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Post-traumatic ankle degenerative joint changes is
more times associated with an ankle injury that has not healed properly. Whether it be a malunion or nonunion, loss of anatomic
reduction will result in altered biomechanics.
Severe injuries occur, but more often isolated regions of either chondromalacia
or an osteochondral defect will occur within one year of the injury.
Gross DJD is more prevalent in cases in which
either the mortise is altered or the ankle range of motion is lost. Post-injury fibrosis is the primary source of DJD. Failure
to restore the ankle back to normal ankle ROM even in anatomic reductions will lead to gross DJD.
As high as 40%
of all ankle fractures will require ankle arthroscopy to remove fibrosis within one year of the injury. Either the loss of
ROM or pain will necessitate the need for surgery.
In some cases, ankle arthroscopy and/or diagnostic arthroscopy maybe
necessary to determine the extent of the DJD changes.
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Looks good? Look closer, the fibular plate is too short and only has two cortices distal to the
fracture. This fracture pattern doesn't need a syndesmotic screw. One was used because the fibula is not too length. Medial
malleolous should have another point of fixation.
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Things are now falling apart. Why, fibular fixation is unstable.
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Instead of re-doing all the fixation, let's just replace the syndesmotic screw with a bigger screw.
The medial malleolous is now rotated. The ankle is now in an unstoppable valgus drift.
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Two years later, she limps into your office
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Patient developed RSD after being casted for 4 months
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Ankle scope then ankle arthrodiastasis
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Both these cases illustrate how some simple principles
were violated and how easily the situation escalates and gets out of control.
Too often surgeons want to get by,
but far too often their original hardware was not satisfactory. Often removing everything and starting over is harder but
the solution.
Placing cases like this in a frame is often the answer. I am placing more diabetic ankle fractures
in circular frames from the start to avoiding open reduction. I'm doing the same for geriatric butter soft bone cases.
I
have only shown xrays. I neglected to include all of the pussed out wound cases.
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After three months of gradual correction
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