|
1
|
Mohammadzadeh Azarabadi J, Shalalfa N, Gökkuş K, Shalalfa S. Radiographic comparison of weight-bearing and non-weight-bearing positions in evaluating the distal tibiofibular syndesmosis: a single-center study of 72 ankles. J Orthop Surg Res 2025; 20:461. [PMID: 40369650 PMCID: PMC12076814 DOI: 10.1186/s13018-025-05886-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2025] [Accepted: 05/05/2025] [Indexed: 05/16/2025] Open
Abstract
INTRODUCTION The distal tibiofibular syndesmosis is a key structure for the ankle joint's stability and function, especially when the body is weight-bearing. Recent literature indicates that weight-bearing radiographs demonstrate superior diagnostic yield compared to non-weight-bearing radiographs. This study aimed to determine the diagnostic yield of the weight-bearing compared to the non-weight-bearing radiographs. MATERIALS AND METHODS A total of thirty-six healthy adult individuals, with an age group ranging from 18 to 65 years, who had never experienced any trauma, were selected for this study. We performed radiographic imaging in three planes of view: anterior-posterior, lateral, and mortise, for both ankles under both weight-bearing and non-weight-bearing conditions. The tibiofibular clear space, tibiofibular overlap, medial clear space, tibiofibular distance-lateral, anteroposterior tibiofibular ratio, and Lateral Tibial (LT) width were measured. RESULTS Tibiofibular clear space and anteroposterior tibiofibular ratio were higher in the weight-bearing position, while tibiofibular overlap, medial clear space, and lateral tibiofibular distance were higher in the non-weight-bearing position. There was a gender effect, as males had higher values for most of the parameters; however, no significant difference was seen in the anteroposterior tibiofibular ratio and tibiofibular distance lateral. The results of this study demonstrate that X-rays of the distal tibiofibular syndesmosis reveal very different outcomes when the person is bearing weight or not pulling weight. These clinically significant differences suggest that weight-bearing radiographs may enhance the identification and diagnosis of syndesmotic injuries. Further studies will be necessary to help with the refinement of the imaging protocols and to improve diagnostic accuracy based on various types of patient demographics. CONCLUSION WB radiographs provide a more functionally accurate assessment of syndesmotic integrity than NWB imaging. They should be incorporated into routine diagnostic protocols, especially for active individuals and those with higher BMI. These findings support the need for demographic-specific imaging strategies to improve diagnostic precision.
Collapse
Affiliation(s)
| | - Neveen Shalalfa
- Palestine Polytechnic University, Hebron, Occupied Palestinian Territory
| | | | - Saleh Shalalfa
- Alquds University, Palestine, Ramallah, Occupied Palestinian Territory
| |
Collapse
|
|
2
|
Abstract
Syndesmotic instability or malreduction is an independent risk factor for an impaired patient-rated outcome. If a syndesmotic injury is suspected, a stepwise diagnostic approach including plane radiographs, MRI, and bilateral stress radiographs should be conducted to differentiate stable from latent unstable and frank diastasis cases. The basic requirement for any surgical treatment approach is a stable and anatomically reduced distal tibio-fibula joint. The best treatment approach for a 2-ligament injury (anterior inferior tibio-fibular ligament [AiTFL] + interosseous ligament [IOL]) seems to be the suture-button system, for a 3-ligament injury (AiTFL + IOL + posterior inferior tibio-fibular ligament), 2 fixation devices.
Collapse
Affiliation(s)
- Sebastian F Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Ziemssenstraße 5, Munich 80336, Germany.
| | - Fabian T Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Ziemssenstraße 5, Munich 80336, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Ziemssenstraße 5, Munich 80336, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Ziemssenstraße 5, Munich 80336, Germany
| |
Collapse
|
|
3
|
Aktan C, Kose O. A novel alphanumeric classification system for ankle fractures: clinical applications and evaluation. J Orthop Surg Res 2025; 20:130. [PMID: 39901191 PMCID: PMC11789300 DOI: 10.1186/s13018-025-05539-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2024] [Accepted: 01/23/2025] [Indexed: 02/05/2025] Open
Abstract
PURPOSE The purpose of this study was to introduce and evaluate the Descriptive Ankle Fracture Classification (DAFC) system, a novel alphanumeric method for categorizing ankle fractures and fracture dislocations, and to assess its reliability and prognostic value compared to traditional classification systems (AO/OTA, Weber, and Lauge-Hansen). MATERIALS AND METHODS A retrospective review was conducted on 90 patients who underwent surgical treatment for ankle fractures. Four observers of varying experience levels classified the fractures using the DAFC, AO/OTA, Weber, and Lauge-Hansen classification systems. Interobserver and intraobserver reliability were evaluated using Fleiss' Kappa coefficient. Functional outcomes were assessed with the American Orthopaedic Foot & Ankle Society (AOFAS) and Olerud Molander Ankle Score (OMAS) systems, and comparisons were made across classification systems to determine prognostic value. RESULTS The DAFC system demonstrated superior interobserver reliability, particularly for medial malleolus fractures (Kappa = 0.935-0.954) and syndesmotic injuries (Kappa = 0.873-0.891), compared to the other systems. Intraobserver reliability was consistently high across all categories in the DAFC system, with Kappa values ranging from 0.967 to 1.000. Functional outcomes revealed significant associations with the DAFC classification: patients with complete dislocation (D2) had significantly lower AOFAS and OMAS scores than those without dislocation (D0) (P = 0.011), and those with larger posterior malleolus fractures (P2) had poorer OMAS scores (P = 0.014). No statistically significant differences in AOFAS or OMAS scores were observed across AO/OTA, Weber, or Lauge-Hansen classifications. CONCLUSIONS The DAFC system offers a reliable and comprehensive framework for ankle fracture classification, with the added benefit of prognostic insights, particularly regarding dislocation and posterior malleolus involvement. Its high interobserver and intraobserver reliability, even among observers with varying experience, suggests that the DAFC system is valuable for clinical use. Future research should focus on validating these findings in larger cohorts and assessing the DAFC system's impact on long-term patient outcomes. LEVEL OF EVIDENCE Level IV, Retrospective cohort.
