New concepts in the treatment of ankle joint fractures

The most important factor in the treatment of ankle joint fractures is stable anatomical reconstruction of the syndesmosis and joint surface. In the course of this, attention must be paid to soft-tissue damage with the risk of deep infections. Early functional therapy and exercise tolerance must be called for. The choice of surgical access route, in particular in the case of critical arterial circulation, and the possible irritation of the soft tissue by the osteosynthesis material prompted us to seek alternative osteosynthesis techniques.

Following a preclinical study and very good initial results with the XS nail in the treatment of patella and olecranon fractures, this was now also used for ankle joint fractures at the medial malleolus and lateral malleolus. In the period from 5/2000 to 1/2002, 194 ankle joint fractures were treated using the XS nail. These were predominantly Weber B, C and bimalleolar fractures. In the case of ankle joint fractures, osteosynthesis was carried out following precise open fracture repositioning. In the case of isolated fibula fractures, early loading was allowed within 1 week; in the case of bimalleolar fractures, there was immediate partial loading with 20 kg for 4 weeks, after which they were subjected to full loading. Where there was an additional Volkmann fracture, we allowed only immediate partial loading with 10 kg for 6 weeks. All 194 patients were observed prospectively, and 162 (83.5%) could be followed up after 15 months. The results were classified according to the scale described by Olerud.

It has been possible to follow up 162 patients, with an average age of 49.7 years. There were 62 (38.3%) Weber B and 45 (27.8%) Weber C fractures. In 55 (34.0%) cases, bimalleolar fractures were present. According to the Olerud score, 95 (58.6%) of the patients had an excellent outcome, 54 (33.3%) a good one, 9 (5.5%) a fair one and 4 (2.5%) an unsatisfactory outcome. In 3 cases a threaded wire dislocation occurred, without complications. Two mesh graft transplants were necessary; otherwise, there were no soft-tissue problems requiring review. One pseudarthrosis was seen.

The XS nail which is introduced here fulfils the requirements made of an implant as regards maximum protection of soft tissue, secure fracture fixation and early exercise tolerance, including ankle fractures. No implant dislocation, no deep infection and no re-osteosynthesis were observed. Its advantages over conventional techniques lie precisely in the treatment of complex fractures and for patients with poor bone, vascular and soft-tissue situations.