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Abstract
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
- Rajeev Vohra
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Avtar Singh
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Babaji Thorat
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Dharmesh Patel
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
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Nichols JA, Baratta C, Reb CW. Biomechanical Sequelae of Syndesmosis Injury and Repair. Foot Ankle Clin 2023; 28:77-98. [PMID: 36822690 DOI: 10.1016/j.fcl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This review characterizes fibula mechanics in the context of syndesmosis injury and repair. Through detailed understanding of fibula kinematics (the study of motion) and kinetics (the study of forces that cause motion), the full complexity of fibula motion can be appreciated. Although the magnitudes of fibula rotation and translation are inherently small, even slight alterations of fibula position or movement can substantially impact force propagation through the ankle and hindfoot joints. Accordingly, implications for clinical care are discussed.
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Affiliation(s)
- Jennifer A Nichols
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, 1275 Center Drive, Gainesville, FL 32611, USA; Department of Orthopaedic Surgery & Sports Medicine, University of Florida, 3450 Hull Road, Gainesville, FL, 32607, USA.
| | - Chloe Baratta
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, 1275 Center Drive, Gainesville, FL 32611, USA
| | - Christopher W Reb
- Orthopaedics, Veterans Health Administration North Florida / South Georgia Health System, Malcolm Randall VA Medical Center, 1601 SW Archer Road, Gainesville, FL, 32608, USA
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3
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Zhang H, lin H, Lin Z, Ke J, Zhong J, Nie D, Zheng Y, Zhang J. Treatment and outcome of a patient with low-energy 'Logsplitter' injury. J Int Med Res 2022; 50:3000605221090849. [PMID: 36224748 PMCID: PMC9561648 DOI: 10.1177/03000605221090849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The low-energy ‘Logsplitter’ fracture, caused by a sprain or fall, is
characterized by an intact or slightly separated inferior tibiofibular joint.
Compared with the high-energy ‘Logsplitter’ fracture, this atypical subtype is
rarely seen and is easily missed. Here, the case of a 33-year-old male patient
with a fractured right ankle as a result of a sprain during walking is reported.
The patient initially received routine surgical treatment comprising internal
fixation of the fibular, medial and posterior malleoli. Unexpectedly,
post-surgery imaging examinations revealed that the medial clear space of the
right ankle had widened to 6 mm, due to incomplete reduction of the lateral
malleolus, shortening and rotation of the fibula, and an unreduced avulsion
fracture block of the anterior malleolus. A revision surgery was then performed
to anatomically reduce and fix the lateral malleolus, as well as the anterior
malleolus avulsion fracture. During 5 months following surgery, the patient
achieved good fracture union and functional restoration of the right ankle. For
this rare injury, the present case demonstrates that complete restoration of the
fracture is required to achieve good clinical efficacy.
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Affiliation(s)
- Hongjie Zhang
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Hai lin
- Department of Neurosurgery, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Zengping Lin
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Junquan Ke
- Department of Orthopaedics, Fujian Provincial 3rd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Jiping Zhong
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Darong Nie
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Yihong Zheng
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China
| | - Jiafang Zhang
- Department of Orthopaedics, Fujian Provincial 2nd People's
Hospital, Affiliated Hospital of Fujian University of Traditional Chinese
Medicine, Fuzhou, China,Jiafang Zhang, Fujian Provincial 2nd
People's Hospital, Affiliated Hospital of Fujian University of Traditional
Chinese Medicine, 5.4 Road, Gulou District, Fuzhou, Fujian 350003, China.
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Ijezie N, Fraig H, Abolaji S. Outcomes of the Routine Removal of the Syndesmotic Screw. Cureus 2022; 14:e26675. [PMID: 35949795 PMCID: PMC9358359 DOI: 10.7759/cureus.26675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/05/2022] Open
Abstract
Background Ankle joint stabilization with fixation following an injury has been the practice for ankle injuries requiring stabilization. When syndesmotic screws are used to stabilize the ankle joint, the current practice encourages the removal of these screws. However, this study was performed to evaluate the outcomes of patients treated with these screws, with the view to challenging routine screw removal. Methodology This was a retrospective study analyzing the records of 52 patients who had been treated with the syndesmotic screw over a two-year span. Results Of the 26 patients who did not retain the screw, 84.6% (n = 22) had it removed based on the advice of the surgeon as per the current practice. In total, 19 (73.1%) of these patients had suffered at least one complication over the two procedures. Conversely, of the 23 patients who had retained the screw through one procedure, 14 (60.7%) had at least one complication. Conclusions Routine syndesmotic screw removal is associated with increased risks of complications compared to retaining the screws, in addition to not producing a superior outcome for the patients.
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Affiliation(s)
| | - Hossam Fraig
- Surgery, Dorset County Hospital NHS Foundation Trust, Dorchester, GBR
| | - Samson Abolaji
- Medicine, All Saints University College of Medicine, Kingstown, VCT
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Hariri AE, Mirzabozorg H, Esmaeili R, Soltani A, Aghajanzadeh M. Predicting ankle joint syndesmotic screw lifetime using finite element and fatigue analysis. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221077274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
After recovery and loading on the patient’s leg, syndesmotic screws mounted on an injured ankle may fail. The main subject of this study is to estimate the lifetime of screws considering the patient’s weight and physical activity. Method: A 3D finite element model of the bone and implemented screws were provided assigning the mechanical properties of ligaments, bones, and screws. Considering axial and tangential physiological loads during the walking phase, the stress and fatigue analyses were performed. Results: The stress distribution had an identical pattern in the screws and all of them experienced the maximum stress during 60–70% of the walking phase. Conclusion: The results of analyses show that body weight has a significant effect on the mounted screw lifetime. Patients with a weight of more than [Formula: see text] kg should prevent applying body load on the operated leg. Conversely, no worry about a patient having less than [Formula: see text] kg body weight.
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Affiliation(s)
- A. E. Hariri
- Civil Engineering Department, K. N. Toosi University of Technology, Tehran, Iran
| | - H. Mirzabozorg
- Civil Engineering Department, K. N. Toosi University of Technology, Tehran, Iran
| | - R. Esmaeili
- Emergency Medicine, Faculty of Medical Science, Iran University of Medical Science, Tehran, Iran
| | - A.R. Soltani
- Civil Engineering Department, K. N. Toosi University of Technology, Tehran, Iran
| | - M. Aghajanzadeh
- Civil Engineering Department, K. N. Toosi University of Technology, Tehran, Iran
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Bartoníček J, Rammelt S, Tuček M. Maisonneuve Fractures of the Ankle: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202202000-00009. [PMID: 35180143 DOI: 10.2106/jbjs.rvw.21.00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. » The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). » The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. » Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. » Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.
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Affiliation(s)
- Jan Bartoníček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany
| | - Michal Tuček
- Department of Orthopaedics, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
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Lee SH, Cho HG, Yang JH. Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes. Foot Ankle Surg 2021; 27:777-783. [PMID: 34583831 DOI: 10.1016/j.fas.2020.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/06/2020] [Accepted: 10/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation. METHODS We performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS. RESULTS In total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021). CONCLUSIONS Obesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.