Collapse
Affiliation(s)
- Cemil Aktan
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey.
| |
Collapse
|
|
4
|
Yao X, Wang C, Pan W, Chao Y, Tang J. Ankle syndesmotic ligaments avulsion fractures: incidence in adult population. J Orthop Surg Res 2024; 19:642. [PMID: 39395996 PMCID: PMC11470608 DOI: 10.1186/s13018-024-05156-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2024] [Accepted: 10/06/2024] [Indexed: 10/14/2024] Open
Abstract
BACKGROUND Distal tibiofibular syndesmosis injury is often associated with ankle fractures in adults. Injuries to the anterior/posterior inferior tibiofibular ligament (AITFL/PITFL) may present as a mid-substance tear or as an avulsion at insertion. Tibial and fibular avulsion of the AITFL is known as Tillaux fracture and Wagstaffe fracture, respectively. Tibial avulsion of the PITFL is referred to as a Volkmann fracture, and fibular avulsion of the PITFL is still undefined and has not been reported yet. The aim of this study is to summarize the incidence of these four avulsions, that is, tibial and fibular avulsions of the AITFL and PITFL. METHOD Radiography and computed tomography (CT) imaging data of all adult patients with ankle fractures treated at our hospital between November 2010 and March 2023 were retrospectively analyzed. All ankle fractures were classified according to the Weber-AO and Lauge-Hansen classification systems by two experienced radiologists and two surgeons. The incidence of the four avulsions of the AITFL/PITFL was determined. RESULTS In total, 1,770 ankle fractures in 1,758 patients were included in this study. The total incidence of avulsions at the four insertions of the AITFL/PITFL (occurring at one, two, or three insertions) was found to be 26.3% (465/1,770). Volkmann fracture had the highest incidence (19.9%, 353/1,770), and it was followed by Tillaux fracture (5.3%, 93/1,770), Wagstaffe fracture (3.3%, 59/1,770), and fibular avulsion of the PITFL (0.5%, 8/1,770). It is noteworthy that fibular avulsion of the PITFL has been reported here for the first time. The incidence of avulsion at one insertion was 23.6% (418/1770) and 2.7% (47/1770) at multiple insertions. CONCLUSION In adult ankle fractures, avulsion occurs at the four insertions of the AITFL/PITFL in more than 25% of patients. The tibial insertion of the PITFL had the highest incidence of avulsion among the four insertions, while the fibular insertion of the PITFL had the lowest. The four types of avulsions can be isolated or in association with other avulsions. Future research studies on these four types of avulsion fractures would help in accurate diagnosis, decision-making and treatment of ankle Syndesmosis injuries. LEVEL OF EVIDENCE Level III, retrospective cohort study.
Collapse
Affiliation(s)
- Xiang Yao
- Department of Orthopaedics, The Affiliated People's Hospital of Jiangsu University, Zhenjiang, Jiangsu, 212001, China
| | - Chong Wang
- Jiangsu University, Zhenjiang, Jiangsu, 212001, China
| | - Weijie Pan
- Jiangsu University, Zhenjiang, Jiangsu, 212001, China
| | - Yicong Chao
- Jiangsu University, Zhenjiang, Jiangsu, 212001, China
| | - Jilei Tang
- Department of Orthopaedics, Qidong Hospital of Traditional Chinese Medicine, Nantong, Jiangsu, 226200, China.
| |
Collapse
|
|
5
|
Sharma A, Wyatt PB, Reiter CR, Anastasio A, Satalich J, O'Neill CN, Patel T, Hanselman A, Adams S, Liles J, Schweitzer K. Readmission within 30-days of open reduction and internal fixation for ankle fractures: NSQIP analysis of 29,905 patients. J Orthop Surg Res 2024; 19:576. [PMID: 39294650 PMCID: PMC11409759 DOI: 10.1186/s13018-024-04895-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 07/03/2024] [Indexed: 09/21/2024] Open
Abstract
BACKGROUND Historically, ankle fractures have been treated with open reduction and internal fixation (ORIF) procedures, which are considered safe and effective. Patient characteristics may contribute to postoperative difficulties thereby increasing risk of hospital readmission. The objective of this study was to determine the frequency of and reasons for 30-day readmission and postoperative complications following ORIF for ankle fractures. METHODS A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2015 to 2021 identified patients undergoing ORIF for ankle fractures. Patient demographics, complication incidence, and reasons for unplanned hospital readmission were collected. Multivariable analyses identified patient risk factors for any adverse event (AAE) and readmission within 30-days of surgery. RESULTS The 29,905 patients queried who underwent ORIF procedures for ankle fractures between 2015 and 2021 were 49.6 ± 18.40 years of age, 30.9 ± 7.10 kg/m2, and 40.81% male. Of this cohort, 981 (3.30%) experienced 30-day postoperative adverse events, with surgical site infections (SSI; 1.25%) the most common. Unplanned readmission was observed in 2.08% of patients after a mean of 14.64 days. Surgical site related readmissions were 20.55% (n = 128) of reported readmissions with the most common being superficial incisional SSI. Notable risk factors for adverse events included ASA class (OR = 1.579, P < .001), COPD (OR = 1.522, P < .001), bleeding disorders (OR = 1.489, P = .001), diabetes (OR = 1.254, P = .008), and current smoking status (OR = 1.295, P = .002). Risk factors for readmission were ASA class (OR = 1.762, P < .001), COPD (OR = 1.599, P < .001), bleeding disorder (OR = 1.711, P < .001), diabetes (OR = 1.494, P < .001), end stage renal disease (OR = 3.304, P < .001), steroid use (OR = 2.144, P < .001), and current smoking status (OR = 1.667, P < .001). CONCLUSION Despite a low adverse event rate, 2% of patients required unplanned readmission after ORIF for ankle fractures. Surgical site complications account for almost half of reported readmissions. ASA class and various medical comorbidities were found to significantly increase the risk of postoperative adverse events and hospital readmission.
Collapse
Affiliation(s)
- Aadi Sharma
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
- , Richmond, VA, USA.
| | - Phillip B Wyatt
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Charles R Reiter
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Albert Anastasio
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - James Satalich
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Conor N O'Neill
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Tejas Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA.
| | - Andrew Hanselman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Samuel Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Liles
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Karl Schweitzer
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
|
6
|
Knapik DM, Gopinatth V, Jackson GR, LaPrade RF, Chahla J, Brophy RH, Matava MJ, Smith MV. Isolated, Proximal Tibiofibular Injuries in Athletic Patients: A Critical Analysis Review. J Knee Surg 2024; 37:773-783. [PMID: 38677295 DOI: 10.1055/a-2315-7691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
While infrequently reported, isolated injuries to the proximal tibiofibular (TF) joint primarily occur in young, athletic patients participating in sporting activities requiring explosive, high-impact movements, increasing the risk for potential twisting injuries, especially across a hyperflexed knee. The proximal TF joint is stabilized by bony, muscular and ligamentous structures, including both the anterior and posterior proximal TF complexes, with the anterior complex providing more robust stability. Proximal TF injuries frequently involve anterior and lateral displacement of the proximal fibula relative to its native articulation with the tibia. Proper diagnosis is dependent on careful and meticulous history and physical examination, as missed injuries are common, leading to the potential for continued pain, weakness and disability, especially in athletic patients. While spontaneous joint reduction has been reported, injuries may require formal closed reduction, with irreducible and chronic injuries requiring open reduction and stabilization, with recent investigations reporting satisfactory outcomes following anatomic reconstruction of the proximal TF ligament.
