j.jfas.2017.07.020

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The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery
j o u r n a l h o m e p a g e : w w w. j f a s . o r g
Original Research
“All-Inside” Arthroscopic Treatment of Tillaux-Chaput Fractures:
Clinical Experience and Outcomes Analysis
Shi-Ming Feng, MD 1, Qing-Qing Sun, MD 1, Ai-Guo Wang, MD, PhD 1,2, Cheng-Kun Li, MD 1
1Orthopaedic
Surgeon, Hand and Foot Microsurgery Department, Xuzhou Central Hospital, Xuzhou Clinical College of Xuzhou Medical University, Xuzhou, Jiangsu, China
Professor of Medicine, Xuzhou Clinical College of Xuzhou Medical University, Xuzhou, Jiangsu, China
2
A R T I C L E
I N F O
Level of Clinical Evidence: 4
Keywords:
arthroscopes
minimally invasive
surgical procedures
Tillaux-Chaput fracture
A B S T R A C T
We investigated all-inside ankle arthroscopy for Tillaux-Chaput fractures. We retrospectively evaluated
19 patients (12 males [63.2%] and 7 [36.8%] females; 11 right [57.9%] and 8 left [42.1%] ankles) treated
from May 2013 to January 2016. Their mean age was 28.1 (range 10 to 55) years. Sixteen (84.2%) had
single Tillaux-Chaput fractures and 3 (15.8%) had combined proximal fibular fractures; 17 (89.5%) were
diagnosed radiographically and 2 (10.5%) by computed tomography. Anterolateral and anteromedial ankle
arthroscopy was used for closed reduction and internal fixation with 1 or 2 Herbert screws. Joint function was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale.
All 19 patients healed by first intention without nerve, vessel, or tendon injuries. The follow-up was 19.0
(range 12 to 25) months; fracture union was achieved by 23.5 (range 12 to 36) weeks. At the last followup, the 19 patients had no restrictions in ankle function and range of motion, with no ankle or walking
pain. The AOFAS score changed from 52.8 to 91.7 points, with an excellent/good rate of 100%. These results
suggest that anterolateral and anteromedial all-inside ankle arthroscopy is a precise and effective method
for closed reduction and internal fixation of Tillaux-Chaput fractures.
© 2017 by the American College of Foot and Ankle Surgeons.
Starting at the first point of the anterior lower tibiofibular ligament, an avulsion fracture in the anterolateral aspect of the distal tibia
(Tillaux-Chaput tubercle) is called a Tillaux-Chaput fracture. It usually
occurs in adolescents aged 12 to 14 years (1). The Tillaux-Chaput fracture can lead to a widening ankle, lower stability, ankle instability, ankle
pain, and traumatic arthritis if an improper method has been used
or treatment is late or missed (2–4). The presence of a whole anterior lower tibiofibular ligament and a well-reduced fracture are the
most effective factors to reduce the rate of ankle complications (5).
The major aim of surgical treatment is to restore the normal position and stability. At present, internal fixation is usually performed
by open reduction, with evidence lacking on the use of arthroscopically
assisted fixation (6). Compared with traditional open surgery, arthroscopic surgery is a more accurate and faster method, with less bleeding,
fewer complications, and a shorter recovery time (7–9).
Our department used all-inside arthroscopy to treat TillauxChaput fractures from May 2013 to January 2016. We retrospectively
Financial Disclosure: None reported.
Conflict of Interest: None reported.
S.-M.F. and Q.-Q.S. contributed equally to the present study.
Address correspondence to: Shi-Ming Feng, MD, Department of Hand and Foot
Microsurgery, Xuzhou Central Hospital, No. 199, The Jiefang South Road, Xuzhou, Jiangsu
221009, China.
E-mail address: [email protected] (S.-M. Feng).
analyzed the data from 19 patients with Tillaux-Chaput fractures who
had been followed up after all-inside ankle arthroscopy. We also discuss
the treatment of Tillaux-Chaput fractures using all-inside arthroscopy. We present the indications, efficacy, and characteristics of the
technique and provide a rationale to extend the all-inside ankle arthroscopy technique to treatment of Tillaux-Chaput fractures.
