Outcome of a Treatment Protocol for Severe Open and Unstable Dislocations of the Ankle
Methods: series of 167 patients with isolated open ankle dislocations were followed. They consisted of 35 grade II, 45 grade IIIA, and 113 grade IIIB open wounds. All patients sustained fractures of the malleoli and/or talus. Ten patients had no fractures.
Results: Eighty patients returned to a preinjury level of social activity. One hundred forty-four of 167 patients had good anatomic reduction, 13 fair, and 10 poor. Functionally, 161 patients regained 15 degrees of dorsiflexion and 35 degrees of plantar flexion. One hundred sixty-five of 167 patients reported some occasional residual pain at follow-up visit. Two patients with persistent osteomyelitis and soft-tissue infection requested a below-knee amputation. One ankle with painful limited motion required fusion.
Discussion: We have instituted a standardized treatment protocol for high-energy, open dislocations of the ankle. The frequency of this group of injuries is increasing. Early, aggressive management of the wound is mandatory along with immediate ORIF and accurate reduction of the ankle dislocation. Early external fixation simplifies soft-tissue management by providing excellent wound access and stable fixation. Overall, good results can be expected by following our treatment protocol. Level of Evidence: IV; Retrospective case series.
Keywords: Open ankle fracture-dislocations; External fixation; Ankle injury outcome.
Fracture-dislocation/open dislocations of the tibiotalar joint were first described by Dupuytren in 1819 . These are complex injuries associated with high-energy trauma, largely as a result of a motor vehicle accident . There is a high incidence of reported treatment complications, particularly deep infection. It is the impression of a number of trauma surgeons that the frequency of this group of injuries may be increasing . This increase could be explained by improved resuscitation of the polytraumatized patient at the scene of the accident, improved patient transit times, and the increasing use of airbags and other safety precautions in motor vehicles. All of these factors contribute to an increased survival rate, enabling patients who would have died in previous years, now to be transported and treated expeditiously at a Level I Trauma Center where their orthopaedic injuries are promptly recognized and managed. This increase in cases is also due to a lack of safety measures in motor vehicles for the lower extremities. Ankle dislocations, with or without associated fractures, are a frequent sequela from these high-energy trauma, and commonly are open injuries. The management of these lesions is controversial and complications are common, leaving many patients with severely altered ankle functions and, thus, altered employment and recreation. We have developed a protocol for these unstable ankle dislocations and found that its institution has led to excellent outcomes, few complications, and the ability for most of our patients to return to work in their preinjury capacity. This standard treatment protocol has been developed to simplify the management of these complex injuries and has been implemented by the senior author for more 20 years. MATERIALS & METHODS
Our protocol consists of initial trauma room evaluation by the orthopaedic resident (Figure 1). The patient is assessed in the emergency room (ER) and the distal neurovascular status is established. The dislocations that were not grossly contaminated are reduced under intravenous analgesia and sedation and a padded trilaminar splint applied as temporary immobilization. Betadine dressings are placed over grossly contaminated open injuries that are splinted without reduction. The intravenous antibiotics (eg, ancef 2g, gentamicin 5mg/kg) and tetanus prophylaxis are administered before the patient leaves the ER. Grossly contaminated wounds also receive 4 million units of penicillin. The patients then are taken to the operating room (OR) emergently for irrigation, surgical exploration, and debridement, followed by skeletal stabilization.
Once internal fixation of the ankle is complete, the foot and ankle are stabilized with an external fixator (Figure 3). Even in cases with fracture of the talus or pure dislocation, we span the reduced ankle joint, applying the ex-fix in the same manner. We have used 1 of 5 types of external fixators over time (Hex Fix; Smith & Nephew; Memphis, TN, USA; Large External Fixator; Synthes; Paoli, PA, USA; Jet-X External Fixator; Smith & Nephew; Memphis, TN, USA; Hoffmann External Fixator, Stryker; Kalamazoo, MI, USA; Dolphix, CiTiEffe, Bologna, Italy). Overall, we favor a simple, inexpensive, pre-packaged unilateral frame which ideally can be applied rapidly, even in the ER, without power tools.
The usual adopted configuration consists of 2 proximal pins that are inserted into the anteromedial aspect of the tibia. Another pin is placed in the calcaneus, and the bars of the fixator are attached to these pins. The calcaneal pin is inserted in a slightly valgus orientation so the ankle is placed into varus/supination once the fixator is tightened. Finally, the foot is dorsiflexed to 90 degrees, and another pin is inserted into the first metatarsal, using the metatarsal paddle and clamp as a drill guide. Care is taken to place the metatarsal pin so it does not obscure the ankle joint on the AP radiograph. The ankle is reduced, and all mountings are then tightened.
