New Technique for Fibular Reduction in Maisonneuve Fractures

Introduction

Maisonneuve fractures are characterized by a high fibular fracture combined with disruption of the distal tibiofibular syndesmosis. If left untreated, they can result in chronic ankle instability and pain. Surgical treatment is recommended, with the goals of restoring fibular length, reducing the syndesmosis, and achieving stable fixation of the syndesmosis. Fibular shortening increases intra-articular contact pressure in the ankle, increasing the risk of secondary surgery and post-traumatic ankle osteoarthritis. Anatomic reduction of the fibula is a prerequisite for anatomic reduction of the syndesmosis, and prior studies have confirmed that anatomic reduction improves overall outcomes.

Previously reported reduction techniques rely on laborious manual traction and distraction to restore fibular length, while the peroneus longus and brevis muscles generate antagonistic deforming forces. Reduction forceps are used to clamp and maintain reduction, followed by provisional fixation with Kirschner wires, requiring an assistant to maintain the reduction continuously; sometimes greater surgical exposure is needed to facilitate placement of the reduction forceps. To overcome these difficulties, this article introduces a novel, simple distraction reduction technique that relies on mechanical advantage to restore fibular length.

Surgical Technique

Patient Positioning

General anesthesia or regional block is used, and the patient is placed in the supine position. A sandbag is placed under the ipsilateral hip to facilitate internal rotation of the affected limb; a foam leg ramp is placed under the affected limb to elevate it. Elevating the limb with the foam pad also prevents overlap with the contralateral lower limb during intraoperative imaging.

Surgical Approach

For a simple Maisonneuve fracture with fibular shortening, a longitudinal straight incision is made over the fibula at the level of the syndesmosis as confirmed by intraoperative fluoroscopy. The fibula is fully exposed, and a 3-hole plate is placed on the lateral aspect of the fibula, with the two distal holes aligned with the plane for syndesmotic fixation. An olive wire may be used to temporarily secure the plate.

A cortical screw is inserted into the most proximal hole of the plate, positioned above the tibiofibular overlap zone.

A 5 mm Steinmann pin is then drilled into the tibia, with the entry point immediately anterior to the fibula, approximately 2 cm proximal to the proximal end of the fibular plate.

A bladed laminar spreader is placed between the cortical screw and the Steinmann pin, and the spreader is opened to distract the distal fibular fragment, indirectly restoring fibular length.

Intraoperative fluoroscopy of the ankle and fibular fracture site is performed to confirm the reduction; radiographic parameters include restoration of the fibular "coin sign" and normalization of the talar tilt angle.

The laminar spreader has a self-locking mechanism that maintains the reduction, allowing the surgeon's hands to be freed for subsequent surgical steps.

Two four-cortex Kirschner wires are inserted through the remaining distal holes of the plate for provisional fixation.

With the ankle maintained in neutral dorsiflexion, large reduction forceps are applied to the medial and lateral malleoli, and double-button plate syndesmotic fixation is performed.

Technical Points

The two distal holes of the plate should be aligned with the plane of syndesmotic fixation.

At least 2 cm of working space should be preserved between the Steinmann pin and the proximal end of the plate to allow room for spreader manipulation.

Ankle fluoroscopy is used to assess the talar tilt angle and fibular coin sign to confirm correction of fibular shortening.

If syndesmotic reduction remains unsatisfactory after distraction via ligamentotaxis, a pointed reduction forceps may be used for further adjustment before placing the four-cortex Kirschner wires.

▲ Illustration of temporary fixation of the 3-hole plate with an olive wire.

▲ Illustration of cortical screw fixation of the plate and marking of the Steinmann pin entry point.

▲ Illustration of cortical screw fixation of the plate and Steinmann pin entry point.

▲ Illustration of the mortise view after fixation via the middle and distal holes of the plate with button plates.

▲ Illustration of the lateral view after button plate fixation.

Typical Cases

Case 1: A 17-year-old male sustained severe left ankle swelling and pain after a sports-related twist injury, unable to bear weight. Emergency radiographs revealed a proximal fibular fracture with marked widening of the medial ankle clear space. Temporary plaster immobilization was applied, and the patient was followed up in the outpatient clinic 2 weeks after injury; open reduction and internal fixation of the syndesmosis was performed 3 weeks after injury.

▲ Preoperative radiographs of Case 1.

▲ Postoperative radiographs of Case 1.

Case 2: A 50-year-old female sustained a high fibular fracture in a traffic accident. She presented 2 weeks after injury; radiographs revealed a comminuted butterfly fracture of the mid-fibula with mild widening of the medial clear space. Syndesmotic reduction and fixation was performed 4 weeks after injury.

▲ Preoperative radiographs of Case 2.

▲ Postoperative radiographs of Case 2.

Case 3: A 71-year-old male sustained a left ankle injury when riding a bicycle and being rear-ended by a motor vehicle. Radiographs revealed a high fibular fracture, medial malleolar fracture, and posterior malleolar fracture with widening of the medial clear space. A posterolateral approach was used, and the distraction reduction technique described in this article was performed concurrently with posterior malleolar fracture fixation. Placement of double button plates through the distal and middle holes of the plate was planned, but the distal hole was obstructed by the posterior malleolar fixation screw, making it unfeasible; the cortical screw was therefore changed to the distal hole, and the second suture button was placed through the proximal hole.

▲ Preoperative radiographs of Case 3.

▲ Postoperative radiographs of Case 3.

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