. RESULTS: Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.
OBJECTIVE: The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. INDICATIONS: Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. CONTRAINDICATIONS: Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. SURGICAL TECHNIQUE: Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3). POSTOPERATIVE MANAGEMENT: Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. RESULTS: Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.
Authors: Jan Bartoníček; Stefan Rammelt; Karel Kostlivý; Václav Vaněček; Daniel Klika; Ivo Trešl Journal: Arch Orthop Trauma Surg Date: 2015-02-24 Impact factor: 3.067
Authors: Thomas O Clanton; Brady T Williams; Jonathon D Backus; Grant J Dornan; Daniel J Liechti; Scott R Whitlow; Adriana J Saroki; Travis Lee Turnbull; Robert F LaPrade Journal: Foot Ankle Int Date: 2016-10-01 Impact factor: 2.827
Authors: Merel F N Birnie; Kaz L J van Schilt; Fay R K Sanders; Peter Kloen; Tim Schepers Journal: Arch Orthop Trauma Surg Date: 2019-02-15 Impact factor: 3.067