Arthroscopically Assisted Open Reduction–Internal Fixation of Ankle Fractures: Significance of the Arthroscopic Ankle Drive-through Sign

Abstract

Standalone open reductioneinternal fixation (ORIF) of unstable ankle fractures is the current standard of care. Intraoperative stress radiographs are useful for assessing the extent of ligamentous disruption, but arthroscopic visualization has been shown to be more accurate. Concomitant arthroscopy at the time of ankle fracture ORIF is useful for accurately diagnosing and managing syndesmotic and deltoid ligament injuries. The arthroscopic ankle drive-through sign is characterized by the ability to pass a 2.9-mm shaver (Smith & Nephew, Andover, MA) easily through the medial ankle gutter during arthroscopy, which is not usually possible with both an intact deltoid ligament and syndesmosis. This arthroscopic maneuver indicates instability after ankle reduction and fixation and is predictive of the need for further stabilization. Furthermore, when this sign remains positive after fracture fixation, it may guide the surgeon to further evaluate the adequacy of fixation for the possible need for further fixation of the syndesmosis or deltoid. We present the case of an ankle fracture managed with arthroscopy-assisted ORIF and describe the clinical utility of the arthroscopic ankle drive-through sign.

Current trends in the diagnosis and management of syndesmotic injury

“…This maneuver tests the stability by trying to pass a 2.9-mm shaver easily through the medial ankle gutter during arthroscopy. In which this would not be possible if there is an intact syndesmosis and deltoid ligament [33]. Importantly, however, these interpretations, while seemingly reasonable, remain essentially invalidated in today's literature.…”

“…This was determined by using the diameter of the arthroscopic shaver at 3 mm to in measuring diastasis, because anything beyond this degree was felt consistent with a diagnosis of unstable syndesmosis [24•]. Another way to determine the stability of both the syndesmosis and deltoid ligament is by the arthroscopic ankle drivethrough sign [33]. This maneuver tests the stability by trying to pass a 2.9-mm shaver easily through the medial ankle gutter during arthroscopy.…”

Identifying Intra-Articular Pathology With Arthroscopy Prior to Open Ankle Fracture Fixation

“…Intraarticular assessment of the cartilage surface of the tibial plafond and the talar dome, as well as the gross integrity of the syndesmotic and deltoid ligaments, were performed. Syndesmotic injuries were diagnosed using previously published techniques: direct visualization of an avulsed/torn anterior inferior tibiofibular ligament or posterior inferior tibiofibular ligament, the "drive-through sign" (the ability to pass a 2.8-mm shaver into the medial gutter) as described by Schairer et al, 13 and widening of the distal tibiofibular joint >2 mm with internal/external rotation of the ankle as measured with an arthroscopic probe, as described by Takao et al 14 Any intra-articular pathology noted at the time of arthroscopy was treated using standard techniques (microfracture, debridement, drilling, removal of loose body, etc.) before the traction was removed and the fracture was addressed with ORIF.…”

Medicina basada en la evidencia. Conclusiones

“…Actualmente, falta evidencia científica que permita validar criterios unificados para el diagnóstico. Estudios previos usan un rango de 2-4 mm de diástasis (en general, la medida de un terminal artroscópico) como corte para el diagnóstico (15,21) ; Schrairer et al describen una maniobra, el arthroscopic drive through sign, para valorar si existe inestabilidad persistente tras la fijación de la fractura de peroné distal (21) .…”