Patients and Methods
We reviewed the clinical medical data of the patients who had undergone TillauxChaput fracture treatment in our hospital. We identified the potentially eligible patients
for inclusion in our retrospective cohort using the International Classification of Diseases, 10 revision (World Health Organization, Geneva, Switzerland) code S82.80.
Patients were included in the study if they met the following criteria: use of allinside ankle arthroscopy for treatment, >2 mm of displacement of the whole joint
between the anterior lower tibiofibular ligament and the fracture, fragments >5 mm
in diameter, voluntary agreement for ankle surgery, and neither ankylosis nor joint space
narrowing preoperatively. The exclusion criteria were as follows: coagulopathy, soft tissue
ankle infection, range of motion restriction with concomitant joint space narrowing,
ankle traction not possible during surgery, tearing of the anterior lower tibiofibular ligament, diastasis of the fragment and anterior lower tibiofibular ligament, or consent
not provided for arthroscopic surgery.
The data extracted included age, sex, mechanism of injury, interval from injury to
surgery, operative time, fracture characteristics, radiographic healing times, followup duration, complications, American Orthopaedic Foot and Ankle Society (AOFAS) anklehindfoot scale score, and visual analog scale (VAS) score.
1067-2516/$ - see front matter © 2017 by the American College of Foot and Ankle Surgeons.
https://doi.org/10.1053/j.jfas.2017.07.020
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We enrolled 19 patients, 12 (63.2%) males and 7 (36.8%) females. These 19 patients had undergone all-inside ankle arthroscopy for Tillaux-Chaput fractures
consecutively from May 2013 to January 2016. The mean age of the patients was
28.1 ± 11.0 (range 10 to 55) years. The mechanism of injury was a sprain in 13 patients (68.4%) and a traffic accident in 6 (31.6%). The right ankle was involved in 11
patients (57.9%) and the left ankle in 8 patients (42.1%). Of the 19 patients, 16 (84.2%)
had a single Tillaux-Chaput fracture and 3 patients (15.8%) had combined proximal fibular
fractures.
The institutional review boards of our hospital approved the present study. Informed consent and Health Insurance Portability and Accountability Act consent were
obtained from each patient. All operations were performed by the same surgical team
who were kept unaware of the measurement results during the study period.
Postoperative Management
The postoperative management protocol included limb lifting and routine antiinflammatory and antiswelling medication. Removal of the drainage tube occurred
according to the fluid volume at 24 to 48 hours after surgery. Passive activity was performed on the affected side toes at 24 hours postoperatively and on the ankle and toes
after 24 hours postoperatively. Before the 24-hour point, the patients were allowed to
ambulate non-weightbearing and perform isometric exercises to strengthen the muscles
of the lower limb. The sutures were removed after 2 weeks, and functional practice
was provided by ambulating with partial weightbearing after 6 weeks. When radiography had confirmed union of the fractures, the patients were allowed to begin full
weightbearing walking. All the patients underwent follow-up radiography at 2, 6, 12,
and 24 months after surgery.
Surgical Technique
Postoperative Follow-Up Data and Outcome Measures
All the surgeries were performed with the patient under epidural anesthesia aided
by pneumatic tourniquet control (applied at the proximal thigh, 45 kPa, for a maximum
of 90 minutes) and the arthroscopic system by the same team of 3 surgeons (S.-M.F.,
Q.-Q.S., A.-G.W.). The ankle puncture was made horizontally on the medial crossing point
between the horizontal projection of the ankle and anterior tibial muscle tendon. Next,
20 mL of normal saline was injected to expand the articular cavity, and a 5-mm-long
ankle incision using an anteromedial approach was made. A 2.7-mm, 30° arthroscope
was placed into the ankle by way of the anteromedial portal to investigate the articular cavity. A 5-mm-long incision using an anterolateral approach was established with
arthroscopic guidance. To examine the articular cartilage, we drained any hemarthrosis and removed the episomes, pieces of articular cartilage, synovial proliferation tissue,
and so forth. Minimally invasive surgery was used for patients with soft tissue injuries. Blood clots between the fracture ends were created to enhance the integrity of
the anterior lower tibiofibular ligament. Above the tibialis anterior lip, a part of the
joint capsule was debrided to expose the Tillaux-Chaput tubercle and fracture fragment over tibial anterior lip to clear the operative field and determine the amount of
displacement and dislocation. Two guide pins (1.0 mm in diameter) were inserted in
the bone block, perpendicular to fracture line, using the arthroscope. With traction and
maintaining moderate flexion of the knee, the foot was internally rotated in
plantarflexion. A guide pin was inserted after the fragments had been reduced using
the ankle arthroscopy, using the guide pin as a holder. C-arm radiographic fluoroscopy was used to confirm fracture reduction and the direction, depth and ideal location
of the guide pin. The guide pin was of medium size with 1 or 2 Herbert screws (3.0 mm
in diameter). Next, arthroscopy and C-arm radiography were used to confirm joint surface
reduction and the length and direction of the Herbert screws. Drainage of the articular cavity occurred as a normal process. The incision was closed with interrupted sutures
using an absorbable cone needle and wound compression. Finally, any concomitant tibial
proximal fracture was treated (Fig.).
