A Fibular Notch Approach for the Treatment of Ankle Fractures Involving the Distal Tibial Plafond

SLR - October 2021 - Samuel Clellen

Reference: Liu T, Cheng Y, Qu W. A Fibular Notch Approach for the Treatment of Ankle Fractures Involving the Distal Tibial Plafond. J Orthop Surg Res. 2021Feb 8;16(1):120

Level of Evidence: 4

Scientific Literature Review

Reviewed By: Samuel Clellen, DPM 
Residency Program: Northwest Medical Center – Margate, FL

Podiatric Relevance: Distal tibial plafond fractures, including traditional pilon and atypical ankle fractures, pose a challenge to foot and ankle surgeons due to their complex nature and need for adequate exposure. Although multifactorial, the efficacy of repairing these fractures is closely associated with surgical approach. Often, combined incisional approaches are taken to allow for visualization of the tibial articular surface; however, these carry an increased risk of narrow skin bridge necrosis. This paper offers a novel technique, inspired by the transfibular approach taken for ankle arthrodesis, in providing adequate exposure to the fibular notch to treat specific ankle fractures. The authors hypothesize that this single-incision technique is a reliable alternative to other incisional approaches and can achieve satisfactory radiographic and clinical results.

Methods: A retrospective study was conducted between 2015 and 2018 at a single institution, which assessed ankle fractures involving the distal tibial plafond with a total of 22 patients meeting inclusion criteria. Fractures were caused by various mechanisms and were classified using the AO/OTA classification (AO/OTA 43-B,C, 44-C). Definitive fixation was performed if in an emergency setting with an adequate soft tissue envelope, or staged, after the appearance of a positive “wrinkle sign”. The study details the incision, which was made along the posterior fibular border and extended toward the 4th metatarsal if deemed necessary. The fibular capital fragment was then retracted posteriorly with a joystick technique, providing direct and excellent visualization the entire plafond articular surface. After reduction and fixation of anterior and lateral fragments, a posterolateral interval was taken between the flexor hallucis longus (FHL) and peroneal tendons to expose the posterior ankle. Patients were immobilized in a posterior splint for three weeks post-op, followed by range of motion (ROM) exercises. Reduction quality was assessed post-operatively within one week by radiography and CT scans. Complications (wound healing, bone union) and ankle ROM were the clinical outcomes assessed. 

Results: Mean follow up was 18.7 +/- 4.3 months. Post-op radiographs revealed adequate restoration of all fractures except for one, which was mildly malreduced. Delayed wound healing and superficial infection were found in one patient, who sustained a heavy-pounding injury. Complete union was achieved on average at 17.3 +/- 3.6 weeks. The average ankle ROM was 21.6 +/- 5.2 degrees dorsiflexion, and 33.9 +/- 6.2 degrees plantarflexion. Four patients presented with post-traumatic arthritis. Average AOFAS score and VAS scores of patients were 88.8 +/- 8.6 and 0.55 +/- 0.86 at the final follow up.

Conclusions: The authors reveal that the proposed fibular notch approach is both a safe and reliable technique for treating distal tibial plafond fractures through direct visualization of fragments and the joint surface, minimizing iatrogenic complications. Combined approaches run an increased risk for complications from insult to the soft tissue envelope. This retrospective study demonstrates an alternative technique for foot and ankle surgeons to treat these types of fractures, providing satisfactory radiographic and clinical results. Although promising, further anatomic and clinical studies are needed to determine its true practicality.