OBJECTIVE: The anterior tibial rim with the anterolateral tibial tubercle provides attachment to the anterior tibiofibular syndesmosis. It may be considered an anterior or "fourth" malleolus. Fixation of a displaced anterior tibial fragment in the treatment of malleolar fractures aims at providing a bone-to-bone fixation of the anterior tibiofibular ligament and restoring the integrity of the tibial incisura. INDICATIONS: Displaced intra-articular fragments of the anterior tibia; fractures involving the tibial incisura; fractures with intercalary fragments; impaction of the anterior tibial plafond; syndesmotic avulsions producing instability or preventing reduction of the distal fibula into the tibial incisura. CONTRAINDICATIONS: Critical local soft tissues preventing an anterolateral approach; missing consent to surgery by the patient; overall critical general condition preventing surgery to the extremities. SURGICAL TECHNIQUE: Anterolateral approach over the tibial tubercle. Identification and mobilization of the anterior tibial fragment without dissecting the anterior syndesmosis. Reduction of the anterior tibial fragment with a pointed reduction clamp. Fixation of extra-articular avulsion fractures (type 1) with suture anchor. Screw fixation of larger fragments involving the joint surface and incisura (type 2). Disimpaction, realignment of the joint surface, bone grafting as needed and plate fixation of impaction fractures of the anterolateral tibial plafond (type 3). POSTOPERATIVE MANAGEMENT: Mobilization with partial weight bearing (15-20 kg) in a special boot (ankle foot orthosis) or cast for 6-8 weeks depending on the overall malleolar fracture pattern, bone quality and patient compliance. RESULTS: Few studies report the results of anterior tibial fractures in adults. Failure to fix displaced fragments frequently leads to nonunions. Overlooked Chaput fractures have been reported to result in malpositioning of the distal fibula in the tibial incisura leading to incongruity of the ankle mortise requiring revision surgery. Secondary avascular necrosis of the anterolateral tibial plafond may develop after joint impaction.

ZUSAMMENFASSUNG: OPERATIONSZIEL: Die Tibiavorderkante mit dem Tuberculum anterius tibiae dient als Ansatz für das Lig. tibiofibulare anterius. Sie kann als vorderer oder „vierter“ Knöchel bezeichnet werden. Ziel der Osteosynthese dislozierter Fragmente ist die knöcherne Stabilisierung der vorderen Syndesmose und die Wiederherstellung der Incisura tibiae für die distale Fibula. INDIKATIONEN: Dislozierte Gelenkfrakturen der Tibiavorderkante, Frakturen mit Verwerfung der vorderen Tibiainzisur, Frakturen mit Intermediärfragment(en), Impression des vorderen Tibiaplafonds, instabile Avulsionen des Lig. tibiofibulare anterius oder in den Syndesmosenspalt eingeschlagene Fragmente. KONTRAINDIKATIONEN: Kritische Weichteilverhältnisse im Zugangsbereich, Ablehnung der Operation durch den Patienten, kritischer Allgemeinzustand des Patienten. OPERATIONSTECHNIK: Anterolateraler Zugang über dem Tuberculum anterius tibiae. Identifikation und Mobilisierung des Tibiavorderkantenfragments ohne Dissektion des Lig. tibifibulare anterius. Reposition des Fragments mit einer spitzen Repositionszange. Fixierung extraartikulärer Avulsionsfrakturen mit Nahtanker. Schraubenosteosynthese größerer Fragmente mit Beteiligung der Gelenkfläche und Inzisur. Anhebung, Wiederherstellung der Gelenkfläche, Spongiosaplastik, wenn erforderlich, und anteriore Plattenosteosynthese von Impressionsfrakturen des vorderen Tibiaplafonds. WEITERBEHANDLUNG: Mobilisation im Verbandsstiefel oder Castverband mit Teilbelastung (15–20 kg) für 6–8 Wochen je nach Frakturmuster, Knochenqualität und Patientencompliance. ERGEBNISSE: Nur wenige Studien berichten über Resultate nach der Osteosynthese von Tibiavorderkantenfrakturen bei Erwachsenen. Bei ausbleibender Fixierung dislozierter Fragmente werden Pseudarthrosen beschrieben. Bei der Versorgung von Sprunggelenkfrakturen übersehene Tibiavorderkantenfragmente können zu einer Fehlplatzierung der distalen Fibula in der Incisura fibularis tibiae mit nachfolgender Inkongruenz der Knöchelgabel und der Notwendigkeit von Revisionsoperationen führen. Sekundäre avaskuläre Nekrosen des anterolateralen Tibiaplafonds können nach Impaktionsverletzungen entstehen.

Orthopedic Department of 1st Faculty of Medicine Charles University and Central Military Hospital Prague Czech Republic

Trauma Unit Amsterdam UMC location AMC University of Amsterdam Amsterdam The Netherlands

University Center of Orthopaedics Trauma and Plastic Surgery University Hospital Carl Gustav Carus at TU Dresden Fetscherstraße 74 01307 Dresden Germany

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