Frakturen des oberen Sprunggelenks

Malleolar fractures predominately result from a dislocation force at the ankle and are usually accompanied by injuries of the collateral ligaments and the tibiofibular syndesmosis. Forced abduction, adduction or external rotation of the foot against the tibia produce the typical sequence of bony and ligamentous injuries at the ankle joint. With the foot in supination at the time of injury, the deforming force acts first on the lateral malleolus, with the foot in pronation the force acts first on the medial malleolus. Fracture-dislocations must be reduced as an emergency under sufficient analgesia. Early stabilization is generally preferable for all displaced and unstable ankle fractures. With operative treatment, exact reconstruction of the articular surface, restoration of the length and rotational alignment of the fibula and fixation of osseous or ligamentous syndesmotic injuries are important prognostic factors. Non-operative, functional treatment leads to good long-term results in isolated, non-displaced fractures of the medial or lateral malleolus provided that instability of the ankle mortise has been definitely ruled out. Treatment of pediatric and adolescent malleolar fractures follows the same principles and has to respect the growth plate which ossifies over an 18 month period. Special attention has to be paid to hereditary or acquired neuropathy with dramatically increased healing times and complication rates.     

Osteosynthese von Frakturen des oberen Sprunggelenks

Detailed knowledge of anatomy and biomechanics of the ankle is necessary for the treatment of ankle fractures. After diagnostic investigations with x-ray and when indicated computed tomography the injury needs to be classified. It is necessary to recognize the injury of the bone and of the ligaments. The operative treatment includes anatomic repositioning, stable osteosynthesis and correct restoration of the ankle joint to avoid posttraumatic arthrosis.     

Frakturen des oberen Sprunggelenks Klassifikation und operative Standardversorgung

Trauma und Berufskrankheit - Die erfolgreiche operative Versorgung der oberen Sprunggelenkfraktur basiert auf einem fundierten Verständnis sowohl der Fraktur als auch der Biomechanik des...     

Frakturen des oberen Sprunggelenks beim älteren Patienten

The number of ankle fractures in elderly patients is increasing. The aim of treatment of ankle fractures in the elderly is to guarantee a possible unlimited autonomy and quality of life for patients. This is achieved by minimization of the complications and impairments after ankle joint fractures. Decisive for the further course is the initial treatment. The results are essentially determined by the soft tissue management, reduction and stable osteosynthesis; however, an orthogeriatric co-management with the implementation of treatment paths and standard operating procedures is recommended. The advantages of an interdisciplinary cooperation of trauma surgeons and geriatricians are obvious in this situation.     

Totalendoprothese des oberen Sprunggelenks nach posttraumatischer Arthrose

In 1997 six patients with posttraumatic ankle arthritis aged 54 (45-71) years were treated with a LINK S.T.A.R. ankle prothesis. The average follow up was 29 (21-36) months. Results were evaluated according to the ankle score of H. Kofoed [7]. Two patients had an excellent outcome and 1 patient had a fair result. In three patients secondary arthrodesis had to be performed, due to loosening of the implant. Based on our experiences we cannot recommend this implant for patients with posttraumatic arthritis at this time.     

Arthrodesen des oberen Sprunggelenks nach Endoprothesenfehlschlägen

Report of four patients. OBJECTIVE: Restoration of a painless gait through ankle arthrodesis after failed total ankle replacement. INDICATIONS: Loosened or infected total ankle replacement. CONTRAINDICATIONS: Poor general health. Absent patient compliance. SURGICAL TECHNIQUE: Removal of total joint components. Filling of the defect with tricortical bone grafts harvested from the ipsilateral iliac crest and internal fixation. In instances of suspected infection a two-stage procedure is recommended, the first stage consisting of a removal of the components, a meticulous debridement, and filling of the defect with gentamycin-laden PMMA beads. Second stage: arthrodesis. RESULTS: The goal of surgery was reached without complications in two out of four patients. An absence of bony bridging was noted in the fourth patient after 9 months. A revision adding cancellous bone grafts and resorting to an intramedullary fixation led to a success.     