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Affiliation(s)
- Sung Hyun Lee
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea.
| | - Hyung Gyu Cho
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
| | - Je Heon Yang
- Department of Orthopedic Surgery, Wonkwang University Hospital, 895, Muwang-Ro, Iksan 54538, Republic of Korea
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Kaiser PB, Bejarano-Pineda L, Kwon JY, DiGiovanni CW, Guss D. The Syndesmosis, Part II: Surgical Treatment Strategies. Orthop Clin North Am 2021; 52:417-432. [PMID: 34538352 DOI: 10.1016/j.ocl.2021.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.
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Affiliation(s)
- Philip B Kaiser
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA.
| | - Lorena Bejarano-Pineda
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - John Y Kwon
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Daniel Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
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9
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Morphometric analysis of the incisura fibularis in patients with unstable high ankle sprains. Skeletal Radiol 2021; 50:1141-1150. [PMID: 33123744 DOI: 10.1007/s00256-020-03649-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The role of the syndesmotic ankle ligaments as extrinsic stabilizers of the distal tibiofibular joint (DTFJ) has been studied extensively in patients with high ankle sprains (HAS). However, research concerning the fibular incisura as intrinsic stabilizer of the DTFJ has been obscured by a two-dimensional assessment of a three-dimensional structure. Therefore, we aimed to compare the morphometry of the incisura fibularis between patients with HAS and a control group using three-dimensional radiographic techniques. MATERIALS AND METHODS Fifteen patients with a mean age of 44 years (SD = 15.2) diagnosed with an unstable HAS and twenty-five control subjects with a mean age of 47.4 years (SD = 6.5) were analyzed in this retrospective comparative study. The obtained CT images were converted to three-dimensional models, and the following radiographic parameters of the incisura fibularis were determined using three-dimensional measurements: incisura width, incisura depth, incisura height, incisura angle, incisura width-depth ratio, and incisura-tibia ratio. RESULTS The mean incisura depth (M = 4.7 mm, SD = 1.1 mm), incisura height (M = 36.1 mm, SD = 5.3 mm), and incisura angle of the control group (M = 137.2°, SD = 7.9°) differed significantly from patients with a HAS (resp., M = 3.8 mm, SD = 1.1 mm; M = 31.9 mm, SD = 3.2 mm; M = 143.2°, SD = 8.3°) (P < 0.05). The incisura width, incisura width-depth ratio, and incisura-tibia ratio demonstrated no significant difference (P > 0.05). CONCLUSION Our three-dimensional comparative analysis has detected a shallower and shorter fibular incisura in patients with HAS. This distinct morphology could have repercussion on the intrinsic or osseous stability of the DTFJ. Future prospective radiographic assessment could determine to what extend the fibular incisura morphology contributes to syndesmotic ankle injuries caused by high ankle sprains.
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10
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Pogliacomi F, De Filippo M, Casalini D, Longhi A, Tacci F, Perotta R, Pagnini F, Tocco S, Ceccarelli F. Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts. World J Orthop 2021; 12:270-291. [PMID: 34055585 PMCID: PMC8152437 DOI: 10.5312/wjo.v12.i5.270] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
| | - Massimo De Filippo
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Daniele Casalini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Alberto Longhi
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Fabrizio Tacci
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Rocco Perotta
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Francesco Pagnini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Silvio Tocco
- Centro Riabilitativo della Mano e Arto Superiore, Parma 43121, Italy
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Cornu O, Manon J, Tribak K, Putineanu D. Traumatic injuries of the distal tibiofibular syndesmosis. Orthop Traumatol Surg Res 2021; 107:102778. [PMID: 33333279 DOI: 10.1016/j.otsr.2020.102778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/15/2020] [Indexed: 02/03/2023]
Abstract
The distal tibiofibular syndesmosis (DTFS) is frequently injured during ankle trauma. The sequelae can be significant, including chronic instability, early osteoarthritis and residual pain. The aim of this study is to summarize the current state knowledge about these injuries by answering four questions. They frequently occur in the context of an ankle sprain (20-40% of cases) or during various types of ankle fractures (20-100% of cases). They cannot be ruled out based solely on fracture type and must be investigated when a fibular or posterior malleolar fracture is present. Clinical examination and imaging are essential but do not provide a definitive diagnosis. Ultrasonography, CT scan and MRI have high sensitivity, but their static nature does not allow a treatment strategy to be defined. Dynamic radiographs must be taken, either with load or during a procedure. If instability is detected, stabilization is the general rule. In fracture cases, reduction is achieved by restoring the length and rotation of the distal fibular fragment, preferably during an open procedure. In sprain cases, reduction is not a problem unless there is ligament interposition. Tibiofibular fixation is done 1.5 to 3cm from the talocrural joint, while ensuring the reduction is perfect. The main complication-non-healing of the syndesmosis-is attributed to poor initial reduction. This or functional discomfort during weight bearing will require removal of the fixation hardware. In most cases, this allows functional recovery and correction of the inadequate reduction. Persistence of instability will require ligament reconstruction or fusion of the syndesmosis. Chronic instability can lead to ankle osteoarthritis. LEVEL OF EVIDENCE: V, expert opinion.
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Affiliation(s)
- Olivier Cornu
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium.
| | - Julie Manon
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
| | - Karim Tribak
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
| | - Dan Putineanu
- Service de chirurgie orthopédique et traumatologie, cliniques universitaires Saint-Luc UCL, université catholique de Louvain, Brussels, Belgium
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12
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Abstract
Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.
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13
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Identification of Surgical Plan for Syndesmotic Fixation Procedure Based on Finite Element Method. APPLIED SCIENCES-BASEL 2020. [DOI: 10.3390/app10124349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Syndesmosis injuries account for approximately 20% of ankle fractures that require surgery. Although multiple surgical options are available, all of them are based on metal screws. Serious complications that arise when applying metal screws include screw loosening or breakage. To prevent such complications, we applied a simulation method using a finite element (FE) analysis. We created a 3D FE model of an ankle joint and conducted an FE analysis focusing on syndesmosis in terms of the level, material, and diameter of the syndesmotic screw and the number of penetrated cortical bones. The magnitude and direction of the force applied to the tibia in the midstance state were considered for simulating the model. The maximum von-Mises stress and syndesmosis widening were analyzed in terms of different biomechanical parameters. We identified the characteristics of the most biomechanically stable syndesmotic screw and its fixation point on the basis of the two parameters. We demonstrated that the ideal syndesmotic screw fixation should be fixed at a level 20 to 25 mm above the ankle using a 4.5 mm titanium screw.
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14
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Kapadia BH, Sabarese MJ, Chatterjee D, Aylyarov A, Zuchelli DM, Hariri OK, Uribe JA, Tsai J. Evaluating success rate and comparing complications of operative techniques used to treat chronic syndesmosis injuries. J Orthop 2020; 22:225-230. [PMID: 32425422 DOI: 10.1016/j.jor.2020.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/09/2020] [Accepted: 04/26/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose To assess the success rate and complications of the surgical interventions used to manage chronic syndesmosis injuries. Methods Multiple online databases were queried to identify studies reporting operative intervention for chronic syndesmosis injuries. Results Modalities of operative fixation include suture-button fixation, arthroscopy and debridement, as well as arthrodesis. The use of operative treatment is effective; however, more direct comparison studies are necessary to evaluate the efficacy of each treatment. Conclusion Various operative procedures have been used for the management of chronic syndesmotic injuries but further prospective studies are necessary to determine the type of treatment that should be indicated.
