Anterior distal tibial plafond-plasty for the treatment of posttraumatic ankle osteoarthritis with anterior translation of the talus

Joint-Preserving Osteotomy of the Lateral Tibial Plafond for Posttraumatic Osteonecrosis: A Prospective Cohort Study

BACKGROUND

Posttraumatic osteonecrosis (ON) of the lateral distal tibia is a rare but severe complication of malleolar fractures. Treatment options include ankle fusion, arthroplasty, osteotomy, and drilling but clinical data on outcomes are limited to single case reports. The aim of this study was to prospectively evaluate the outcome following joint-preserving reconstruction.

METHODS

Over a 10-year period, 10 patients (8 females and 2 males, average age 36 years; range, 27-68 years) with posttraumatic ON were treated with intra-articular osteotomy of the distal tibia and bone grafting. All patients initially sustained a closed pronation injury, 7 with initial tibiotalar subluxation. Chronic syndesmotic instability following initial treatment was present in 4 patients and 5 were smokers. All patients were followed for a median of 68 (range, 12-103) months, 7 returned in person for clinical and radiographic follow-up.

RESULTS

No immediate postoperative complications were seen. Secondary ankle fusion was necessary in 1 case (10%) because of progressive osteoarthritis. At the time of follow-up, anterior ankle arthritis leading to impingement and requiring cheilectomy was noted in 4 cases, partial graft necrosis, and secondary syndesmotic instability requiring revision surgery was seen in 1 case each. Compared with the preoperative values, significant improvement in the Olerud-Molander Ankle Score (P = .012), EuroQuol-5 Score (P = .008), and Foot Function Index (FFI-D pain, P = .028; FFI-D restriction, P = .038) was seen. Average range of motion at the ankle was 45 degrees.

CONCLUSION

In our limited series of patients with posttraumatic ON of the lateral distal tibia, we found that joint-preserving reconstruction using an intra-articular distal tibial osteotomy with autologous bone grafting usually provided significant functional improvement and pain relief. In our cohort secondary fusions by a median 5.5-year follow-up were rare, but secondary, joint-sparing surgeries were common.

LEVEL OF EVIDENCE

Level III, prospective study.

Joint Preservation for Posttraumatic Ankle Arthritis After Tibial Plafond Fracture

Management of posttraumatic ankle arthritis due to tibial plafond fracture is technically demanding. The distal tibial plafond-plasty could be an alternative to preserve the ankle joint for young patients with limited ankle arthritis. The surgical principles are to realign the mechanical axis, reconstruct the articular surface of the distal tibial plafond, and achieve a congruent and stable ankle joint. In addition to the anteroposterior view of the ankle joint, the lateral view was also paramount for surgeons to fully evaluate the reduction quality. The revision procedures are as follows: osteotomy for exposure, articular surface reconstruction, bone grafting, and osteotomy fixation.