Die reorientierende Rearthrodese des oberen Sprunggelenks nach fehlgeschlagener Arthrodese

There are three important principles for the correction of nonunion and/or malunion of the ankle joint: (1) reorientation back to anatomic shape and to the normal biomechanical axis of the ankle and foot; (2) respect for the biology of bone by resecting all sclerotic bone and/or transplantation of autogenous bone graft; and (3) achievement of optimal biomechanical stability by using the four-screw technique, a limited-contact dynamic-compression plate or a blade plate. CT scanning is the most reliable method for detecting nonunion of the ankle joint after arthrodesis. According to Saltzman, in order to understand the pathology of malunions and nonunions and to plan their correction, weight-bearing anteroposterior radiographs with a 20 degrees internal rotation of the feet, precise lateral views, and rear views of both sides are highly recommended.     

Revisionsarthrodesen des oberen Sprunggelenks

OBJECTIVE: Ankle arthrodesis with the foot at 90 degrees with minimal as possible leg shortening. Regain of a pain-free use of the limb. INDICATIONS: Failure of arthrodesis, septic or aseptic in origin, accompanied by pain interfering with weight bearing. CONTRAINDICATIONS: General surgical or anesthesiologic risks. Acute reflex sympathetic dystrophy. Significant arterial circulatory disturbances or extensive neurologic deficits. Extensive bone or soft-tissue defects after previous surgeries. SURGICAL TECHNIQUE: Approach using existing scars. Resection of nonunion making allowance for the planned position of arthrodesis. Removal of all necrotic bony and soft tissue. Posterior translation of talus by 1 cm. Autogenous bone grafting of major defects. Temporary fixation with a Kirschner wire with the foot at 90 degrees in the sagittal plane, in 0 degrees in the frontal plane, and 10-20 degrees of external rotation. Application of an external fixator, removal of Kirschner wire and compression of resection surfaces. If needed, apposition of cancellous bone harvested from iliac crest. Suction drain. Wound closure. RESULTS: Revision of arthrodesis in 13 men and three women (average age 48 years [27-76 years]). Average follow-up 10.8 months (3-26 months). In spite of problematic preoperative conditions (local infection eight times, malposition five times) a bony consolidation occurred in 15 of 16 patients, 14 times in a perfect position. Average leg shortening 2.8 cm (1-8.5 cm). Satisfactory soft-tissue healing in twelve patients. Superficial ulceration in two patients, fistula in one. Successful repeat revision of arthrodesis in one patient on account of persisting nonunion and infection.     

Impingement des oberen Sprunggelenks

Ankle impingement syndromes are one of the most frequent chronic and posttraumatic pathologies of the ankle joint. Anterior and posterior impingement result from the abutting of anatomical structures leading to pain and limitation in the range of motion of the ankle joint. Ankle impingement can be classified based on the localization or the underlying cause. Besides chronic ankle pain, further symptoms are movement and load-dependent swelling of the ankle joint and limitations in dorsiflexion and plantar flexion. The clinical symptoms and physical examination play an essential role in diagnosing soft tissue impingement, whereas various imaging techniques are important for the diagnostics of bony impingement. From a therapeutic perspective, conservative treatment should be initially attempted. If non-operative treatment fails, arthroscopic resection and debridement of the underlying cause is nowadays the standard method of surgical treatment. With a current complication rate of approximately 3?% ankle arthroscopy is a safe operative method, which is associated with a high postoperative rate of patient satisfaction and significant relief of symptoms.     

Arthroskopie des oberen Sprunggelenks

At present, arthroscopy of the ankle joint is mostly an operative procedure; it is quite rare for it to be performed for the purpose of reaching a diagnosis. Arthroscopic operations are divided into reconstructive and resective procedures. Arthrodesis of the ankle joint under arthroscopic control and arthroscopy for the treatment of ankle fractures are not currently performed routinely.     