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Affiliation(s)
- Bhaveen H Kapadia
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Michael J Sabarese
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Dipal Chatterjee
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Alexandr Aylyarov
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Daniel M Zuchelli
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Omar K Hariri
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Jaime A Uribe
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Justin Tsai
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute - New York, NY, USA
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15
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Bae KJ, Kang SB, Kim J, Lee J, Go TW. Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. J Int Med Res 2019; 48:300060519882550. [PMID: 31885342 PMCID: PMC7607056 DOI: 10.1177/0300060519882550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. Methods We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively. Results Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94. Conclusion Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.
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Affiliation(s)
- Kee Jeong Bae
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jihyeung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jaewoo Lee
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Tae Won Go
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations. J Orthop Trauma 2019; 33:e318-e324. [PMID: 31335507 DOI: 10.1097/bot.0000000000001503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system. DESIGN Web-based survey. PARTICIPANTS Orthopaedic Trauma Association (OTA) members. METHODS A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures. RESULTS One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available. CONCLUSIONS Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.
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Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review. INTERNATIONAL ORTHOPAEDICS 2019; 43:2539-2547. [PMID: 31440891 DOI: 10.1007/s00264-019-04396-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/14/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Tibiofibular syndesmosis injury leads to ankle pain and dysfunction when ankle injuries are not treated properly. Despite several studies having been performed, many questions about diagnosis and treatment remain unanswered, especially in ankle syndesmosis injury with interosseous membrane injury. Therefore, the purpose of this study was to help guide best practice recommendations. METHODS This review explores the mechanism of injury, clinical features, diagnosis methods, and the treatment strategy for ankle syndesmosis injury with interosseous membrane injury to highlight the current evidence in terms of the controversies surrounding the management of these injuries. RESULTS Radiological and CT examination are an important basis for diagnosing ankle syndesmosis injury. Physical examination combined with MRI to determine the damage to the interosseous membrane is significant in guiding the treatment of ankle syndesmosis injury with interosseous membrane injury. In the past, inserting syndesmosis screws was the gold standard for treating ankle syndesmosis injury. However, there were increasingly more controversies regarding loss of reduction and broken nails, so elastic fixation has become more popular in recent years. CONCLUSIONS Anatomical reduction and effective fixation are the main aspects to be considered in the treatment of ankle syndesmosis injury with interosseous membrane injury and are the key to reducing postsurgery complications.
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Kromka JJ, Chambers MC, Popchak A, Irrgang J, Hogan MV. In a small retrospective cohort of patients with syndesmotic injury, only athletes benefited from placement of a suture button device: a pilot study. J ISAKOS 2018. [DOI: 10.1136/jisakos-2018-000234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
ObjectivesInjuries to the ankle are common, with a significant number of ligamentous injuries involving the syndesmosis. In syndesmotic injuries severe enough to require surgical fixation, the two leading techniques are rigid screw and suture button fixation. The literature has shown that both techniques are effective, but there remains debate on the optimum method of treatment. The goal of this study was to evaluate patient-reported outcomes for these repair methods in a population of athletes.MethodsThis study was a retrospective cross-sectional study of patients who had undergone rigid screw or suture button fixation for an injury to the ankle syndesmosis. Specifically, a subpopulation of athletes was examined as it was hypothesised that these high-demand patients would have higher patient-reported outcomes with ongoing suture button fixation. Study participants were identified through a search of the medical record and were recruited through mailed letters and phone calls. Participants completed patient-reported outcome questionnaires including the Activities of Daily Living and Sports Subscales of the Foot and Ankle Ability Measure (FAAM) survey, FAAM Sports Subscale survey, Veteran’s Rand 12-item Health Survey (VR-12) and a customised athletic activity questionnaire. These patient-reported outcomes were compared between those who underwent screw fixation and those who underwent suture button fixation.Results32 patients completed the study, with 17 of these designated as ‘athletes’ competing in strenuous sports activities that involve jumping, cutting and hard pivoting including football, soccer, basketball, volleyball and gymnastics at the high school level or above. Patients were on average 3.9 years post op (SD 2.2). With the numbers available, no difference in outcomes between patients with rigid screw or suture button fixation was observed in the study as a whole. In a subpopulation of athletes, patients who received suture button fixation had higher FAAM scores compared with those treated with rigid screw fixation (p=0.02). Still, in the subpopulation of athletes, no statistical difference was observed with the available numbers for the other patient-reported outcomes.ConclusionThis pilot study of outcomes in an athletic population suggests that athletic patients may benefit from suture button fixation and lays the groundwork for future work examining the use of suture button fixation in high-demand patients.Level of evidenceLevel III—Retrospective Comparative Study.
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Abstract
Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057.
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Burssens A, Peeters J, Peiffer M, Marien R, Lenaerts T, Vandeputte G, Victor J. Reliability and correlation analysis of computed methods to convert conventional 2D radiological hindfoot measurements to a 3D setting using weightbearing CT. Int J Comput Assist Radiol Surg 2018. [PMID: 29524088 DOI: 10.1007/s11548-018-1727-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- A Burssens
- Department of Orthopaedic Surgery, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - J Peeters
- AZ Monica, Florent Pauwelslei 21, 2100, Deurne, Belgium
| | - M Peiffer
- Department of Orthopaedic Surgery, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - R Marien
- Materialise N.V., Technologielaan 15, 3001, Louvain, Belgium
| | - T Lenaerts
- Materialise N.V., Technologielaan 15, 3001, Louvain, Belgium
| | - G Vandeputte
- Department of Orthopaedic Surgery, H.-Hartziekenhuis, Mechelstraat 24, 2500, Lier, Belgium
| | - J Victor
- Department of Orthopaedic Surgery, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
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Affiliation(s)
- Pieter D'Hooghe
- 1 Orthopaedic Surgeon and Assistant Chief of Surgery for Research, Department of Orthopaedic Surgery and Sportsmedicine, Aspetar Hospital, Doha, Qatar
| | - Philip J York
- 2 Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jean Francois Kaux
- 3 Physical and Rehabilitation Medicine (SPORTS2), University Hospital of Liège, Belgium, Liège, Belgium
| | - Kenneth J Hunt
- 2 Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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de-Las-Heras Romero J, Alvarez AML, Sanchez FM, Garcia AP, Porcel PAG, Sarabia RV, Torralba MH. Management of syndesmotic injuries of the ankle. EFORT Open Rev 2017; 2:403-409. [PMID: 29071125 PMCID: PMC5644422 DOI: 10.1302/2058-5241.2.160084] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Injuries to the tibioperoneal syndesmosis are more frequent than previously thought and their treatment is essential for the stability of the ankle mortise. Recognition of these lesions is essential to avoid long-term morbidity. Diagnosis often requires complete history, physical examination, weight-bearing radiographs and MRI. Treatment-oriented classification is mandatory. It is recommended that acute stable injuries are treated conservatively and unstable injuries surgically by syndesmotic screw fixation, suture-button dynamic fixation or direct repair of the anterior inferior tibiofibular ligament. Subacute injuries may require ligamentoplasty and chronic lesions are best treated by syndesmotic fusion. However, knowledge about syndesmotic injuries is still limited as recommendations for surgical treatment are only based on level IV and V evidence. Cite this article: EFORT Open Rev 2017;2:403–409. DOI: 10.1302/2058-5241.2.160084
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Affiliation(s)
- Jorge de-Las-Heras Romero
- Department of Orthopaedics and Traumatology, University General Hospital Reina Sofía, Avda Intendente Jorge Palacios 1, Murcia 30003, Spain
| | | | - Fernando Moreno Sanchez
- Department of Orthopaedics and Traumatology, University General Hospital Reina Sofía, Murcia, Spain
| | - Alejandro Perez Garcia
- Department of Orthopaedics and Traumatology, University General Hospital Reina Sofía, Murcia, Spain
| | | | - Raul Valverde Sarabia
- Department of Orthopaedics and Traumatology, University General Hospital Reina Sofía, Murcia, Spain
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van Zuuren WJ, Schepers T, Beumer A, Sierevelt I, van Noort A, van den Bekerom MPJ. Acute syndesmotic instability in ankle fractures: A review. Foot Ankle Surg 2017; 23:135-141. [PMID: 28865579 DOI: 10.1016/j.fas.2016.04.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Revised: 09/14/2015] [Accepted: 04/15/2016] [Indexed: 02/04/2023]
Abstract
Ankle fractures are among the most common fracture types, and 10% of all ankle fractures lead to accessory syndesmotic injury. An injury that is challenging in every respect is syndesmotic instability. Since the range of diagnostic techniques and the therapeutic options is extensive, it still is a controversial subject, despite the abundance of literature. This review aimed to summarize the current knowledge on syndesmotic instability in ankle fractures and to formulate some recommendations for clinical practice. Chronic instability and the operative osseous treatment of ankle fractures are not part of this review.