Collapse
Affiliation(s)
- Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Gopinatth
- St. Louis University School of Medicine, St. Louis, Missouri
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | | | - Jorge Chahla
- Department of Orthopaedic Surgery, Midwest Orthopaedics at Rush University, Chicago, Illinois
| | - Robert H Brophy
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew J Matava
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew V Smith
- Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, Missouri
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
|
7
|
Calek AK, Ongini E, Hochreiter B, Sutter R, Wirth SH, Beeler S. The Contralateral Ankle Joint Is a Reliable Reference for Testing Syndesmotic Stability Using Bilateral External Torque CT. Foot Ankle Int 2024; 45:1018-1026. [PMID: 39075760 PMCID: PMC11391660 DOI: 10.1177/10711007241262771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
BACKGROUND Subtle chronic or latent instabilities are difficult to delineate with currently available diagnostic modalities and do not allow assessment of ligamentous functionality. The noninvasive bilateral external torque computed tomography (CT) was able to reliably detect syndesmotic lesions in a cadaveric study. The aim of the study was to test the external torque device in young, healthy subjects at 3 different torque levels and to demonstrate comparability with the contralateral side. METHODS Ten healthy subjects without history of injury or surgery to the ankle joint were enrolled in this cross-sectional study. Four CT scans were performed. During the scans, the lower legs and feet were placed in an external torque device with predefined external rotation torques of 0, 2.5, 5, and 7.5 Nm. Five different radiographic measures of syndesmotic stability were measured: anterior distance (AD), tibiofibular clear space (TCS), posterior distance (PD), external rotation (ER), and β angle. RESULTS With increasing external torque, slight increases in AD, ER, and β angle were observed, whereas TCS and PD decreased slightly. Large absolute differences were found between the healthy subjects for all measured parameters, regardless of the external torque applied. Differences from the contralateral side using the same external torque were minimal for all parameters, but smallest for AD with a maximum difference of 0.5 mm. CONCLUSION Using the healthy contralateral ankle joint is appropriate for assessing syndesmotic stability based on minimal intraindividual side differences using the external torque device. Side differences >0.5 mm in AD and >0.9 mm in PD may be considered abnormal and may indicate significant instability of the syndesmosis. However, future studies are needed to define definitive cutoff values for relevant side differences in acute and chronic syndesmotic instability to guide clinicians in their treatment decisions.
Collapse
Affiliation(s)
- Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Esteban Ongini
- Institute of Biomechanics, Balgrist Campus, ETH Zurich, Zurich, Switzerland
| | - Bettina Hochreiter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Stephan H Wirth
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Silvan Beeler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
|
8
|
Voight ML, Norman C, Wilk KE, Lucas M, Wolfe C. Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play. Int J Sports Phys Ther 2024; 19:513-521. [PMID: 38707856 PMCID: PMC11065778 DOI: 10.26603/001c.116862] [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: 05/07/2024] Open
Abstract
The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice. Level of Evidence V.
Collapse
|
|
9
|
Sanda II, Hosin S, Vermesan D, Deleanu B, Pop D, Crisan D, Al-Qatawneh M, Mioc M, Prejbeanu R, Rosca O. Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2048. [PMID: 38138151 PMCID: PMC10744725 DOI: 10.3390/medicina59122048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.
Collapse
Affiliation(s)
- Isabella-Ionela Sanda
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania;
- Department of Laboratory Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Samer Hosin
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania;
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Dinu Vermesan
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Bogdan Deleanu
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Daniel Pop
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Dan Crisan
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Musab Al-Qatawneh
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Mihai Mioc
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Radu Prejbeanu
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Ovidiu Rosca
- Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
| |
Collapse
|
|
10
|
Li Y, Luo R, Li B, Xia J, Zhou H, Huang H, Yang Y. Analysis of the epidemiological characteristics of posterior malleolus fracture in adults. J Orthop Surg Res 2023; 18:507. [PMID: 37464426 DOI: 10.1186/s13018-023-04007-w] [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] [Received: 05/15/2023] [Accepted: 07/13/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND This study explores the latest epidemiological characteristics of posterior malleolus fracture and compares the epidemiological differences of posterior malleolus fracture in different periods, regions, and adult age groups. METHODS Clinical information of inpatients with posterior malleolus fracture in Shanghai Tongji Hospital and Karamay Central Hospital from January 2014 to February 2022 was reviewed and collected. The imaging data of patients were acquired using the Picture Archiving and Communication Systems. A statistical analysis was performed as to gender, current age, year of admission, injury mechanism, fracture type, and posterior malleolus fracture classification. Moreover, a comparative analysis was conducted on the injury mechanisms and morphological differences of posterior malleolus fracture at different periods, regions, and age groups. RESULTS A total of 472 patients (210 patients from Shanghai Tongji Hospital and 262 patients from Karamay Central Hospital) with posterior malleolus fracture and an average age of 48.7 ± 15.6 were included in this study. The peak of posterior malleolus fracture occurs in the age group of 50-59. The injury mechanisms mainly involve low-energy fall and sprain (411 cases, 87.1%), followed by traffic accidents (52 cases, 11.0%), and fall injury from height (9 cases, 1.9%). With aging, the number of fall and sprain cases increases and reaches the peak at the age of 50-59, followed by progressive decline. Traffic accidents presents a relatively flat small peak in the age group of 40-59. The number of cases according to different fracture types shows the following ascending order: trimalleolar fracture-supination external rotation (335 cases, 71.0%) > bimalleolar fracture (60 cases, 12.7%) > trimalleolar fracture-pronation extorsion (43 cases, 9.1%) > posterior malleolus + tibial shaft fracture (19 cases, 4.0%) > simple posterior malleolus fracture (15 cases, 3.2%). The numbers of cases corresponding to the Haraguchi I Type, II Type, and III Type of posterior malleolus fractures were 369 (78.2%), 49 (10.4%), and 54 (11.4%), respectively. The Tongji IIA Type represented the highest number of cases (249 cases, 52.8%), followed by the IIB Type (120 cases, 25.4%), I Type (54 cases, 11.4%), IIIB Type (36 cases, 7.6%), and IIIA type (13 cases, 2.8%). The trimalleolar fracture-supination external rotation, Haraguchi I Type and Tongji IIA Type of posterior malleolus fractures all presented an obvious peak of incidence in the age group of 50-59. However, no obvious statistical difference was observed in the injury mechanism, Haraguchi classification, and Tongji classification of posterior malleolus fractures among different years and regions in recent years (P > 0.05). CONCLUSIONS The injury mechanism of posterior malleolus fracture mainly involves low-energy fall and sprain cases. The trimalleolar fracture-supination external rotation, Haraguchi I type and Tongji IIA type of posterior malleolus fracture are predilection fracture types, and all present an obvious incidence peak in the age group of 50-59. Elderly patients have high risks of falling and their bones are more fragile, conditions which are potential risk factors of posterior malleolus fracture. Early positive control has important significance. This study provides references for relevant basic and clinical studies of posterior malleolus fracture.