Revisionsarthroplastik des oberen Sprunggelenks

In the last 20?years total ankle replacement has become a viable alternative to arthrodesis for end-stage osteoarthritis of the ankle. Numerous ankle prosthesis designs have appeared on the market in the past and attracted by the encouraging intermediate results reported in the literature, many surgeons have started to perform this procedure. With increased availability on the market the indications for total ankle replacement have also increased in recent years. In particular, total ankle replacement may now be considered even in younger patients. Therefore, despite progress in total ankle arthroplasty the number of failures may increase. Up to now, arthrodesis was considered to be the gold standard for salvage of failed ankle prostheses. Because of extensive bone loss on the talar side, in most instances tibiocalcaneal fusion is the only reliable solution. An alternative to such extended hindfoot fusions would be revision arthroplasty. To date, however, there are no reported results of revision arthroplasty for salvage of a failed ankle replacement.Based on our experience prosthetic components with a flat undersurface are most likely to be able to find solid support on remaining bone stock. The first 83 cases (79?patients, 46 males, 33 females, average age 58.9 years, range 30.6-80.7?years) with a average follow-up of 5.4 years (range 2-11 years) showed excellent to good results in 69 cases (83%), a satisfactory result in 12 cases (15%) and a fair result in 2 cases (2%) and 47?patients (56%) were pain free. Primary loosening was noted in three cases and of these two cases were successfully revised by another total ankle replacement and in one case with arthrodesis. Another case with hematogenous infection was also revised by arthrodesis. At the last follow-up control two components were considered to be loose and the overall loosening rate was thus 6%.This series has proven that revision arthroplasty can be a promising option for patients with failed total ankle prosthesis. The most challenging issue is the solid anchoring of available components on residual bone. More experience is needed, however, to better define the possibilities and limitations of revision arthroplasty.     

Fraktur des oberen Sprunggelenks

For an optimal result to be achieved after a displaced ankle fracture it is essential for a graduated treatment schedule taking account not only of the soft tissue damage and the fracture type and/or severity of the instability, but also of any pre-existing illnesses to be set up. Whatever form the definitive therapy is to take, any severe dislocation should be reduced as an emergency procedure at the site to protect the soft tissues. All joint facets must be reduced anatomically, which means that open reduction plus internal fixation is the treatment of choice in almost all cases. However, the timing of the operative treatment and the options open for surgery are determined by the nature and severity of the soft tissue lesions. Conventional standard X-rays are sufficient to classify most ankle fractures. Anatomical reduction and stable internal fixation together with adequate physical therapy are apparently essential for, but do not definitively guarantee, a good result.     

Arthrodese des oberen Sprunggelenks

The indications for arthrodesis of the ankle joint are explained, as are the surgical technique and the postoperative treatment, with particular reference to the procedure followed by the authors themselves, including the preparation of expert assessments.     

Die Kompressionsarthrodese des oberen Sprunggelenks

Zusammenfassung Es wird zuerst die Wirkungsweise, dann das notwendige Instrumentarium und die Operationstechnik der Kompressionsarthrodese des oberen Sprunggelenks besprochen. Hierauf folgen die Ergebnisse der Nachuntersuchung von 25 isolierten Druckarthrodesen des oberen Sprunggelenks und 23 kombinierten des oberen und unteren Sprunggelenks (18 davon Triplearthrodesen).Die Hauptindikationen zur Operation waren bei den isolierten Arthrodesen die posttraumatischen Arthrosen, bei den kombinierten die Fußdeformierungen nach Poliomyelitis. Die Resultate der komplikationslos verlaufenen Fälle sind sich bei beiden Gruppen ungefähr gleich: Entfernung der Schraubenspanner und Steinmann-Nägel 4–5 Wochen nach der Operation. Unterschenkelgehgips für 9–10 Wochen. Gesamtdauer der Gipsfixation ca. 14 Wochen. Diese 14 Wochen genügen in der Regel, um klinische Festigkeit der Arthrodese und einen im Röntgenbild gut sichtbaren Knochendurchbau zu erreichen. Bei den kombinierten Arthrodesen trat früher und in mehr Fällen Beschwerdefreiheit ein.Als Vorteile der Kompressionsarthrodese ergeben sich: kurze Fixationsdauer im Gipsverband, große Wahrscheinlichkeit der knöchernen Versteifung und Erhaltenbleiben der primär erreichten Fußstellung.Mit 3 Textabbildungen     