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Affiliation(s)
- W J van Zuuren
- Department of Orthopaedics, Spaarne Ziekenhuis Hoofddorp, The Netherlands.
| | - T Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - A Beumer
- Department of Orthopaedics, Amphia Ziekenhuis Breda, The Netherlands
| | - I Sierevelt
- Department of Orthopaedics, Spaarne Ziekenhuis Hoofddorp, The Netherlands
| | - A van Noort
- Department of Orthopaedics, Spaarne Ziekenhuis Hoofddorp, The Netherlands
| | - M P J van den Bekerom
- Department of Orthopaedics and Traumatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Steinmetz S, Puliero B, Brinkert D, Meyer N, Adam P, Bonnomet F, Ehlinger M. Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair. Orthop Traumatol Surg Res 2016; 102:1069-1073. [PMID: 27592847 DOI: 10.1016/j.otsr.2016.06.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 05/24/2016] [Accepted: 06/03/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Tibiofemoral syndesmosis injuries are common but have not been extensively researched. The primary objective of this study was to evaluate the outcomes after temporary screw fixation with ligament repair of these injuries. The secondary objective was to look for factors that could impact these outcomes. We hypothesised that this double fixation (screw+suture) would lead to good outcomes with minimal secondary opening of the syndesmosis upon screw removal. MATERIAL AND METHODS This was a retrospective study of 285 patients with a tibiofemoral syndesmosis injury (01/2004-12/2011) who were treated by temporary tricortical or quadricortical screw fixation and ligament repair. The operated leg was unloaded for 6-8 weeks postoperative with the patient wearing a walking cast. The screw was removed in all patients before weight bearing was allowed. At follow-up, the range of motion, return to sports, pain, and functional scores (AOFAS and OMAS) were determined, and a radiological assessment was performed. RESULTS One hundred twenty-six patients were reviewed after a mean follow-up of 5.9±5.7years (2.9-10.5). Mean plantarflexion was 95% of the contralateral side and mean dorsiflexion was 93%. Return to sports occurred after a mean of 10weeks; 83% of patients returned to their pre-injury level of participation. Pain on VAS was 0.8/10 on average. The mean AOFAS and OMAS scores were both above 90 points. At the review, 4% of screws had broken. Diastasis was found in 5.6% of cases, osteoarthritis in 6.3% and an osteophyte in 11.1% of cases, but with no clinical repercussions. No risk factors were identified. DISCUSSION AND CONCLUSION Treatment by temporary screw fixation and ligament repair leads to good objective results, confirming our hypothesis. However, there is little published data and no consensus on the fixation method or the need to remove the screw. LEVEL OF EVIDENCE IV, retrospective, non-comparative.
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Affiliation(s)
- S Steinmetz
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - B Puliero
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - D Brinkert
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - N Meyer
- GMRC, service de santé publique, CHU de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - P Adam
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - F Bonnomet
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France
| | - M Ehlinger
- Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, CHU de Strasbourg, 1, avenue Molière, 67098 Strasbourg, France; Laboratoire Icube-CNRS - UMR 7357, Illkirch, France.
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Er MS, Verim O, Eroglu M, Altinel L, Gokce B, Tasgetiren S. Biomechanical evaluation of syndesmotic screw design via finite element analysis and Taguchi's method. J Am Podiatr Med Assoc 2016; 105:14-21. [PMID: 25675221 DOI: 10.7547/8750-7315-105.1.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Screw fixation of syndesmotic injuries facilitates ligament healing and restoration of ankle stability, but failure of the screw might threaten the success of the treatment. Screw design parameters, such as outer diameter, inner diameter, thread pitch, leading edge radius, trailing edge radius, leading edge angle, and trailing edge angle, might have effects on the stresses that occur in the screws. This is the first study, to our knowledge, to investigate which geometric screw parameters play key roles in stresses that occur in screws used for syndesmotic fixation. METHODS A three-dimensional finite element model of an ankle was reconstructed. Four different types of titanium screws—4.5-mm malleolar, 4-mm cancellous, 4-mm machine, and 3.5-mm cortical—were placed on this model. Physiologic load was applied to evaluate the stress in the screw. Then the contribution of each design factor to stress in the screws was analyzed systematically by Taguchi's robust design method. RESULTS The maximum equivalent ductile failure (von Mises equivalent stress) value was found in the 4-mm cancellous screw (402 MPa). Taguchi's analysis showed that the descending order of contribution of the design factors to stress emerging on the screw is inner diameter, leading edge angle, thread pitch, outer diameter, and trailing edge angle. CONCLUSIONS Stress that occurs in syndesmotic screws is closely related to their geometry and dimensions. According to the results, a 3.5-mm cortical screw with the ideal screw design regarding optimal parameters to resist against stresses in the syndesmosis seems more reasonable to choose in syndesmotic fixation.
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Affiliation(s)
- Mehmet Serhan Er
- Department of Orthopedics and Traumatology, University of Akdeniz, School of Medicine, Antalya, Turkey
| | - Ozgur Verim
- Department of Mechanical Engineering, Faculty of Technology, University of Afyon Kocatepe, Afyonkarahisar, Turkey
| | - Mehmet Eroglu
- Department of Orthopedics and Traumatology, University of Afyon Kocatepe, School of Medicine, Afyonkarahisar, Turkey
| | - Levent Altinel
- Department of Orthopedics and Traumatology, University of Akdeniz, School of Medicine, Antalya, Turkey
| | - Bariş Gokce
- Department of Mechatronics Engineering, Faculty of Technology, University of Afyon Kocatepe, Afyonkarahisar, Turkey
| | - Suleyman Tasgetiren
- Department of Biomedical Engineering, Faculty of Engineering, University of Afyon Kocatepe, Afyonkarahisar, Turkey
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van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 2016; 24:1217-27. [PMID: 26846658 DOI: 10.1007/s00167-016-4017-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/20/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries. METHODS A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015. RESULTS The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries. CONCLUSIONS The ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- C Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, PO Box 22700, 1100, DE, Amsterdam, The Netherlands
| | - Umile Giuseppe Longo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy.