Collapse
Affiliation(s)
- Yongqi Li
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
- Department of Orthopedics, Karamay Central Hospital, Karamay, 834000, China
| | - Rui Luo
- Department of Neurology, Karamay Central Hospital, Karamay, 834000, China
| | - Bing Li
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Jiang Xia
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Haichao Zhou
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Hui Huang
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China
| | - Yunfeng Yang
- Department of Orthopedics, Tongji Hospital, School of Medicine, Tongji University, Shanghai, 200065, China.
| |
Collapse
|
|
11
|
Wu C, Wang X, Zhang H, Xie S, He J. Biomechanical analysis of different internal fixation methods for special Maisonneuve fracture of the ankle joint based on finite element analysis. Injury 2023:110917. [PMID: 37400327 DOI: 10.1016/j.injury.2023.110917] [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] [Received: 03/13/2023] [Revised: 06/15/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the biomechanical properties of different internal fixation methods for Maisonneuve fractures under physiological loading conditions. METHODS Finite element analysis was used to numerically analyze various fixation methods. The study focused on high fibular fractures and included six groups of internal fixation: high fibular fracture without fixation + distal tibiofibular elastic fixation (group A), high fibular fracture without fixation + distal tibiofibular strong fixation (group B), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation (group C), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular strong fixation (group D), high fibular fracture with 5-hole plate internal fixation + distal tibiofibular elastic fixation (group E), and high fibular fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation (group F). The finite element method was employed to simulate and analyze the different internal fixation models for the six groups, generating overall structural displacement and Von Mises stress distribution maps during slow walking and external rotation motions. RESULTS Group A demonstrated the best ankle stability under slow walking and external rotation, with reduced tibial and fibular stress after fibular fracture fixation. Group D had the least displacement and most stability, while group A had the largest displacement and least stability. Overall, high fibular fracture fixation improved ankle stability. In slow walking, groups D and A had the least and greatest interosseous membrane stress. Comparing 5-hole plate (E/F) and 7-hole plate (C/D) fixation, no significant differences were found in ankle strength or displacement under slow walking or external rotation. CONCLUSION Combining internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula is optimal for orthopedic treatment. It yields superior outcomes compared to no fibular fracture fixation or strong fixation of the lower tibia and fibula, especially during slow walking and external rotation. To minimize nerve damage, a smaller plate is recommended. This study strongly advocates for the clinical use of 5-hole plate internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula (group E).
Collapse
Affiliation(s)
- Chaomeng Wu
- Jiangxi university of Traditional Chinese Medicine, Nanchang 33004, China
| | - Xingyu Wang
- Jiangxi Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanchang 33003, China
| | - Hao Zhang
- Jiangxi Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanchang 33003, China
| | - Shuihua Xie
- Jiangxi Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanchang 33003, China
| | - Jianhua He
- Jiangxi Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Nanchang 33003, China.
| |
Collapse
|
|
12
|
Baxter S, Farris E, Johnson AH, Brennan JC, Friedmann EM, Turcotte JJ, Keblish DJ. Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of Interosseous Suture and Endobutton Across Age Groups. Cureus 2023; 15:e40355. [PMID: 37456394 PMCID: PMC10339668 DOI: 10.7759/cureus.40355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.
Collapse
Affiliation(s)
| | - Eleanor Farris
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | | | - Jane C Brennan
- Orthopedic Research, Anne Arundel Medical Center, Annapolis, USA
| | | | | | - David J Keblish
- Orthopedic Surgery, Anne Arundel Medical Center, Annapolis, USA
| |
Collapse
|
|
13
|
Zhao Y, Chen W, Su T, Zhou G, Jiang D, Yuan H. Comparison of the diagnostic value of measurements of transverse syndesmotic interval and 'lambda sign' in distinguishing latent syndesmotic diastasis in chronic lateral ankle instability: a cross-sectional study of 188 cases. Arch Orthop Trauma Surg 2023; 143:2037-2045. [PMID: 35729435 DOI: 10.1007/s00402-022-04500-7] [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] [Received: 01/20/2022] [Accepted: 05/28/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Chronic lateral ankle instability (CLAI) could accompany with latent syndesmotic diastasis (LSD), which is difficult to distinguish before surgery. Tibiofibular interval width and extravasation of joint fluid ('lambda sign') on MRI are widely used in the diagnosis of syndesmotic injury, but the reliability of these methods in distinguishing the associated LSD in CLAI was rarely studied. Our objective was to compare the diagnostic value of the measurement of the transverse tibiofibular interval and 'lambda sign' on MRI in distinguishing LSD in CLAI and to investigate the radiological predictor that best matched the intraoperatively measured syndesmotic width. METHODS 138 CLAI patients undergoing arthroscopy in our institute from March 2017 to June 2020 were enrolled (CLAI group). Anterior space width (ASW) and posterior space width (PSW) at 10 mm layer above tibial articular and fluid height above tibial articular surface (FH) were measured on preoperative MRI. The same parameters were measured on MRI of 50 healthy volunteers as control group. At arthroscopy, syndesmotic width was measured and the patients were divided into arthroscopic widening (AW) and arthroscopic normal (AN) subgroup taking 2 mm as critical value. The CLAI group was compared with the control group to explore the interval changes related to CLAI. The AW and AN subgroups were compared to explore the potential diagnostic indicators and reference values for the LSD. RESULTS All parameters showed significant difference between CLAI group and control group (p < 0.05), but only PSW (p = 0.004) showed significant difference between AW and AN subgroups other than FH (p = 0.461). Only PSW was involved in formula of multiple-factor analysis (p = 0.005; OR, 1.819; 95%CI, 1.196-2.767). ROC analysis showed critical value of PSW was 3.8 mm (sensitivity, 66%; specificity, 66%; accuracy, 66.7%), while accuracy of lambda sign was 41.3%. CONCLUSIONS Transverse tibiofibular interval measurements were more reliable than the 'lambda sign' in distinguishing associated LSD in CLAI patients. The PSW ≥ 3.8 mm could be a predictor of syndesmotic diastasis.
