Arthroscopic Articular Reduction for Posterior Malleolar Fracture using a “Handlebar”

CATEGORY: Trauma; Ankle; Arthroscopy INTRODUCTION/PURPOSE: Posterior malleolar fracture (PMF) of the ankle is one of the most challenging fractures to reconstruct. Recent studies suggest that the intra-articular step-off of PMFs should be <1 mm. However, very few surgical approaches for PMF repair allow direct visualization of the intra-articular fracture. The arthroscopic handlebar technique, our novel surgical method for the reduction and fixation of PMFs, involves the restoration of PMFs under arthroscopy and the use of Kirschner wire as a handlebar, which penetrates the fractured posterior malleolus. METHODS: The arthroscopic handlebar technique was used in patients with a displaced AO/OTA type-44 ankle trimalleolar fracture (Haraguchi type 1 or 2 PMF). After fibular fracture reduction and internal fixation, the lateral side of the PMF was pierced with a Kirschner wire, such that it emerged from the medial edge of the PMF. The wire was guided through the medial incision to the outside, creating a bar that could be used to control the PMF, similar to the handlebar of a bicycle. Then, anterior ankle arthroscopy was performed. The PMF was reduced using the handlebar and a bone reduction forceps under arthroscopy. Subsequently, the PMF was fixed via the anterior incision using several screws. Eleven consecutive patients who had underwent this arthroscopic procedure and who were followed for at least one year and their postoperative AOFAS score, postoperative articular step-offs in CT sagittal section, and surgical complications were retrospectively evaluated. RESULTS: The patients included four men and seven women (mean age 57.8 years [range 20-81 years]). The Haraguchi classification was type 1 in 4 cases and type 2 in 7 cases. The postoperative AOFAS score +- standard deviation was 93.1+-10.9 points. In one patient, CT revealed that a postoperative articular step-off of 1.5 mm remained at the PMF. In all other patients, the articular step-off of the PMF was <1 mm. Surgical complications revealed one case of dorsal foot neuropathy that healed spontaneously. CONCLUSION: This arthroscopic procedure provides an easier and less invasive approach to treat PMF. Articular PMF reduction can be performed under anterior ankle arthroscopic guidance. Surgeons can confirm the entire articular reduction status of the PMF. We believe that using this surgical procedure will change the standard of care for PMF cases.