| | - Mattia Loppini
- Department of Orthopaedic and Trauma Surgery, Humanitas Research Hospital, Via Alessandro Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Pino Florio
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Ludovica Maltese
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Mauro Ciuffreda
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University, Via Alvaro del Portillo, 200, 00128, Trigoria, Rome, Italy
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Switaj PJ, Mendoza M, Kadakia AR. Acute and Chronic Injuries to the Syndesmosis. Clin Sports Med 2015; 34:643-77. [DOI: 10.1016/j.csm.2015.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Scolaro JA, Marecek G, Barei DP. Management of Syndesmotic Disruption in Ankle Fractures. JBJS Rev 2014; 2:01874474-201412000-00004. [DOI: 10.2106/jbjs.rvw.n.00028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 2014; 41:601-14. [PMID: 26037997 DOI: 10.1007/s00068-014-0466-8] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/20/2014] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy. METHODS The majority of purely ligamentous injuries ("high ankle sprains") is not sassociated with a latent or frank tibiofibular diastasis and may be treated with an extended protocol of physical therapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments that require surgical stabilization. Syndesmosis disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists in anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. Proposed means of fixation are refixation of bony syndesmotic avulsions, one or two tibiofibular screws and suture button. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. RESULTS/COMPLICATIONS The most frequent complication is syndesmotic malreduction and may be minimized with open reduction and intraoperative 3D scanning. Other complications include hardware failure, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. CONCLUSION The single most important prognostic factor is anatomic reduction of the distal fibula into the tibial incisura.
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Affiliation(s)
- S Rammelt
- University Center for Orthopaedics and Traumatology, University Hospital Carl-Gustav Carus, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - P Obruba
- Department of Traumatology, Masarykova Nemocnice, Socíalní péče 3316/12A, 401 13, Ústí Nad Labem, Czech Republic.
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Magan A, Golano P, Maffulli N, Khanduja V. Evaluation and management of injuries of the tibiofibular syndesmosis. Br Med Bull 2014; 111:101-15. [PMID: 25190761 DOI: 10.1093/bmb/ldu020] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Injury to the tibiofibular syndesmosis often arises from external rotation force acting on the foot leading to eversion of the talus within the ankle mortise and increased dorsiflexion or plantar flexion. Such injuries can present in the absence of a fracture. Therefore, diagnosis of these injuries can be challenging, and often stress radiographs are helpful. Magnetic resonance imaging scans can be a useful adjunct in doubtful cases. The management of syndesmotic injuries remains controversial, and there is no consensus on how to optimally fix syndesmosis. This article reviews the mechanism of injury, clinical features and investigations performed for syndesmotic injuries and brings the reader up-to-date with the current evidence in terms of the controversies surrounding the management of these injuries. SOURCES OF DATA Embase, Pubmed Medline, Cochrane Library, Elsevier and Google Scholar (January 1950-2014). AREAS OF CONTROVERSY The management of syndesmotic injuries remains controversial, and there is no consensus on: (i) which ankle fractures require syndesmotic fixation, (ii) the number or the size and the type of screws that should be used for fixation, (iii) how many cortices to engage for fixation, (iv) the level of screw placement above the ankle plafond, (v) the duration for which the screw needs to remain in situ to allow the tibiofibular syndesmosis to heal and (vi) when should patients weight bear. AREAS OF AGREEMENT (i) A high proportion of syndesmotic fixations demonstrates malreduction of the syndesmosis, (ii) no need to remove screws routinely, (iii) two screws appear to better one alone and (iv) if syndesmosis injury is not detected or not treated long term, it leads to pain and arthritis. GROWING POINTS (i) How to assess the adequacy of syndesmotic reduction using imaging in the peri-operative period, (ii) the use of bio-absorbable materials and Tightrope and (iii) evidence is emerging not to remove syndesmotic screws unless symptomatic. AREAS OF TIMELY FOR DEVELOPMENT RESEARCH (i) A bio-absorbable material that can be used to fix the syndesmosis and allow early weight bearing, and (ii) there is a need for developing a surgical technique for adequately reducing the syndesmosis without the exposure to radiation.
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Affiliation(s)
- Ahmed Magan
- Addenbrooke's Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Pau Golano
- Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Surgery, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy Centre for Sport and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK
| | - Vikas Khanduja
- Addenbrooke's Cambridge University Hospitals NHS Trust, Cambridge, UK
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Peek AC, Fitzgerald CE, Charalambides C. Syndesmosis screws: how many, what diameter, where and should they be removed? A literature review. Injury 2014; 45:1262-7. [PMID: 24917210 DOI: 10.1016/j.injury.2014.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 05/08/2014] [Indexed: 02/02/2023]
Abstract
Although screw fixation remains the most commonly used method of syndesmosis fixation, the ideal screw size, placement, and number remain controversial. In addition, there has been debate as to whether the screw should always be removed, and a number of studies have looked at radiological and functional outcomes. In addition a number of cadaveric models have been developed, but the correlation between cadaveric findings and functional outcomes remains unclear. This systematic review of the literature aims to summarise the available evidence on how many screws should be placed, of what diameter, through how many cortices, at what level, and whether they should be removed.
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Affiliation(s)
- A C Peek
- Whittington Hospital, London, UK.
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Gough BE, Chong ACM, Howell SJ, Galvin JW, Wooley PH. Novel flexible suture fixation for the distal tibiofibular syndesmotic joint injury: a cadaveric biomechanical model. J Foot Ankle Surg 2014; 53:706-11. [PMID: 24846162 DOI: 10.1053/j.jfas.2014.04.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Indexed: 02/03/2023]
Abstract
Syndesmotic injuries of the ankle commonly occur by an external rotation force applied to the ankle joint. Ten fresh-frozen lower extremities from cadavers were used. A specially designed apparatus was used to stabilize the specimen and rotate the ankle joint from internally rotated 25° to externally rotated 35° at a rate of 6°/s for 10 cycles. Two stages were tested (stage I, specimens intact; and stage II, simulated pronation external rotation type injury with fixation). Group 1 was fixed with a novel suture construct across the syndesmotic joint, and group 2 was fixed with a single metallic screw. The torque, rotational angle, and 3-dimensional syndesmotic diastasis readings were recorded. Three-dimensional tibiofibular diastasis was identified. The fibula of the intact specimens displaced an average of 8.6 ± 1.7, 2.4 ± 1.0, and 1.4 ± 1.0 mm in the anterior, lateral, and superior direction, respectively, when the foot was externally rotated 35°. The sectioning of the syndesmostic ligaments and deltoid ligament resulted in a significant decrease in syndesmotic diastasis and foot torsional force (p < .05). The ligament-sectioned specimen lost 57% (externally rotated) and 17% (internally rotated) torsional strength compared with the intact specimen. Groups 1 and 2 provided similar biomechanical stability in this cadaveric model of a syndesmosis deficiency.
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Affiliation(s)
- Brandon E Gough
- Submitted while Fifth-Year Resident, Orthopaedics Residency, The University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Alexander C M Chong
- Research Engineer and Teaching Associate, Via Christi Health, Orthopedic Research Institute, Wichita, KS.
| | - Steven J Howell
- Associate Professor, Department of Orthopaedics Surgery, The University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Joseph W Galvin
- Submitted while Fourth-Year Medical Student, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Paul H Wooley
- Research Director and Professor, Via Christi Health, Orthopedic Research Institute, Wichita, KS
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Abstract
➤ Despite being common, syndesmotic injuries are challenging to diagnose and treat.➤ Anatomic reduction of the ankle syndesmosis is critical for good clinical outcomes.➤ Intraoperative three-dimensional radiography and direct syndesmotic visualization can improve rates of anatomic reduction.➤ The so-called gold-standard syndesmotic screw fixation is being brought increasingly into question as new fixation techniques emerge.➤ Syndesmotic screw removal remains controversial, but may allow spontaneous correction of malreductions.
