Ankle AVN 8 years After Car Accident
This unfortunate 30-year-old was involved in a car accident 8 years previously. She sustained significant injuries that required immediate treatment. She had a compound tibia fracture to her left leg, as well as a compound fibula fracture. This required a total of 3 plates and 22 screws. She was non-weight bearing on that leg for over 6 months and spent 2 weeks in the hospital with an external fixator.
The Aftermath: Leg and Ankle Pain and Numbness
She had continued pain in her leg, ankle as well as numbness on both sides of her feet. She had 3 large scars. It was decided to remove the 3 plates and all but 2 screws. She noticed some leg pain had decreased, but the numbness and ankle pain remained. Walking and standing were difficult. She began limping and favoring her uninvolved right leg.
Consult with Dr. Lox
Dennis M. Lox M.D. is a Sports and Regenerative Medicine expert with offices in the Tampa Bay, Florida, and in Beverly Hills, California. As an expert, Dr. Lox treats simple sports injuries, and also some rather complex problems. This one was complex. No doctor had looked into her ankle pain. Due to the hardware of 3 plates and 22 screws, the immediate concern was her compound fractures, and with so much metal in her leg, an MRI evaluation of her ankle was not possible due to metallic artifact. However, once most of the metallic hardware was removed, she only had 2 screws remaining in her mid fibula. Dr. Lox consulted with a radiologist about noise-reducing software in an MRI to get a clearer idea of what internal pathology was underlying her ankle pain. Clearly from a trauma point of view, if the force of the car accident resulting in the compound tibia and fibula fractures near the ankle joint, that impactful force most certainly had an impact on the less rigid soft tissues inside and outside the ankle joint. The concerning factor for Dr. Lox was it was 8 years later, and now she had been walking abnormally with a limp, overburdening her right leg. An MRI with noise-reducing software was quickly arranged. Dr. Low noted on his office x-rays she had severe degenerative arthritis of her left ankle and moderate right ankle degenerative arthritis. This was not surprising given the severity of the trauma, and the 8 years since the date of her injury.
MRI of the Ankle
Not surprisingly, her ankle was read by the radiologist as severe degenerative arthritis of the ankle mortise. The ankle mortise is the connection between the leg tibia bone (which was fractured), and the talus bone. This joint allows the ankle to rock up and down. Dr. Lox is a meticulous and thorough physician, to be an expert and caring physician it is necessary. He reviewed the MRI and then called the radiologist to go over the MRI. Dr. Lox was concerned with two factors, not in the Radiology report. One was AVN, the other was a talar dome fracture. Both could be seen with the type of trauma she had. The Radiologist agreed both could be present or were more evident years ago, however, now her degenerative arthritis had progressed to the point if there was Avascular Necrosis (AVN) it was obscured by degenerative arthritis, meaning the necrotic portion of bone had already collapsed, resulting in ankle joint degradation. A talar dome fracture occurs from forceful trauma in which the top of the talus forcefully hits the tibia above, resulting in a crack or depression of the top of the talar dome. Again, over an 8 year period, which such extensive trauma this too would not unsurprisingly collapse or degenerative into an undistinguishable medical fact lost in the extensive joint degenerative changes of the ankle. Additionally, she had a complete tear of her anterior talo-fibula ligament, the ligament most commonly injured in ankle sprains. She was extremely swollen about the lateral malleolus, the exact region of this ligament. There was also a partial tear of the deltoid ligament on the inside of the ankle. Combined with her moderate ankle arthritis of her non-injured leg this was very troublesome.
Surgical Options
Surgery had been suggested by an orthopedic surgeon. Plate fusion across the ankle joint. This would eliminate all ankle motion. It would also accelerate the degenerative arthritis of her “good” ankle due to an increasing abnormal gait. It would also contribute to her developing degenerative arthritis of other joints due to her abnormal walking. Hips, knees, and spine are typically affected. This is a serious concern with a young 30-year-old woman. Unfortunately, high heels were not in her future.
Dennis M. Lox M.D.: Sports and Regenerative Medicine Expert
Understanding the problem is first and foremost. Even in the most difficult cases. Often with significant trauma, emergency rooms and surgeons address the most obvious problems. In this case, 2 compound fractures needing 3 plates and 22 screws. Unfortunately, overlooking the ankle joint only led to significant problems 8 years later. Dr. Lox often tells patients, “I only get you when I get you, and the person we have to fix is the person in front of me”, there is no rewind button or going back in time. We must deal with the situation as we have it, no matter how bad. Luckily, she was in good shape and did not need to lose more than 10-15 pounds to help unload the ankle joint. Walking would be reduced and a specific personalized exercise program was developed for her injury. She was a good candidate for Regenerative Medicine, and Stem Cell Science applications. Helping the body to heal itself is a cornerstone of Regenerative Medicine and stem cell therapy.Dr. Lox has helped patients with significant ankle injuries, including Avascular Necrosis or AVN from around the world. It is very rewarding to help patients’ lives. This patient is young, and if ankle fusion is done at 30 years of age, there will be more surgeries as her other joints degenerate from abnormal wear. Understanding the problem, making accurate diagnoses, spending the time to take detailed physical examinations, and developing a personalized treatment approach to fit the needs of each and every patient, is essential to obtaining the best possible outcome.