Our study evaluated 167 patients treated by this protocol. Follow-up was done at an average of 24.5 months (range 9 months to 5 years) (Figure 4). The open injuries included 35 grade II, 45 grade IIIA, and 113 grade IIIB. Since all these lesions involved the ankle joint, they were further classified as type IV open joint injuries, the most severe grade per Collins & Temple . The average age of the patient was 35.7 years (range 21-62); 108 were men and 59 women. The mechanism of injury was an MVA in 108, a fall in 58, and timber fall in one patient. Alcohol intoxication was involved in more than 50% of the cases. All patients were treated by 1 surgeon. Only injuries involving the tibiotalar joint were included in this study. Any injury with a concomitant pilon fracture was excluded.
Fracture-dislocations of the ankle are severe injuries associated with significant soft-tissue and bone damage . We have focused our attention on open injuries involving the ankle joint treated and followed by the same surgeon. All cases had gross capsular disruption with instability associated with soft-tissue contamination.
The immediate aggressive debridement and stabilization of open ankle injuries, particularly grade IIIB injuries, is paramount. Early series of open-ankle fractures treated by ORIF had disturbingly high rates of infection. More recent studies, however, have reported lower infection rates after early external fixation. The reduction in infection is attributed to improved surgical techniques and attention to soft-tissue handling. Also, in cases of open injuries, the thorough, repeated irrigation and debridement with either delayed wound closure or early soft-tissue coverage combined with strict adherence to AO/ASIF principles have improved the overall results [2,3,6,7].
There have been a number of experimental and clinical studies on the syndesmosis which have increased our understanding of the syndesmotic injury and, in turn, may lead to improved functional results [8-10]. Fracture-dislocations represent severe ankle injuries, and when the syndesmosis is disrupted, the instability is even more severe. We therefore recommend accurate reduction of a tibiofibular diastasis before fixation with a syndesmosis screw. A large Weber reduction forceps is used and the reduction is carefully assessed radiographically before screw insertion.
It is the practice of most surgeons to put the majority, if not all, of their operatively treated ankle fractures into a cast for 2-6 weeks after fixation. Clearly, cast immobilization of severe ankle fracture-dislocations after internal fixation would cause numerous problems because a high incidence of open injuries have associated soft-tissue swelling, blistering, and edema. External fixation simplifies soft-tissue management by providing excellent wound access and is less cumbersome than the traditional cast. Previous literature has supported the efficacy and safety of spanning ankle external fixators for severe ankle trauma [10-12]. The secure immobilization ensures optimal capsular and ligamentous healing as well as further stabilization after bone dislocation or fracture fixation. There is no need for constrictive padding or bandages and wounds can be easily monitored for signs of infection. Plastic surgery is facilitated by the soft-tissue stability the fixator provides for vascularized free flaps and skin grafts. We have selected a very simple frame configuration which can be rapidly constructed and applied to the injured extremity. The average time of frame application in our series of cases was around 30 minutes. We feel it is important when applying an external fixator to the tibia that care is taken to avoid an equinus deformity at the ankle. Despite the external fixator’s ease of application, care must be taken when inserting the medial calcaneal pin to avoid the medial calcaneal and the lateral plantar nerves .
Our treatment protocol was designed to offer the surgeon a relatively quick, safe, and reliable way to address severely unstable ankle dislocations, while providing ease of access for soft-tissue management and ease of care for the patient. Gustilo and Anderson  noted that the most important prognostic factor in open fractures is the amount of energy absorbed to create the soft-tissue injury.
Our study shows that internal fixation with adjuvant external fixation is a viable option for even high-grade open fractures. This combination was designed to obtain anatomic restoration and stabilization of the ankle joint as an aid to manage the soft tissues, since early fracture stabilization maximizes the ability of the soft tissues to resist infection and to heal .
By using an external fixator as a supplement to internal fixation, we found we provided an ideal environment for soft-tissue healing and, therefore, an ideal environment for recovery . Success can be defined in many terms, mainly by salvage of an extremity, patient satisfaction, and good functional use of the extremity. We found that this treatment protocol can be successful, with the majority of the patients able to return to their pre-injury social capacity. REFERENCES
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