Collapse
Affiliation(s)
- Yuqing Zhao
- Radiology Department, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Wen Chen
- Radiology Department, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Tong Su
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Guangjin Zhou
- Radiology Department, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China
| | - Dong Jiang
- Department of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital. Institute of Sports Medicine of Peking University, No.49 North Garden Road, Haidian, Beijing, 100191, China.
| | - Huishu Yuan
- Radiology Department, Peking University Third Hospital, No.49 North Garden Road, Haidian, Beijing, 100191, China.
| |
Collapse
|
|
14
|
Comparison of a Novel Modified All-Suture Construct versus Suspensory Suture-button Fixation in a Syndesmotic Injury Model. J Orthop Trauma 2023; 37:e104-e110. [PMID: 36219777 DOI: 10.1097/bot.0000000000002503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To biomechanically investigate a novel modified all-suture construct compared with commercially available suspensory button fixation for stabilization of the syndesmosis. METHODS Eight matched pairs of cadaver lower limbs were obtained. We used a material testing machine and Optotrak optoelectronic 3D motion measurement system for testing. Syndesmotic injuries were simulated, and specimens were fixed with either a suspensory suture button or modified all-suture construct. Repaired specimens were then cyclically loaded for 500 cycles. Spatial relationship of the tibia and fibula were continuously monitored for the intact, destabilized, and repaired states. The results were analyzed using independent samples t test. RESULTS There was no significant difference in sagittal or coronal plane translation between intact and either repair. Compared with the intact state, both repair techniques demonstrated significantly more external rotation of the fibula relative to the tibia and decreased construct stiffness. Cycling of the specimens did not significantly increase coronal or sagittal plane translation; however, external rotation of the fibula relative to the tibia increased and stiffness decreased with cycling for both repair techniques. CONCLUSIONS Our data suggest that sagittal and coronal plane translation is no different from the intact state for both fixation techniques. However, rotation of the fibula relative to the tibia was increased, and construct stiffness was decreased compared with the intact state for both fixation techniques. These findings suggest that an all-suture construct could offer syndesmotic fixation comparable with proprietary suspensory button fixation in a cadaver model.
Collapse
|
|
15
|
Cost-effectiveness of on-demand removal of syndesmotic screwsx. Eur J Trauma Emerg Surg 2022; 49:921-928. [PMID: 36372813 PMCID: PMC10175308 DOI: 10.1007/s00068-022-02158-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022]
Abstract
Abstract
Purpose
Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw.
Methods
Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs.
Results
Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p < 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness.
Conclusion
The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.
Collapse
|
|
16
|
Guedes S, Sousa-Pinto B, Torres J. Radiological outcomes of bimalleolar fractures: Are timing of surgery and type of reconstruction important? Orthop Traumatol Surg Res 2022; 108:103314. [PMID: 35568298 DOI: 10.1016/j.otsr.2022.103314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 09/06/2021] [Accepted: 01/31/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The goal of open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is to reconstitute ankle anatomy. The most commonly used radiological parameters to assess adequacy of reduction are talocrural angle (TCA), medial clear space (MCS), tibiofibular overlap (TFO) and tibiofibular clear space (TFCS). There is little research about the radiological outcomes of surgery in bimalleolar fractures. We aimed at assessing the adequacy of ORIF and the factors involved in anatomical restoration (specifically time to surgery), postoperatively and at follow-up. METHODS TCA, MCS, TFO and TFCS were measured in preoperative and postoperative radiographs of 107 bimalleolar ankle fractures and in 83 follow-up radiographs, accounting for a total of 297 radiographs and 1182 measurements. Preoperative radiographs were categorized according to Danis-Weber classification. For all included cases, basic demographic data, dates of radiographs and surgery, and type of fixation used were acquired. Variables associated with postoperative and follow-up total anatomical reconstitution (i.e., when the four assessed radiological parameters were normalized), normalization of each radiological parameter, and improvement in the number of normalized radiological parameters were identified through univariable Cox regression analysis. RESULTS In our sample, 23.8% of the ankle fractures in postoperative radiographs and 28% in follow-up radiographs achieved a complete anatomical restoration. Type C fractures (hazard ratio [HR]=0.1, 95% confidence interval [CI]=0.02-0.7, P=0.021) were associated with lower chances of total anatomical reconstitution. The use of reconstruction plates (HR=0.1, 95% CI=0.03-0.7, P=0.014) and one third tubular plates (HR=0.2, 95% CI=0.03-0.8, P=0.026) decreased the chances of improving the number of normalized radiological parameters. Waiting days until surgery impaired total anatomical reconstitution (HR=0.8, 95% CI=0.6-0.9, P=0.012) and also reduced the chances of improving the number of normalized radiological parameters (HR=0.9, 95% CI=0.9-1.0, P=0.045). CONCLUSION The radiological results for the treatment of bimalleolar fractures are time sensitive, and surgery should thus be performed as soon as possible, using adequate fixation materials, in order to achieve a better restoration of ankle anatomy. LEVEL OF EVIDENCE IV, retrospective study.
Collapse
Affiliation(s)
- Sara Guedes
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Bernardo Sousa-Pinto
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Torres
- Faculty of Medicine, University of Porto, Porto, Portugal; Orthopaedics and Traumatology Department, Centro Hospitalar de São João, E.P.E., Porto, Portugal
| |
Collapse
|
|
17
|
Kang L, Helms E, Broadhead M. Bilateral ankle syndesmosis injury: a rare case report. Orthop Rev (Pavia) 2022. [DOI: 10.52965/001c.35494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This report describes a case of bilateral acute ankle syndesmosis injuries in a 15-year-old male basketball player. The patient had a background of previous inversion injuries but no symptoms of chronic pain or instability. The case report illustrates the importance of clinical suspicion when evaluating acute syndesmosis injuries in conjunction with radiographic assessments in primary care. This is the first reported case of such injury in bilateral limbs.
