Strategies in Trauma and Limb Reconstruction

Register      Login

VOLUME 17 , ISSUE 2 ( May-August, 2022 ) > List of Articles

CASE REPORT

Late Ankle Reconstruction in a Child with Remote Traumatic Medial Malleolus Loss: Clinical and Radiographic Outcomes

Ethan Ponton, Ali Bakkai, Douglas J Courtemanche, Anthony Cooper

Keywords : Growth arrest, Iliac crest autograft, Lawn mower injury, Leg length discrepancy, Medial malleolus reconstruction, Physeal fracture, Severe open ankle injury, Traumatic bone loss, Varus deformity

Citation Information : Ponton E, Bakkai A, Courtemanche DJ, Cooper A. Late Ankle Reconstruction in a Child with Remote Traumatic Medial Malleolus Loss: Clinical and Radiographic Outcomes. 2022; 17 (2):131-135.

DOI: 10.5005/jp-journals-10080-1552

License: CC BY-NC-SA 4.0

Published Online: 28-07-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Aim: This article aims to describe a novel surgical technique for medial malleolar reconstruction in a young child. Background: Severe open ankle injuries that result in bone and soft tissue loss carry a high risk for complications, especially in children who are still growing. These injuries can cause abnormal growth patterns, degenerative diseases, and recurrent instability. Cases of medial malleolar reconstruction have been previously described but none in a child this young. Case description: We present a case of an 13-year-old girl who suffered an open injury to the medial distal tibia with traumatic loss of the medial malleolus at the age of 2 and later suffered a Salter-Harris II fracture to the ipsilateral distal fibula. She presented with varus alignment, a leg length discrepancy, premature asymmetrical growth arrest, chronic non-union of the distal fibula physeal fracture, and severe attenuation of the deltoid ligament. Her secondary deformities were managed with distal fibula osteotomy and fixation, distal tibial hemi-plafond corrective osteotomy, and medial malleolus reconstruction with iliac crest autograft. Her leg length discrepancy was corrected by epiphysiodesis of the contralateral distal femur and proximal tibia. At the 2-year follow-up, the alignment was well maintained, the graft was healing well, and the patient reported no pain and being able to walk and play sports without a brace. Conclusion: Surgical reconstruction of the medial malleolus with correction for abnormal angulation and leg length discrepancies is critical to promoting healthy growth patterns and quality of life for paediatric patients. This severe open ankle injury can be successfully managed by distal fibula osteotomy and fixation, distal tibial intra-articular osteotomy, and medial malleolus reconstruction with iliac crest autograft. Clinical significance: This novel technique is an effective method for the surgical management of paediatric traumatic medial malleolar bone loss in children who are skeletally immature and are at risk of complications due to further growth.


PDF Share
  1. Kay RM, Matthys GA. Pediatric ankle fractures: evaluation and treatment. J Am Acad Orthop Surg 2001;9(4):268–278. DOI: 10.5435/00124635-200107000-00007.
  2. Cass J, Peterson H. Salter-Harris Type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Jt Surg 1983;65(8):1059–1070. PMID: 6630250.
  3. Peterson HA, Jacobsen FS. Management of distal tibial medial malleolus type-6 physeal fractures. J Child Orthop 2008;2(2):151–154. DOI: 10.1007/s11832-008-0091-3.
  4. Peterson HA. Physeal fractures: Part 2. Two previously unclassified types. J Pediatr Orthop 1994;14(4):431–438. DOI: 10.1097/01241398-199407000-00003.
  5. Mayr JM, Gerhard PR, Wolfgang LE. Reconstruction of part of the distal tibial growth plate with an autologous graft from the iliac crest. J Bone Jt Surg 2000;82(4):558–560. DOI: 10.1302/0301-620x.82b4.9760.
  6. Lareau CR, Bariteau JT, Paller DJ, et al. Contribution of the medial malleolus to tibiotalar joint contact characteristics. Foot Ankle Spec 2015;8(1):23–28. DOI: 10.1177/1938640014546862.
  7. Khan U, Smitham P, Pearse M, et al. Management of severe open ankle injuries. Plast Reconstr Surg 2007;119(2):578–589. DOI: 10.1097/01.prs.0000246506.58128.ec.
  8. Peterson H. Physeal fractures: Part 3. Classification. J Pediatr Orthop 1994;14(4):439–448. DOI: 10.1097/01241398-199407000-00004.
  9. Varni JW, Burwinkle TM, Seid M, et al. The PedsQL™* 4.0 as a pediatric population health measure: feasibility, reliability, and validity. Ambul Pediatr 2003;3(6):329–341. DOI: 10.1367/1539-4409(2003)003 <0329:tpaapp>2.0.co;2.
  10. Clarke A, Flowers MJ, Davies AG, et al. Morbidity associated with anterior iliac crest bone graft harvesting in children undergoing orthopaedic surgery: a prospective review. J Child Orthop 2015;9(5):411–416. DOI: 10.1007/s11832-015-0698-0.
  11. Wu S. Clinical study of reconstructing the medial malleolus with free grafting of fibular head composite tendon bone flap. Chin J Traumatol Engl Ed 2008;11(1):34–36. PMID: 18230289.
  12. Boyer MI, Bowen V, Weiler P. Reconstruction of a severe grinding injury to the medial malleolus and the deltoid ligament of the ankle using a free plantaris tendon graft and vascularized gracilis free muscle transfer: case report. J Trauma 1994;36(3):454–457. DOI: 10.1097/00005373-199403000-00042.
  13. Abbo O, Accadbled F, Laffosse J-M, et al. Reconstruction and anticipatory Langenskiöld procedure in traumatic defect of tibial medial malleolus with type 6 physeal fracture. J Pediatr Orthop B 2012;21(5):434–438. DOI: 10.1097/BPB.0b013e328348da0d.
  14. Nithyananth M, Cherian VM, Jepegnanam TS. Reconstruction of traumatic medial malleolus loss: a case report. Foot Ankle Surg 2010;16(2):e37–e39. DOI: 10.1016/j.fas.2009.07.004.
  15. Kow RY, Yuen JC, Ahmad Alwi AA, et al. Surgical reconstruction of an open medial malleolus fracture using a novel technique: a case report. JBJS Case Connect 2019;9(2):e0163–e0163. DOI: 10.2106/JBJS.CC.18.00163.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.