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Affiliation(s)
- Tyler J Van Heest
- University of Minnesota-Regions Hospital, 640 Jackson Street, St. Paul, MN 55101. E-mail address for T.J. Van Heest: . E-mail address for P.M. Lafferty:
| | - Paul M Lafferty
- University of Minnesota-Regions Hospital, 640 Jackson Street, St. Paul, MN 55101. E-mail address for T.J. Van Heest: . E-mail address for P.M. Lafferty:
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Schepers T, van der Linden H, van Lieshout EMM, Niesten DD, van der Elst M. Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury. Injury 2014; 45:775-9. [PMID: 24139172 DOI: 10.1016/j.injury.2013.09.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 09/15/2013] [Accepted: 09/19/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Much of the currently available data on the technical aspects of syndesmotic screw placement are based upon biomechanical studies, using cadaveric legs with different testing protocols, and on surgeon preference. The primary aim of this study was to investigate the effect of the level of syndesmotic screw insertion on functional outcome. Further, the effects of number of cortices engaged, the diameter of the screw, use of a second syndesmotic screw and the timing of removal on functional outcome were tested. MATERIAL AND METHOD All consecutive patients treated for an ankle fracture with concomitant acute distal tibiofibular syndesmotic injury that had a metallic syndesmotic screw placed, between 1 January 2004 and 31 December 2010, were included. Patient characteristics (i.e., age at injury and gender), fracture characteristics (i.e., affected side, trauma mechanism, Weber fracture type and number of fractured malleoli), and surgical characteristics (i.e., level of screw placement, screw diameter, tri- or quadricortical placement, number of syndesmotic screws used and the timing of screw removal) were recorded. Outcome was measured using validated questionnaires, which were sent by post, and consisted of the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS), the Olerud-Molander Ankle Score (OMAS) and a single question Visual Analog Scale (VAS) for patient satisfaction with outcome. RESULTS During the 7-year study period, 122 patients were treated for syndesmotic injury. A total of 93 patients (76%) returned the questionnaire. The median follow-up was 51 months. The outcome scoring systems showed an overall score for the entire group of 92 points for the AOFAS, 77 for the OMAS and 8.2 for the VAS. Outcome was statistically significantly influenced by the number of fractured malleoli, age, trauma mechanism and the level of screw insertion. CONCLUSION Overall, the functional outcome of acute syndesmotic injuries treated with a syndesmotic screw was good and mainly influenced by patient and fracture characteristics. Most different technical aspects of placement appeared not to influence these results. Only screw placement above 41 mm negatively influenced outcome.
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Affiliation(s)
- Tim Schepers
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | | | - Esther M M van Lieshout
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dieu-Donné Niesten
- Department of Orthopaedics, Reinier de Graaf Groep, Delft, The Netherlands
| | - Maarten van der Elst
- Department of Surgery and Traumatology, Reinier de Graaf Groep, Delft, The Netherlands
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Abstract
OBJECTIVES To evaluate the stresses in syndesmotic screws and widening of syndesmosis under loading after placement of the screws at different levels from the ankle joint line and to determine the optimal level. METHODS From a set of computed tomographic data of an ankle, a 3-dimensional finite-element model was reconstructed. Six fixation configurations of the syndesmosis with placement of 3.5 or 4.5 mm single tricortical screws at 20-45 mm from the tibiotalar joint were performed on this model. Physiological loads approximating those during both midstance and heel-off states of stance phase of normal walking were applied to evaluate the stress in the screw and widening of the syndesmosis. RESULTS Among the 6 fixation configurations, the lowest von Mises stress was found in the screws placed 30-40 mm above the joint line (373.31-380.17 MPa for 3.5 mm cortical screw and 284.06-327.31 MPa for 4.5 mm cortical screw in midstance phases), whereas the least syndesmosis widening was determined when the screw was placed 30 mm above the tibial plafond (0.005 mm) for 3.5 mm cortical screw and 20, 25, and 30 mm above the tibial plafond (0.004 mm for each, respectively) for 4.5 mm cortical screw during midstance phases. CONCLUSIONS This study showed that syndesmosis fixation at the level of 30-40 mm above the tibiotalar joint has advantages with regard to stress in screws in comparison with the other evaluated levels.
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Er MS, Verim O, Altinel L, Tasgetiren S. Three-dimensional finite element analysis used to compare six different methods of syndesmosis fixation with 3.5- or 4.5-mm titanium screws: a biomechanical study. J Am Podiatr Med Assoc 2014; 103:174-80. [PMID: 23697720 DOI: 10.7547/1030174] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Use of thicker and longer (four cortices) screws or of multiple screws seems to be more stable and efficient for syndesmosis fixation. METHODS A three-dimensional finite element model of an ankle was constructed from serial axial sections from an existing two-dimensional computed tomographic image. Constructions of syndesmosis fixation with 3.5-mm single tricortical, 3.5-mm single quadricortical, 3.5-mm double tricortical, 3.5-mm double quadricortical, 4.5-mm single tricortical, and 4.5-mm single quadricortical screws were performed on this model. Physiologic loads approximating those during stance phase normal walking were applied to this ankle system. Stress values on the screws using the six fixation methods were compared. RESULTS The highest maximum stress was determined over 3.5-mm cortical screws applied as single quadricortical, and the lowest maximum stress was determined over the 4.5-mm cortical screw applied as single quadricortical. Stress on the 3.5-mm single screw with quadricortical application was found to be higher than that with tricortical application and also compared with the 4.5-mm quadricortical screw application. Differences between the 4.5-mm single tricortical and quadricortical screws and between the 3.5-mm single tricortical and 3.5-mm double tricortical screw applications were not significant. CONCLUSIONS Quadricortical application of 3.5-mm single screws and tricortical application of 3.5-mm double cortical screws are not good choices for syndesmosis fixation. If the plan is tricortical application, a 3.5-mm single cortical screw is adequate. If quadricortical application of syndesmosis fixation is planned, a 4.5-mm cortical screw should be used.
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Affiliation(s)
- Mehmet Serhan Er
- Department of Orthopedics and Traumatology, University of Afyon Kocatepe, School of Medicine, Afyonkarahisar, Turkey.
