ARTICLE IN PRESS 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 ARTICLE IN PRESS 2 S.-M. Feng et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■ 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. ARTICLE IN PRESS S.-M. Feng et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■ 3 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 ARTICLE IN PRESS 4 S.-M. Feng et al. / The Journal of Foot & Ankle Surgery ■■ (2017) ■■–■■ 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. 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