Collapse
|
|
18
|
Lee J, Lee HS, Kim JW, Lee BS, Choi Y. Radiographic parameters of the normal ankle syndesmosis: Comparison between hindfoot alignment view and anteroposterior view. J Int Med Res 2022; 50:3000605221098862. [PMID: 35570658 PMCID: PMC9112776 DOI: 10.1177/03000605221098862] [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: 11/16/2022] Open
Abstract
OBJECTIVE To compare the parameters associated with the normal ankle syndesmosis between the hindfoot alignment view (HAV) and anteroposterior (AP) view and determine which view is more accurate for comparing the left and right ankles. METHODS This study involved 61 subjects without syndesmosis injury who had radiographs of both ankles. The tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS) were measured in each view. Intraclass correlation coefficients were used to assess the agreement between the two ankles. Difference ratios for the measured parameters between the ankles were also compared. RESULTS The agreement for TFCS showed wide disparity between the two ankles (AP view, 0.576; HAV, 0.858). The highest degree of agreement was seen for TFO (AP view, 0.733; HAV, 0.926). The agreement for MCS was low in both groups. The mean difference ratio for TFCS was also lower in the HAV group (9.9%) than in the AP view group (16.4%); a similar result was observed for TFO (16.4% vs. 25.8%). CONCLUSIONS For evaluation of the syndesmosis, use of the HAV showed increased accuracy and few measurement errors when comparing the left and right ankles relative to use of the AP view.
Collapse
Affiliation(s)
- Jaehyung Lee
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi-do, Republic of Korea
| | - Ho Seong Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Bum-Sik Lee
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Youngrak Choi
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
|
19
|
Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med 2022; 11:jcm11020331. [PMID: 35054025 PMCID: PMC8780481 DOI: 10.3390/jcm11020331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.
Collapse
|
|
20
|
Elabd A, Abdullah S, Kandel W, Hegazy M. Syndesmotic Stabilization: Syndesmotic Screw Versus Flexible Fixation: A Systematic Review. J Foot Ankle Surg 2021; 60:998-1007. [PMID: 33846031 DOI: 10.1053/j.jfas.2020.09.021] [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: 05/24/2019] [Revised: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 02/03/2023]
Abstract
Syndesmotic injuries are common injuries that occur in isolation or associated with ankle fractures. The suture button device fixation (SBDF) has become increasingly attractive to orthopedic surgeons as an alternative to metallic screw fixation (MSF) for syndesmotic fixation. This review involved the highest-quality clinical biomechanical and cost analysis studies to provide a comprehensive review. A literature search in the electronic databases was conducted to identify clinical, biomechanical as well as cost analysis studies in which the MSF was compared to SBDF from 1990 to 2018. Only comparative clinical studies with a level of evidence I or II were included besides any comparative biomechanical or cost analysis study. The (PRISMA) guidelines were followed. Eight clinical, 11 biomechanical, and 3 cost analysis studies were included. The clinical studies consisted of 5 randomized controlled trials (RCTs) and 3 cohort studies. The average American Orthopaedic Foot and Ankle Society score for the SBDF group was (92.4) compared to (86.6) for the MSF group at 1 year follow-up. SBDF group showed a lower rate of malreduction, implant removal, implant failure, and complications. The biomechanical studies showed better reduction accuracy in the SBDF group. The reduction maintenance was comparable in the coronal plane but not in the sagittal plane. The cost-effectiveness of the SBDF was highly dependent on the difference in implant removal rate. In conclusion, the SBDF showed comparable to better outcomes compared to the MSF. It may be a better option for syndesmotic fixation.
Collapse
Affiliation(s)
- Ahmed Elabd
- Department of Orthopaedic Surgery, Banha School of Medicine, Banha, Egypt.
| | - Samir Abdullah
- Department of Orthopaedic Surgery, Banha School of Medicine, Banha, Egypt
| | - Wael Kandel
- Department of Orthopaedic Surgery, Banha School of Medicine, Banha, Egypt
| | - Mohamed Hegazy
- Department of Orthopaedic Surgery, Banha School of Medicine, Banha, Egypt
| |
Collapse
|
|
21
|
Brand J, Moran J, Yoo B. Vector Appropriate Distraction and Reduction of a Neglected Trimalleolar Fracture-Dislocation Performed with a Temporary Intraoperative External Fixator. Case Rep Orthop 2021; 2021:5577626. [PMID: 34336330 PMCID: PMC8286194 DOI: 10.1155/2021/5577626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
Traumatic fractures of the ankle can occur with concomitant tibiotalar dislocations, necessitating complex treatment. These injuries have higher rates of loose bodies, open injuries, postoperative complications, and worse patient reported outcomes compared to ankle fractures without dislocation. Patients with neglected or delayed presentations are associated with even higher rates of postoperative complications and worse outcomes compared to acute injuries. The chronicity of the injury leads to soft tissue contractures and malunited fractures, obligating a care plan which involves gradual reduction with a multiplanar external fixator with or without internal fixation at a later date. We discuss a 60-year-old homeless man who presented four weeks after an open trimalleolar fracture-dislocation and was definitely treated with an acute one-stage procedure. Anatomic reduction and stable fixation was achieved through a lateral malleolus osteotomy, soft tissue releases, TAL, and a temporary intraoperative external fixator. This technique was advantageous in this instance of anticipated patient noncompliance. We advocate for the judicious use of the described technique in similar challenging situations.
Collapse
Affiliation(s)
- Jordan Brand
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, CT, USA
| | - Jay Moran
- Yale School of Medicine, New Haven, CT, USA
| | - Brad Yoo
- Yale School of Medicine, Department of Orthopaedics and Rehabilitation, New Haven, CT, USA
| |
Collapse
|
|
22
|
Gourbault LJ, Fennelly JT, Stedman T, Price MJ, Ward AE. The Current UK Consensus on the Management of Weber B and Posterior Ankle Fractures: A Questionnaire Study as Part of the Acute Management of Ankle Fractures (AUGMENT) Audit. J Foot Ankle Surg 2021; 60:669-675. [PMID: 33573901 DOI: 10.1053/j.jfas.2020.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 03/31/2020] [Accepted: 04/18/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are common conditions which are associated with significant morbidity when managed incorrectly. With the incidence due to triple by 2030, standards of practice were created by the British Orthopaedic Association and the British Orthopaedic Foot and Ankle Society to ensure optimal treatment. In spite of this, anecdotally there is still a variation in practice and therefore a questionnaire study was designed to explore clinician decision-making around Weber B and Posterior Malleolus ankle fractures. Five scenarios explored management regarding minimally and grossly displaced injuries, as well as the use of further imaging. The questionnaires were distributed via AUGMENT collaborators at their sites and at the British Orthopaedic Foot and Ankle Society congress 2018. About 315 questionnaires were completed and included in analysis. For Weber B injuries, overall there was a consensus across all respondents with minimally displaced and grossly displaced fractures being treated conservatively and operatively respectively. For Posterior Malleolus injuries, there was variation in practice between Foot and Ankle specialists and their non-Foot and Ankle colleagues. Computed tomography (CT) was more likely to be used to assess these injuries by specialists (97.50 vs 69.79%) and these injuries were more likely to be treated operatively across the board. This study identified key variation in practice of the management of Posterior Malleolar ankle fractures, including the use of imaging to further define the anatomy and the decision to operate. Foot and Ankle surgeons were more likely to organize CT scans and to surgically manage these injures.