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Liu Q, Zhang K, Zhuang Y, Li Z, Yu B, Pei G. Analysis of the stress and displacement distribution of inferior tibiofibular syndesmosis injuries repaired with screw fixation: a finite element study. PLoS One 2013; 8:e80236. [PMID: 24312464 PMCID: PMC3848989 DOI: 10.1371/journal.pone.0080236] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 10/01/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Studies of syndesmosis injuries have concentrated on cadaver models. However, they are unable to obtain exact data regarding the stress and displacement distribution of various tissues, and it is difficult to compare models. We investigated the biomechanical effects of inferior tibiofibular syndesmosis injuries (ITSIs) and screw fixation on the ankle using the finite element (FE) method. METHODOLOGY/PRINCIPAL FINDINGS A three-dimensional model of a healthy ankle complex was developed using computed tomography (CT) images. We established models of an ITSI and of screw fixation at the plane 2.5 cm above and parallel to the tibiotalar joint surface of the injured syndesmosis. Simulated loads were applied under three conditions: neutral position with single-foot standing and internal and external rotation of the ankle. ITSI reduced contact forces between the talus and fibula, helped periarticular ankle ligaments withstand more load-resisting movement, and increased the magnitude of displacement at the lower extreme of the tibia and fibula. ITSI fixation with a syndesmotic screw reduced contact forces in all joints, decreased the magnitude of displacement at the lower extreme of the tibia and fibula, and increased crural interosseous membrane stress. CONCLUSIONS/SIGNIFICANCE Severe syndesmosis injuries cause stress and displacement distribution of the ankle to change multidirectional ankle instability and should be treated by internal fixation. Though the transverse syndesmotic screw effectively stabilizes syndesmotic diastasis, it also changes stress distribution around the ankle and decreases the joint's range of motion (ROM). Therefore, fixation should not be performed for a long period of time because it is not physiologically suitable for the ankle joint.
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Affiliation(s)
- Qinghua Liu
- Department of Orthopaedic Trauma, Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Kun Zhang
- Department of Orthopaedic Trauma, Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Yan Zhuang
- Department of Orthopaedic Trauma, Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
| | - Zhong Li
- Department of Orthopaedic Trauma, Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China
- * E-mail: (ZL); (BY)
| | - Bin Yu
- Department of Orthopaedic Trauma, Nanfang Hospital, Southern Medical University, Guangzhou, China
- * E-mail: (ZL); (BY)
| | - Guoxian Pei
- Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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Tucker A, Street J, Kealey D, McDonald S, Stevenson M. Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal - Is it really necessary? Injury 2013; 44:1880-4. [PMID: 24021584 DOI: 10.1016/j.injury.2013.08.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/16/2013] [Accepted: 08/10/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Syndesmotic disruption can occur in up to 20% of ankle fractures and is more common in Weber Type C injuries. Syndesmotic repair aims to restore ankle stability. Routine removal of syndesmosis screws is advocated to avoid implant breakage and adverse functional outcome such as pain and stiffness, but conflicting evidence exists to support this. The aim of the current study is to determine whether functional outcome differs in patients who had syndesmosis screws routinely removed, compared to those who did not, and whether a cost benefit exists if removal of screws is not routinely necessary. PATIENTS AND METHODS A retrospective review of consecutive syndesmosis repairs was performed from 1 January 2008 to 31 December 2010 in a single regional trauma centre. We identified 91 patients who had undergone open reduction internal fixation of an ankle fracture with placement of a syndesmosis screw at index procedure. As many as 69 patients were eligible for the study as defined by the inclusion criteria and they completed a validated functional outcome questionnaire. The functional outcomes of patients with 'retained screws' and 'removed screws' were analysed and compared using the Olerud Molander Ankle Score (OMAS). RESULTS A total of 63 patients responded with a mean follow-up period of 31 months (range 10-43 months). Of those patients, 43 underwent routine screw removal whilst 20 had screws left in situ. The groups were comparable considering age, gender and follow-up time. The 'retained' group scored higher mean OMAS scores, 81.5±19.3 compared to 75±12.9 in the 'removed' group (p=0.107). The retained group achieved higher functional scores in each of the OMAS domains as well as experiencing less pain. When adjusted for gender, the findings were found to be statistically significant (p=0.046). CONCLUSION Our study has shown that retained-screw fixation does not significantly impair functional capacity, with additional cost-effectiveness. We therefore advocate that syndesmosis screws be left in situ and should only be removed in case of symptomatic implants beyond 6 months postoperatively.
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Affiliation(s)
- Adam Tucker
- Orthopaedic Department, C/O Fracture Clinic, Level 2, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK.
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Abstract
Traumatic injuries to the distal tibiofibular syndesmosis commonly result from high-energy ankle injuries. They can occur as isolated ligamentous injuries and can be associated with ankle fractures. Syndesmotic injuries can create a diagnostic and therapeutic challenge for musculoskeletal physicians. Recent literature has added considerably to the body of knowledge pertaining to injury mechanics and treatment outcomes, but there remain a number of controversies regarding diagnostic tests, implants, techniques, and postoperative protocols. Use of the novel suture button device has increased in recent years and shows some promise in clinical and cadaveric studies. This article contains a review of syndesmosis injuries, including anatomy and biomechanics, diagnosis, classification, and treatment options.
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Affiliation(s)
- Kenneth J Hunt
- Department of Orthopaedic Surgery, Stanford University, 450 Broadway Street, MC 6342, Redwood City, CA, 94063, USA,
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McCollum GA, van den Bekerom MPJ, Kerkhoffs GMMJ, Calder JDF, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc 2013; 21:1328-37. [PMID: 23052109 DOI: 10.1007/s00167-012-2205-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 09/03/2012] [Indexed: 12/25/2022]
Abstract
PURPOSE Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete. METHODS A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed. RESULTS The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete. CONCLUSION Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.
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Affiliation(s)
- Graham A McCollum
- Chelsea and Westminister Hospital, 369 Fulham Road, London, SW10 9NH, UK.
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Hsu AR, Gross CE, Lee S. Intraoperative O-arm computed tomography evaluation of syndesmotic reduction: case report. Foot Ankle Int 2013; 34:753-9. [PMID: 23637241 DOI: 10.1177/1071100712468872] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Andrew R Hsu
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
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Markolf KL, Jackson SR, McAllister DR. Syndesmosis fixation using dual 3.5 mm and 4.5 mm screws with tricortical and quadricortical purchase: a biomechanical study. Foot Ankle Int 2013; 34:734-9. [PMID: 23405026 DOI: 10.1177/1071100713478923] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Grade 3 syndesmosis (high ankle) sprains of the ankle are frequently treated using screws that fix the distal fibula to the tibia. We hypothesized that forces acting on the distal fibula and displacements of the distal fibula relative to the tibia recorded during simulated ankle loading tests would be significantly affected by syndesmosis screw size and the number of engaged tibial cortices. METHODS Distal fibular forces and displacements were measured after cutting the distal inferior tibiofibular ligaments and fixing the distal fibula to the distal fibula with 2 syndesmosis screws. Screws of 3.5 mm and 4.5 mm were applied with tricortical and quadricortical purchase. RESULTS There were no significant differences in distal fibular forces or displacements between any combination of screw size and cortical purchase tested. The highest mean fibular force recorded in the study (110.2 N) occurred when 10 N-m of external foot torque was applied to a dorsiflexed ankle loaded with 1000 N axial weight-bearing force. For ankle dorsiflexion and external foot torque tests, the distal fibula always displaced posteriorly with respect to the tibia. Mean displacements of the fibula from 1000 N applied axial weight-bearing force (maximum 0.15 mm) and from 10 N-m of forced foot dorsiflexion (maximum 0.43 mm) were considerably less than those from 10 N-m external foot torque (1.7 mm to 2.7 mm). CONCLUSIONS Screw size and the number of engaged tibial cortices had no significant effect on mechanical stability of the distal fibula during these tests. Application of external foot torque (internal tibial torque) to a weight-bearing ankle produced the greatest bending displacements of the screws, and should be avoided during rehabilitation to reduce the possibility of screw breakage. CLINICAL RELEVANCE In terms of mechanical stability, surgeons may have considerable flexibility with regard to screw fixation of high ankle sprains.