Frakturen des oberen Sprunggelenkes

Upper ankle injuries are the most common reason for presentation in emergency departments. The initial treatment is often left in the hands of young clinical professionals. While the mechanism of injury might appear banal, insufficient diagnosis and treatment can lead to long periods of disability and functional impairment of the joint. Therefore, it is the aim of this work to provide a thorough understanding of the anatomy, biomechanics, mechanism of injury, diagnostic and operative procedures of ankle joint fractures.     

Endoprothetischer Ersatz des oberen Sprunggelenks

Die Ergebnisse der Sprunggelenkendoprothetik in den 1970er und 80er Jahren waren nicht akzeptabel. Mit zunehmender Standzeit nahmen Lockerungsraten und funktionelle Beschwerden deutlich zu. Die Gründe für das Prothesenversagen waren multifaktoriell, es konnten jedoch 2 Aspekte analysiert werden, die eine zentrale Bedeutung hatten: das gekoppelte Prothesendesign und die Zementfixation. Die Prothesen der heutigen Generation sind ungekoppelt und favorisieren die kn?cherne Fixation durch ein entsprechende Oberfl?chenbeschichtung.     

Posttraumatische Arthrose des oberen Sprunggelenks

Arthritis of the ankle is primarily posttraumatic and therefore found in younger, active patients. Accompanying injuries involving soft tissue damage and axial misalignment are often seen. In case of severe arthritis ankle arthrodesis is an established method with an almost unlimited spectrum of application which also results in reliable freedom from pain. Due to advances in total ankle replacement (TAR), and in cases where individual indications are fulfilled, TAR offers an excellent alternative to arthrodesis. Thus physiological gait can be almost completely maintained and shortening of the leg or development of arthritis in adjacent joints can be prevented. Since TAR and secondary fusion are facilitated by minimal bone loss using modern prostheses, the procedure can be recommended even in younger patients. Correct positioning and soft tissue balance, which should be performed secondarily, are preconditions for perfect results. Due to greater fields of application, arthrodesis remains the gold standard, whereas TAR will remain reserved for specialized centres until case numbers increase.     

Die Vier-Schrauben-Arthrodese des oberen Sprunggelenks

OBJECTIVE: Arthrodesis of the ankle at 90 degrees and perfect axial alignment for restoration of a painless function. Early functional postoperative care. INDICATIONS: Painful posttraumatic or idiopathic osteoarthritis of the ankle either unresponsive to conservative measures or where these measures are not expected to be successful. Posttraumatic malalignment of the ankle, paralysis or instability, that cannot be improved or eliminated by joint-preserving measures. Joint destruction after infection. Failure of total joint replacement. CONTRAINDICATIONS: Acute osteitis. Poor skin or soft-tissue conditions. Severe peripheral arterial occlusive disease. SURGICAL TECHNIQUE: Anterior approach, judicious resection of the remaining articular cartilage. Freshening of the zones of sclerosis. Preservation of the anatomic shape of the mortise. Correction of malalignments in the sagittal and frontal planes and placement of the talus in line with the tibial axis. Tibiotalar stabilization with four 7.3-mm self-cutting cannulated cancellous lag screws or with four 6.5-mm cancellous lag screws. RESULTS: Between January 1, 1994 and December 31, 1998 this technique was performed in 50 ankles of 48 patients. 40 patients could be followed up for an average of 5.6 years (4.8-7.6 years). No serious complications. The average compensatory movement of the Chopart joint amounted to 26 degrees . Osteoarthritis of the subtalar joint was seen in 13%, and of the talonavicular joint in 12.5% of patients. Preexisting osteoarthritis of these joints remained in general unchanged. The AOFAS Score was assessed pre- and postoperatively. Preoperatively, 17.5% of patients showed a satisfactory and 82.5% a poor score. Postoperatively, 52.5% had an excellent, 30% a good, 10% a satisfactory, and 7.5% a poor outcome.