Each patient was examined at follow-up visits at 6 weeks, 12 weeks, and 6 months
postoperatively. The follow-up duration was decided by clinical examination and the
imaging test results obtained by review. Follow-up examinations were continued until
the patients were satisfied with the result or were lost to follow-up. A 10-cm-line VAS,
divided into mild (0 to 3 cm), moderate (4 to 6 cm), and severe (7 to 10 cm), was used
to evaluate pain. The outcome and time required to achieve union were recorded, and
the patients completed a VAS at 6 months postoperatively. The AOFAS ankle-hindfoot
scale was completed by the last follow-up visit. The symptoms of pain were analyzed
on a scale of 40 points, with none, mild, moderate, and serious pain. The joint function was assessed using a scale of 50 points. The questionnaire included the ability to
move, the longest walking distance, walking attitude, activity of the forefoot and hindfoot,
and stability of the foot and ankle. The alignment assessment, with a total of 10 points,
was divided into good, fair, and poor. Good was described as plantarflexion and an aligned
foot and ankle; fair as plantarflexion, with some degree of lesser toe malalignment and
asymptomatic; and poor as severe malalignment with symptoms present. The treatment outcome was also assessed, with 90 to 100 points considered excellent, 80 to 89
good, 70 to 79 fair, and <70 poor. These standard tests were performed by an experienced surgeon (Wei-Wei Chang, MD, Xuzhou Central Hospital, Xuzhou, China), who
was not a part of the surgical team that performed all the surgeries.
Statistical Analysis
Statistical analysis was performed by an experienced surgeon (C.-K.L.). All calculations were made using SPSS, version 17.0, software (IBM Corp., Armonk, NY).
Quantitative variables are expressed as the mean ± standard deviation. The pre- and
postoperative VAS and AOFAS ankle-hindfoot scale scores were compared using the
Fig. A 26-year-old female patient (case 4) presented to the hospital 20 hours after experiencing what was thought to be an ankle sprain. She could not weight bear owing to the
intense pain, and the ankle was swollen. On physical examination, the soft tissues were intact with no contusion. (A,B) Computed tomography assessment revealed a simple
Tillaux-Chaput fracture of the left ankle. Under lower nerve block anesthesia, ankle arthroscopy was used to complete closed reduction and internal fixation of the fracture within
37 hours after the injury. (C) At surgery, the anterior tibiofibular ligament was found to be intact. (D) It was also determined that the fracture fragment had displaced and the
articular surface was uneven. One 3.0-mm bidirectional compression hollow screw was used to fix the fragment. (E,F) Arthroscopic exploration revealed satisfactory fracture
reduction and fixation placement. (G,H) Radiographs revealed well-healed incisions, a smooth ankle articular surface, normal articular space, and correct inferior tibiofibular position. (I) At the follow-up examination, the incision had an excellent aesthetic appearance.