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Affiliation(s)
- Keith L Markolf
- Biomechanics Research Section, Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1759, USA.
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Abstract
OBJECTIVE The goal of this investigation was to determine if obese patients with syndesmotic injuries have a higher incidence of early postoperative failure compared with nonobese patients. DESIGN Retrospective cohort study. SETTING Level 1 urban trauma center. PATIENTS AND METHODS Two hundred thirteen patients with operative syndesmotic injuries were divided into 2 cohorts: obese and nonobese. All syndesmotic injuries were confirmed by intraoperative stress testing, reduced, and stabilized with internal fixation. INTERVENTION Fixation of displaced syndesmosis injuries with solid 3.5- and 4.5-mm screws. MAIN OUTCOME MEASURES The primary outcome was early failure of fixation, defined as revision surgery within 3 months for ankle mortise and/or syndesmosis displacement. RESULTS Two hundred thirteen patients were identified with operative syndesmosis injuries, of which 102 (48%) were obese and 111 (52%) were nonobese. Fifteen percent (n = 15) of patients in the obese cohort sustained a failure of fixation compared with 1.8% (n = 2) of patients in the nonobese cohort (P = 0.0005). Diabetes mellitus, smoking status, and the type of construct used (eg, screw caliber, number of screws, and number of cortices) were not predictive of loss of reduction. Adjusting for injury severity, obese patients were 12 times more likely to suffer a loss of reduction compared with nonobese patients (odds ratio = 12.0, P = 0.02). CONCLUSIONS There is a strong association between obesity and loss of reduction after operative treatment of the syndesmosis. Further research is warranted to determine if a stronger mechanical construct or more conservative postoperative protocol can reduce the risk of loss of reduction in obese patients who sustain a syndesmotic injury.
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Stabilization of the syndesmosis in the Maisonneuve fracture--a biomechanical study comparing 2-hole locking plate and quadricortical screw fixation. J Orthop Trauma 2013; 27:212-6. [PMID: 22576647 DOI: 10.1097/bot.0b013e31825cfac2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study is to determine whether a 2-hole locking plate has biomechanical advantages over conventional screw stabilization of the syndesmosis in this injury pattern. METHODS Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. Each limb was compared with its pair; the syndesmosis in one being stabilized with two 4.5-mm quadricortical cortical screws, the other a 2-hole locking plate with 3.2-mm locking screws. The limbs were then mounted on a servohydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Fibula shortening and diastasis were measured. Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening, or axial migration >2 mm. RESULTS Both constructs effectively stabilized the syndesmosis during the cyclical loading within 0.1 mm of movement. However, the locking plate group demonstrated greater resistance to torque compared with quadricortical screw fixation (40.6 Nm vs. 21.2 Nm, respectively, P value < 0.03). CONCLUSION A 2-hole locking plate (with 3.2-mm screws) provides significantly greater stability of the syndesmosis to torque when compared with 4.5-mm quadricortical fixation.
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Schepers T, van Zuuren WJ, van den Bekerom MPJ, Vogels LMM, van Lieshout EMM. The management of acute distal tibio-fibular syndesmotic injuries: results of a nationwide survey. Injury 2012; 43:1718-23. [PMID: 22795845 DOI: 10.1016/j.injury.2012.06.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 05/22/2012] [Accepted: 06/17/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands. MATERIALS AND METHODS A postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw. RESULTS A total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the 'Hook test'. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1-4.0cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. CONCLUSION Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication.
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Affiliation(s)
- Tim Schepers
- Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Abstract
BACKGROUND Screw fixation of syndesmotic injuries facilitates ligament healing and restoration of ankle stability, but little information regarding screw performance is available. This study quantified the reduction obtained with three common 2-screw configurations using different methods of reduction and novel methods of subsequently provoking and measuring diastasis. METHODS Seven fresh-frozen lower extremities were subjected to 100 N medial and lateral tibia loads with the talus restrained. Tibia displacement, indicative of ankle clear space, was recorded. The syndesmosis and distal interosseous ligament were disrupted and measurements repeated. A pressure sensor was inserted into the syndesmosis and three 2-screw fixation methods were evaluated in each specimen: 3.5-mm screws engaging both fibula cortices and the lateral tibial cortex, inserted while using a clamp to achieve syndesmosis reduction; 3.5-mm lag screws engaging both tibia cortices; and 4.5-mm lag screws engaging both tibia cortices. One thousand 100 N medial and lateral loads were applied and clear space and syndesmosis compression were quantified every 100 cycles. RESULTS Normal ankle clear space averaged 1.98 mm and increased to 3.02 mm after syndesmosis disruption. Fixation decreased the clear space to 1.36 mm, 1.22 mm, and 1.19 mm for the 3.5-mm tricortical, 3.5-mm lag, and 4.5-mm lag screws, respectively, remaining steady throughout cyclic loading. Syndesmosis compression dropped markedly from 61N to 23 N on clamp release after tricortical screw insertion. The 3.5-mm and 4.5-mm lag screws exerted 112 N and 131 N, respectively, after insertion, and maintained compression several-fold greater than the tricortical screws during cyclic loading. No difference was demonstrable between the two lag screw sizes. CONCLUSION While all screw configurations successfully reduced ankle clear space, syndesmosis reduction was more effectively maintained by lag screws than by tricortical screws inserted with clamp reduction. The transient nature of compression achieved by the reduction clamp suggests that use of lag screws for this application may more reliably maintain syndesmosis reduction in vivo. CLINICAL RELEVANCE Optimizing reduction of syndesmosis injuries is critical for favorable outcomes. This study offers concrete information on screw performance in this application.
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Affiliation(s)
- Husam H Darwish
- Department of Orthopedic Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
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Rammelt S, Heim D, Hofbauer L, Grass R, Zwipp H. Probleme und Kontroversen in der Behandlung von Sprunggelenkfrakturen. Unfallchirurg 2011; 114:847-60. [DOI: 10.1007/s00113-011-1978-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Abstract
BACKGROUND A standard protocol for the management of syndesmosis injuries has yet to be established. Debate persists regarding number of screws, screw diameter, number of cortices purchased, and the need for and timing of screw removal. The purpose of this study was to identify factors related to screw fixation that may lead to the ultimate failure of syndesmosis fixation defined as a loss of reduction of the syndesmosis, screw breakage, screw loosening, or widening of the medial clear space. MATERIALS AND METHODS A retrospective assessment of 137 consecutive patients who underwent open reduction and internal fixation of the distal tibiofibular joint at a single institution from 2004 to 2008 was performed. Clinical and radiographic data were recorded regarding problems with questionable clinical significance (number of syndesmotic screws, number of cortices, screw diameter, screw location, hardware failure) and loss of syndesmosis reduction. A series of Fisher's exact tests were used to evaluate outcomes. A p value of 0.05 defined as significant. RESULTS The 3.5-mm diameter screws were statistically more likely to break than 4- or 4.5-mm screws, but there was no difference in frequency of loss of reduction of the syndesmosis as a function of screw diameter; however, a power study revealed an n value of 1656 would be required to show a significant difference. CONCLUSION Screw diameter may have an effect on screw breakage but clinical significance of hardware failure itself is unknown including whether or not it results in a loss of reduction or failure of syndesmotic fixation.
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Affiliation(s)
- Kyle Stuart
- Department of Orthopedics, University of Texas Medical Branch, UTMB Galveston, TX 77555-0165, USA
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