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Treatment of Anteroinferior Tibiofibular Ligament Avulsion
Fracture Accompanied with Ankle Fracture
AOFAS 2012 ANNUAL SUMMER MEETING
My disclosure is in the Final AOFAS Program Book.
I have no potential conflicts with this presentation.
Introduction
Anterior inferior tibiofibular ligament avulsion fracture
- A part of syndesmosis injury
- Rotational injury
- May not be apparent on plain X-rays
- Nonunion, Malunion ; pain, impingement, arthrosis (Akseki D et al. 1999, Acta Orthop Scand)
(Bassett FH et al. 1990, JBJS)
Classification ( modified Wagstaffe`s classification)
Type 1 ; displaced avulsion fracture of the distal end of the fibula
Type 2 ; fracture of the anterior spike of the proximal fibular fragment
Type 3 ; avulsion fracture from the tibia by AITFL (Chaput fracture)
Type 4 ; fracture of the anterior tubercles from both of the tibia and fibula
(Wagstaffe WW, 1875, Pankovich AM, 1979)
Purpose : To evaluate the clinical results of anteroinferior tibiofibular ligament
avulsion(wagstaffe) fracture accompanied ankle fractures treated with anatomical
reduction and internal fixation
From Jan. 2007 to April. 2010
31 cases / 249 cases of total ankle fracture
All cases : AITFL avulsion fractures
Male / Female : 11 / 20
Age : average 53 Y.
Follow-up : average 26 M.
Cause : Slip(29), Traffic Accident(1), Fall down(1)
Materials
● ● ●
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Diagnosis Preoperative X-ray
1. AITFL Avulsion Fx.
2. Distal TF diastasis - TF Overlap, TF Clear space,
Medial clear space
Preoperative CT
- Suspected in simple X-ray
Intraoperative check
Operative Techniques Ankle Fracture ORIF
Ant. Inf. TF lig. Avulsion Fracture
Fixation or Repair Mini Screw ; 12 cases
K-wire ; 10 cases
Mini Screw + K-wire ; 3 cases
Ligament repair (pull-out suture) ; 6 cases
Methods
Total Ankle Fracture ; 249 cases Supination - Ext. Rotation ; 192 cases (77.1 %)
Supination - Adduction ; 16 cases
Pronation - Ext. Rotation ; 24 cases
Pronation - Abduction ; 17 cases
31 cases of AITFL Fx. (12.4%) / 249 cases of Total Ankle Fracture
Fracture / Dislocation ; 2 cases
Maisonneuve Fx. ; 1 case
Supination – ER type ; 28 cases
(Stage II 8 cases, Stage III 3 cases, Stage IV 17 cases)
Results
AITFL avulsion Fx. Classification
Type 1 ; 1 case
Type 2 ; 23 cases
Type 3 ; 5 cases
Type 4 ; 2 cases
Radiologic findings
AITFL avulsion Fx. Union ; all cases Distal TF diastasis (Preoperative ⇒ Postoperative)
- TF clear space ; 2.5 ⇒ 2.4
- TF overlap ; 6.3 ⇒ 6.8
- MCS ; 4.0 ⇒ 3.2
AOFAS Score
Excellent ( 90 ~ ) ; 23 cases
Good ( 80 ~ ) ; 6 cases
Fair ( 70 ~ ) ; 2 cases
Poor ( ~ 60 ) ; 0 case
Complications
ROM limitation ; 7 cases - Fracture-Dislocation ; 1 case - Trimalleolar Fracture ; 4 cases - Bimalleolar Fracture ; 2 cases
Pain ; 2 cases - SPN Irritation / Hardware Irritation
Results
Anteroinferior Tibiofibular Ligament Avulsion Fracture (Park et al. JOT, 2002)
13 cases of AITFL avulsion Fx. / 93 cases of Ankle Fractures (14 %)
All cases of AITFL avulsion Fx.
- in Weber B type
- Wagstaffe type 2
TF Diastasis ; 11 / 13 (84.6%)
1 cases of Fair Result ; Nonunion & Impingement
Our Study 31 cases / 249 cases of Total Ankle Fracture (12.4%)
Supination – ER type ; 28 / 31 cases (90.3%)
Wagstaffe Classification - Type 2 ; 23 cases (74.1 %)
Discussion
AITFL Avulsion Fx.
Incidence ; 12.4% of Ankle Fracture
- Most common at SER type (90.3%)
- Wagstaffe Type 2 ; most common (74.1%)
Diagnosis - Preoperative X-ray ± CT
- Intraoperative Check
Treatment - Anatomical Reduction & Fixation
Anteroinferior tibiofibular ligament avulsion fracture accompanied with ankle fracture is a good clinical outcome with internal fixation. We should not miss out the anteroinferior tibiofibular ligament avulsion fracture in preoperative and intraoperative evaluation.
Conclusion
Akseki D, Pinar H, Bozkurt M, Yaldiz K, Araç S: The distal fascicle of the anterior inferior tibio-fibular ligament as a cause of anterolateral ankle impingement: results of arthroscopic resection. Acta Orthop Scand.70:478-82, 1999. Bassett FH 3rd, Gates HS 3rd, Billys JB, Morris HB, Nikolaou PK: Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am. 72:55-9, 1990. Pankovich AM: Fractures of the fibula at the distal tibiofibular syndesmosis. Clin Orthop Relat Res. 138-47, 1979. Park JW, Kim SK, Hong JS, Park, JH: Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture. J Trauma. 52:655-9, 2002. Wagstaffe WW: An unusual form of fracture of the fibula. Cited by. ST thomas Hosp Rep. 6:43, 1875.
References