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Table
Patient demographics and results
Pt. No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Mean
SD
Age (y)
23
10
23
26
29
16
20
26
48
27
29
35
33
38
20
18
36
22
55
28.1
11.0
Sex
F
M
M
F
M
F
F
M
M
F
F
M
M
M
F
M
M
M
M
NA
NA
Cause
S
S
TA
S
S
S
S
S
S
TA
TA
S
S
S
TA
S
TA
S
TA
NA
NA
Lauge-Hansen
Classification
Injury to Surgery
Interval (hr)
Operative
Time (min)
Injured
Side
Follow-Up
(mo)
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
SER I
NA
NA
3
48
2
37
22
18
6
70
57
10
9
42
38
29
16
63
72
20
13
30.3
23.0
20
40
25
42
29
36
45
37
35
28
65
40
50
36
25
30
48
37
22
36.3
11.0
Left
Right
Left
Left
Right
Left
Right
Left
Right
Right
Right
Right
Left
Right
Left
Right
Left
Right
Right
NA
NA
24
20
14
15
24
15
22
17
25
12
25
19
21
23
18
12
18
16
21
19.0
4.3
AOFAS Score
VAS Score
Pre
Post
Pre
Post
53
55
55
53
59
60
56
45
50
43
39
56
45
59
58
59
55
45
59
52.8
6.4
85
92
95
90
86
92
95
97
90
85
87
93
88
90
95
91
100
97
94
91.7
4.3
8
9
8
9
7
7
8
9
7
9
9
9
8
7
8
9
8
7
8
8.1
0.8
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
0.1
0.3
Interval to
Union (wk)
Complications
18
12
21
24
28
12
32
30
23
21
21
26
24
30
24
15
27
22
36
23.5
6.4
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
NA
NA
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society (ankle-hindfoot scale); F, female; M, male; NA, not applicable; Post, postoperative; Pre, preoperative; Pt.
No., patient number; SD, standard deviation; SER, supination external rotation; VAS, visual analog scale.
Student t test. The significance level was set at 5%, and p < .05 was considered statistically significant.
Results
The patient demographics and clinical analysis results are presented in the Table. The ankle of the affected side underwent
conventional lateral and mortise radiographs and computed tomography (CT) with 3-dimensional reconstruction. Of the 19 cases, 17
(89.5%) were diagnosed using radiography and 2 (10.5%) using CT. The
imaging studies revealed a Tillaux-Chaput fracture with >2 mm of displacement. The mean interval from injury to surgery was 30.3 ± 23.0
(range 2 to 72) hours. The interval was <24 hours for 10 patients (52.6%)
and was <1 to 3 days for 9 (47.4%). All the injuries were closed without
soft tissue injuries to the ankle. The VAS was 8.1 ± 0.8 (range 7 to 9)
points, and the AOFAS ankle-hindfoot scale score was 52.8 ± 6.4 points
before surgery.
The mean operative time was 36.3 ± 11.0 (range 20 to 65) minutes.
All incisions healed by first intention, without evidence of nerve, vessel,
and tendon injuries. One 3.0-mm dynamic bidirectional cannulated
screw was placed in 12 patients (63.2%) and 2 in 7 patients (36.8%).
All the patients were followed up for ≥12 (range 12 to 25; mean
19.0 ± 4.3) months after the operation. All the fractures had united by
23.5 ± 6.4 (range 12 to 36) weeks postoperatively. Union was defined
as radiographic evidence of a smooth articular surface, a normal bone
space, and an adequate position of the inferior tibiofibular. None of
the patients had any restriction in ankle range of motion or pain. At
the 2-month follow-up visit, 1 patient (5.3%; case 1) presented with
intermittent swelling of ankle, which had recovered with symptomatic treatment at 4 months postoperatively. All the patients had fully
recovered by their last follow-up visit. The patients had normal ankle
function, were able to perform their regular activities, experienced no
claudication or pain, and be able to fully weight bear. The follow-up
radiograph showed no evidence of repeat fracture or fracture displacement. The difference between the mean preoperative (8.1 ± 0.8,
range 7 to 9 points) and postoperative (0.1 ± 0.3, range 0 to 1 point)
VAS scores was statistically significant (t = 39.5; p < .01). The postoperative AOFAS ankle-hindfoot scale score postoperatively (mean
91.7 ± 4.3, range 85 to 100 points) was higher than the preoperative
score (mean 52.8 ± 6.4, range 39 to 60 points). The difference was statistically significant (t = −24.4; p < .01). Based on the AOFAS anklehindfoot scale score, the results were excellent for 14 patients (73.7%)
and good for 5 patients (26.3%), for an excellent to good rate of 100%.
