Description of patient (type of occupation, indication of age, intensity of sport):
42 years old patient sustained inversion type injury. He is slightly overweight, not a sportsman. Uses his legs for regular everyday walking. Office employee with some external activity, nothing physical.
History and previous treatment:
Sustained inversion type injury to his right ankle- Maisonneuve type injury. Operatred on the same day with two suprasyndesmotic screws and plaster cast. No weight bearing for 10 weeks. Screws removed after 13 weeks. Dislocation at distal TF syndesmosis was noticed.
Current complaints:
Complains on pain with even a slight attempt to run, normal walking is still ok. The ankle swelling is prominent especially in the afternoon
Physical examination:
There is no obvious swelling nor locally elevated temperature. ROM is generally fine, slightly diminished in endpoints and testing is generally not painful. Painful exorotation of the foot and slightly more laxity on mediolateral testing compared to the healthy side. Ligaments have firm end points.
Radiology:
X-ray:
[Picture1]
Additional investigation (CT/MRI):
MRI- chondral damage to distal tibial cartilage on the lateral side of the tibia with evidence of subchondral oedema.
CT with i.v. contrast arthrography- osteochondral lesion to the lateral distal tibia initial signs of bony aposition to anterior tibial border.
Postoperative:
Widening of the syndesmotic space, widening of medial joint space. Two screws are removed.
[Picture 2]
Images:
Case summary:
42 years old male 1 year after Maisonneuve with osteochondral damage to distal lateral tibia and X-ray evidence of ligamentous damage to syndesmosis- grade 2.
Question(s) to this case:
I am leaning towards arthroscopy of the tibiotalar joint and revision of the syndesmotic area to possibly remove osteochondral fragment- I can not decide however if reconstruction of syndesmosis ligaments is needed or not.
Expert:
This is a malunion of a Maisonneuve Pronation-External Rotation (PER) ankle fracture.
The solution is not arthroscopy.
There are 2 possibilities: the first is to perform a correction osteotomy of the fibula = lenghtening, medialisation and derotation of the fibula + removal of soft tissue from the syndesmotic space + medial arthrotomy with removal of soft tissue between med malleolus and talus(can be done by arthroscopy).
Better solution in this case is to perform a synostosis. When you perform this synostosis you also need to lenghten, medialise and derotate the fibula + remove soft tissue from the syndesmotic space + medial arthrotomy with removal of soft tissue between med malleolus and talus which can be done by arthroscopy or by arthrotomy.