Collapse
Affiliation(s)
| | | | - Tobias Stedman
- Registrar, Doncaster Royal Infirmary, Doncaster, United Kingdom
| | | | | | | |
Collapse
|
|
23
|
Jiao C, Gui J, Kurokawa H, Tanaka Y, Yung P, Han SH, Angthong C, Song Y, Hua Y, Li H, Shi Z, Li Q, Ling SKK. APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 1: Clinical Manifestation, Radiologic Examination, Diagnosis Criteria, Classification, and Nonoperative Treatment. Orthop J Sports Med 2021; 9:23259671211021057. [PMID: 34222547 PMCID: PMC8221687 DOI: 10.1177/23259671211021057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background Clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies regarding chronic syndesmosis injury remain unclear. Purpose An international group of experts representing the fields of sports injuries in the foot and ankle area were invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injuries. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). Study Design Consensus statement. Methods From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 15 clinical questions and statements were related to the clinical manifestation, radiologic examination, diagnostic criteria, classification, and nonoperative treatment strategies for chronic syndesmosis injury and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; unanimous, 100%. Results Of the 15 questions and statements, 5 reached unanimous support and 10 achieved strong consensus. Conclusion This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with diagnosis, classification, and nonoperative treatment strategies for chronic syndesmosis injury.
Collapse
Affiliation(s)
- Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jianchao Gui
- Department of Sports Medicine, Nanjing First Hospital, Nanjing, China
| | - Hiroaki Kurokawa
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Patrick Yung
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chayanin Angthong
- Division of Digital and Innovative Medicine, Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Yujie Song
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhongmin Shi
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, Jiaotong University, Shanghai, China
| | - Qi Li
- Department of Orthopedic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Samuel K K Ling
- Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
|
24
|
Song Y, Shi Z, Kurokawa H, Tanaka Y, Ling SKK, Yung P, Angthong C, Han SH, Hua Y, Li H, Jiao C, Gui J, Li Q. APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 3: Fusion Techniques, Comorbidity Treatments, Postoperative Rehabilitation, and Return-to-Sport Indications. Orthop J Sports Med 2021; 9:23259671211021059. [PMID: 34222548 PMCID: PMC8221682 DOI: 10.1177/23259671211021059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Questions regarding surgical fusion techniques, postoperative treatment, and indications for return to sport after chronic syndesmosis injury or its comorbidities remain unanswered. Purpose: An international group of experts representing the field of injuries in the foot and ankle area was invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injury. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS). Study Design: Consensus statement. Methods: From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 6 clinical questions and statements were related to surgical fusion techniques, comorbidity treatments, postoperative rehabilitation, and return-to-sports indications and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%. Results: Of the 6 questions and statements, 5 achieved unanimous support and 1 reached strong consensus. Conclusion: This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with surgical and postoperative treatment strategies for chronic syndesmosis injury.
Collapse
Affiliation(s)
- Yujie Song
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhongmin Shi
- Department of Orthopedics, Shanghai Sixth People Hospital, Jiaotong University, Shanghai, China
| | - Hiroaki Kurokawa
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopedic Surgery, Nara Medical University, Nara, Japan
| | - Samuel K K Ling
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Patrick Yung
- Department of Orthopaedics & Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Chayanin Angthong
- Division of Digital and Innovative Medicine, Faculty of Medicine, King Mongkut's Institute of Technology Ladkrabang, Bangkok, Thailand
| | - Seung Hwan Han
- Department of Orthopaedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Jiao
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jianchao Gui
- Department of Sports Medicine, Nanjing First Hospital, Nanjing, China
| | - Qi Li
- Department of Orthopedics, West China Hospital of Sichuan University, Sichuan, China
| |
Collapse
|
|
25
|
Influence of unstable ankle fracture (type Weber C), osteosynthesis and syndesmotic transfixation on position of fibula in tibiofibular notch: a cadaveric study. Eur J Trauma Emerg Surg 2021; 48:1445-1452. [PMID: 34137911 DOI: 10.1007/s00068-021-01721-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aim of the cadaveric study was to determine the effects of an unstable ankle fracture on the position of the fibula in the incisural notch and subsequently to evaluate the alterations resulting from the individual steps of a guideline-based osteosynthesis. METHODS In a specimen model with 20 uninjured fresh-frozen lower legs with induced unstable fracture of the fibula (type Weber C), a guideline-based osteosynthesis was performed. The distances between the anterior and posterior edges of the tibia and fibula and in the center of the incisural notch, as well as the rotation angle of the fibula, were measured in the acquired 3D image data sets and were compared with the intact condition of the ankle mortise. RESULTS The dissection of the syndesmosis and osteotomy of the fibula results in an external rotation the fibula by 3.6° (p = 0.000), while the distance between the anterior edge of the tibia and the fibula widens by 1.86 mm (p = 0.000). After osteosynthesis of the fibula and transfixation of the syndesmotic region using a positioning screw, the posterior distance is no longer substantially increased by 0.22 mm (p = 0.103) but also reduced by 0.1 mm (p = 0.104) in the tibiofibular notch. The external rotation of the fibula remains slightly increased by just 0.45° (p = 0.009). CONCLUSION The results indicate that there is a tendency for over-compression when adjusting the tibiofibular distance and that the fibula in the tibiofibular notch tends to remain slightly rotated externally.
Collapse
|
|
26
|
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.
Collapse
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
| | | |
Collapse
|
|
27
|
Jona James J, Al-Dadah O. Ankle injuries in athletes: A review of the literature. World J Meta-Anal 2021; 9:128-138. [DOI: 10.13105/wjma.v9.i2.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/26/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023] Open
Abstract
Ankle injuries are commonplace in the athletic population, with lateral ligament sprains accounting for the majority of them. The medial ligament complex, the distal tibiofibular syndesmosis as well as any of the bones that constitute the ankle joint can also be injured. Typical mechanisms of injury include inversion-plantarflexion and external rotation on a supinated, dorsiflexed or pronated foot. Lesions of the ankle present with similar symptoms of pain, swelling and tenderness. Therefore, a thorough history and physical examination must be obtained to make the correct diagnosis. This is especially critical for athletes as certain injuries can lead to termination of their career if not treated accurately on time. Imaging may be useful in some cases to confirm or rule out differential diagnoses. Most injuries can be managed conservatively using the Protection, Rest, Ice, Compression and Elevation protocol followed by a comprehensive rehabilitation programme. Surgery is reserved for grade III ligament tears that are refractory to initial non-operative treatment and displaced fractures that are unlikely to unite without surgical intervention. The objective of this review is to discuss the common ankle injuries encountered in the athletic population and the approaches to their diagnosis and management.
