Cutting Edge Orthopedics - Issue 3

Distal Tibia and Ankle Nonunions Kevin J. Pugh K.J. Pugh, MD (  ) Orthopedic Trauma and Reconstructive Surgery, Grant Medical Center, 285 E. State St. #500, Columbus, OH 43215, USA e-mail: kjportho@mac.com Introduction Normal gait is dependent on normal function of the ankle joint [1, 2]. Disruption of the ankle mortise by fracture of the plafond, malleoli, or syndesmosis can lead to ankle instability or lack of articular congruity, both of which can lead to degenerative arthritis. Anatomic reduction and stable fixation of fractures about the ankle is required to restore function and to obtain union. Nonunions of the ankle lead to stiffness, dysfunctional gait, prolonged morbidity, and prolonged social stress on the patient. In addition, malreduced nonunions affect the mechanical axis of the limb, leading to dysfunction of the adjacent knee and subtalar joint. Analysis of the Fracture There is no one method of treatment for a nonunion. Instead, it is an analysis and correction of the cause of the nonunion and the unique features of each specific case. The fact that there is no one technique or implant to treat nonunions is what makes them both challenging and satisfying to treat. The treatment plan, whether simple or involving several stages, is devised by following a set of principles as illustrated throughout this book. The principles of treating nonunions about the ankle will be illustrated in this chapter. Injury to bone, whether it be due to a fracture, osteotomy, or attempted arthrodesis, initi- ates a predictable series of events that under normal circumstances should proceed to a union. The initial inflammatory process leads to cell recruitment and differentiation, the laying down of new bone matrix, and eventually to ossification, boney union, and remodeling of the imma- ture construct. However, not all fractures are created equally. They differ in terms of the energy imparted, the size of the zone of injury, whether they are open or closed, the fracture pattern and comminution, the bone involved as well as the region on that bone, and the presence of articular