Ankle malunion and arthritis Case for small group discussion AOTrauma—Foot & Ankle Module 7: Ankle arthritis Stefan Rammelt, DE

Case description 52-year-old active plumber Internal fixation of a malleolar fracture 1 year previously

Case description Presents with pain on walking 2 years after the fracture, 1 year after implant removal

Which treatment option would you choose? Pain medication, orthosis Corrective osteotomy Corrective ankle fusion Total ankle replacement Decide during surgery

Intraoperative findings Complete cartilage cover despite 1st–2nd degree chondromalacia

Principles of correction (BG Weber) Realignment of the distal fibula Reestablishing the ankle mortise

Correction Lengthening Varus shift Medial translation

2-year follow-up Continues working full time as a plumber

Take-home messages Most important—realignment Joint-preserving osteotomy for posttraumatic malunion even with radiographic evidence of arthritis Good long-term results Simpler fusion/total ankle replacement with well-aligned ankle References: Weber BG. Lengthening osteotomy of the fibula to correct a widened mortice of the ankle after fracture. Int Orthop. 1981;4(4):289–293. Reidsma, II, Nolte PA, Marti RK, Raaymakers EL. Treatment of malunited fractures of the ankle: A long-term follow-up of reconstructive surgery. J Bone Joint Surg Br. 2010 Jan;92(1):66–70. Rammelt S, Marti RK, Zwipp H (2013) Joint-preserving osteotomies of malunited ankle and pilon fractures. Unfallchirurg. 2013 Sep;116(9):789–796. German. Weber. Int Orthop. 1981;4:289–293. Reidsma II et al. J Bone Joint Surg Br. 2010;92:66–70. Rammelt S et al. Unfallchirurg. 2013;116:789–796.