Discussion
Tillaux fractures tend to occur when an external rotation injury leads
to an avulsion fracture of the anterolateral tibial epiphysis (10,11). The
integrity of the anterior tibiofibular ligament is important for stabilization of the ankle. An early diagnosis plays a significant role in
successful treatment and recovery (12). The fragments of TillauxChaput fracture are smaller and result in slight swelling, deformity,
and obstruction of the fibula, with the result that these fractures tend
to be misdiagnosed as a simple ankle sprain (13–15). For suspected
Tillaux-Chaput fractures, CT will be more accurate than plain radiography for determining the shape of the fracture fragments, amount
of displacement, and condition of the articular surface (16,17). The
Tillaux-Chaput fracture is a typical intraarticular fracture; thus, when
fragment displacement is >2 mm, the patient requires open reduction and internal fixation (18,19). Previously, this fracture was treated
using an anterolateral tibial incision. Operative reduction was achieved
with 1 or 2 hollow compression screw fixation. However, the traditional procedure, with an excellent rate of 80% to 95%, destroyed the
blood supply, required a large incision, causing trauma, and ignored
any cartilage injury (20,21). With the development of minimally invasive and precision medicine, ankle arthroscopy will be more widely
used in the treatment of ankle injuries. To improve the operative effect
and reduce surgical trauma, we used ankle arthroscopy for treatment of Tillaux-Chaput fractures. The results of the present study have
shown that the excellent rate for ankle arthroscopy was 100%, better
than that with the traditional procedure (22).
Using traditional open reduction and internal fixation to treat fractures of the ankle joint, owing to the anatomy of the ankle, one can
only observe the alignment of the lateral cortex and not the alignment of the fracture fragments or articular surface, even if C-arm
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radiography is used. Accordingly, the traditional operation used to treat
an ankle fracture can accelerate degeneration of the ankle joint by joint
malalignment and cartilage injury (20). With the application and development of ankle arthroscopy, physicians can detect and treat the
cartilage injury and joint displacement of ankle fractures early. In addition, arthroscopy of the articular cavity is a favorable method to clear
the fragments and surface of the cartilage. For epiphysis injury in children, arthroscopy can be used to observe reduction of the epiphysis,
which help complete precise reduction and fixation.
The Tillaux-Chaput fracture is an intraarticular fracture of the ankle.
Ankle arthroscopy used to treat Tillaux-Chaput fractures can be used
to find any cartilage injury and displacement, explore the epiphysis
injury, clear the fragments and surface of the cartilage, and confirm
reduction of the fracture. Compared with the traditional open procedure, ankle arthroscopy provides the following advantages: low
surgical trauma; closed reduction; no subperiosteal stripping; maintenance of a normal blood supply to the fracture fragments; improved
fracture healing; visualization of fracture displacement and cartilage injury; clearance of cartilage fragments; precise reduction of
fracture fragments, epiphysis, and articular surface; shorter operative time; less bleeding (mean blood loss only 6.8 mL); rapid
postoperative recovery; and lower infection risk. None of our patients developed an ankle infection.
To ensure the expected treatment efficacy, we believe attention
should be given to the following points. First, when exposing and separating the fracture fragments, the integrity and continuity of the
anterior tibiofibular ligament should be preserved. In our study, none
of patients experienced pain at ankle postoperatively, and all had recovered normal function of ankle, which requires the integrity and
continuity of the anterior tibiofibular ligament. When the fragments
are separated, extraperiosteal separation can be used to preserve the
integrity of the fragment periosteum and shorten the healing time.
In our study, the mean fracture healing time was only 23.5 weeks. For
children, fracture fixation screws should avoid the epiphysis. Also, any
fragments of tissue and cartilage and any blood clots should be
removed. Because of the thorough cleaning, none of our 19 patients
developed ankle arthritis during the follow-up period. For patients
whose skin condition is unsuitable for ankle arthroscopy, one should
consider open surgery or treatment to improve the skin condition.
The present study had some limitations. These included the small
sample size, that it was a single-center study with all successful results,
nonrandomized study design, no comparative analysis, and no systematic review of the reported data. Also, our use of the International
Classification of Disease code to identify potentially eligible patients
might have been subject to a coding (information) bias.
In conclusion, we found that all-inside ankle arthroscopy using the
anterolateral and anteromedial approaches is a precise and effective
method for closed reduction and internal fixation of Tillaux-Chaput
fractures and deserves clinical application. It provides satisfactory aesthetic and functional recovery. In addition, the results of our
investigation could be used in the development of future randomized controlled trials or prospective cohort studies focusing on the same
or similar conditions.
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