Collapse
Affiliation(s)
- Jenita Jona James
- The Medical School, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| |
Collapse
|
|
28
|
Liu J, Pathak G, Joshi M, Andrews K, Lee J. A meta-analysis comparing the outcomes of syndesmotic injury treated with metal screw, dynamic fixation, and bioabsorbable screw. J Orthop 2021; 25:82-87. [PMID: 33994703 DOI: 10.1016/j.jor.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022] Open
Abstract
Background Currently there is significant controversy regarding which fixation method is most effective for the treatment of syndesmotic ankle injuries. Objective This meta-analysis was designed to compare the metal screw, dynamic, and bioabsorbable screw fixation methods for treatment of syndesmotic ankle injuries. Methods An online search for RCT and prospective/retrospective clinical comparison studies between January 1998 and December 2018 on syndesmotic fixation was conducted. The main parameters collected include functional scores, mean time to full weightbearing, postoperative tibiofibular clear spaces, tibiofibular overlap, medial clear spaces, and complication rates. Statistical analysis was conducted using One Way ANOVAs and Chi-Squared tests using Review Manager and Excel. Results A total of 18 comparison studies, with 509 patients in the metal screw fixation group, 275 in the dynamic fixation group, and 226 in the bioabsorbable screw fixation group, were included in this meta-analysis. For the metal screw group, dynamic fixation group, and bioabsorbable screw group, the mean AOFAS score were 83.8, 87.2, and 84.3 (p < 0.05), the mean time to full weightbearing were 9.0 weeks, 7.2 weeks, and 7.7 weeks (p < 0.05), and the complication rates were 0.19, 0.09, and 0.19, respectively (p < 0.05). Similarly, the mean postoperative TFCS were 4.85, 3.87, and 5.70 for the metal screw group, dynamic fixation group, and bioabsorbable screw fixation group, respectively (p < 0.05). Conclusion The dynamic fixation group was found to have significantly improved functional scores, lower complication rates, and lower mean time to full weight-bearing than the metal screw and bioabsorbable screw fixation methods. Level of evidence Meta-analysis of all relevant Level 1-3 Evidence Comparative Studies.
Collapse
Affiliation(s)
- Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA
| | - Gautam Pathak
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA
| | - Mihir Joshi
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA
| | - Kyle Andrews
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA
| | - Joseph Lee
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, OH, 43614, USA
| |
Collapse
|
|
29
|
Weng Q, Lin C, Liu Y, Dai G, Lutchooman V, Hong J. Biomechanical Analysis of a Novel Syndesmotic Plate Compared With Traditional Screw and Suture Button Fixation. J Foot Ankle Surg 2021; 59:522-528. [PMID: 31864842 DOI: 10.1053/j.jfas.2019.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/06/2019] [Accepted: 07/17/2019] [Indexed: 02/03/2023]
Abstract
Many lateral malleolus fractures have been found to have syndesmosis injuries after anatomic reduction. The main methods for the treatment of syndesmosis injuries are screw fixation and suture-button flexible fixations. In pursuit of innovation, we have designed a novel syndesmotic plate (NSP) for simultaneous fixation of lateral malleolus fractures and distal tibiofibular syndesmosis injuries. The purpose of this study is to compare the biomechanical characteristics of the NSP to syndesmotic screw and suture-button fixations. Twelve adult cadaveric specimens were used in this experiment. Axial loading as well as rotation torque were applied in 3 different ankle positions: neutral, dorsiflexion, and plantarflexion. After the initial specimens were tested, they were made into a pronation-abduction III fracture model as described by Lauge-Hansen. Subsequently, the specimens were fixed sequentially using a distal fibular anatomic locking plate (DFALP) combined with syndesmotic screws, DFALP combined with suture button, and NSP. Then the above tests were repeated. The syndesmotic displacement and the strain of the tibia and fibula were recorded during the experiment. In most cases, the displacements and strains of the NSP group and the screw group were smaller than the suture button groups and the native (SBGAN) (p < .05), and the displacements and strains of the NSP group were also slightly smaller than the screw group in most cases, and there was no significant difference between the 2 groups. The NSP we developed has a fixed strength no less than the traditional syndesmotic screw fixation. This provides us a new idea for the treatment of distal tibiofibular syndesmosis injuries.
Collapse
Affiliation(s)
- Qihao Weng
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China; Master's Student, The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Chuanlu Lin
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China; Master's Student, The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Yang Liu
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China; Master's Student, The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Gaole Dai
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China; Master's Student, The Second School of Medicine, Wenzhou Medical University, Wenzhou, China
| | - Vinesh Lutchooman
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianjun Hong
- Foot and Ankle Surgeon, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China.
| |
Collapse
|
|
30
|
Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review. J Orthop Trauma 2021; 35:e116-e125. [PMID: 32890071 DOI: 10.1097/bot.0000000000001954] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries. DATA SOURCES A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal." STUDY SELECTION Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS. DATA EXTRACTION The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet. DATA SYNTHESIS The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified. CONCLUSIONS The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
|
31
|
Reconstruction of Chronic Injured Distal Tibiofibular Syndesmosis with Autogenous Tendon Graft: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3182745. [PMID: 33604371 PMCID: PMC7870304 DOI: 10.1155/2021/3182745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 01/05/2021] [Accepted: 01/20/2021] [Indexed: 11/17/2022]
Abstract
Background Chronic injuries of the distal tibiofibular syndesmosis are common in patients who fail to receive adequate diagnosis and timely treatment. Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon graft in these patients is effective, although relatively rarely reported. Purpose To investigate clinical outcomes of syndesmosis reconstruction with an autogenous tendon graft for chronic injuries of the distal tibiofibular syndesmosis by reviewing the current literature. Methods An English literature search was conducted in the MEDLINE, CENTRAL, and Cochrane databases to identify published studies up to October 2017. Preset inclusion and exclusion criteria were applied to identify all eligible articles. Results Five studies (all with level IV evidence) that included a total of 51 patients who underwent reconstruction with an autogenous tendon graft were identified. It was reported that the symptoms were relieved postoperatively, including obviously improved functional outcomes and restoration of motions and exercise capacity. The mean American Orthopedic Foot and Ankle Society scale score of 16 patients was 53 preoperatively and 89 postoperatively. The visual analogue scale score of 14 patients decreased from 82.4 preoperatively to 12.6 postoperatively. A total of 5 (9.8%) complication cases were reported. Conclusion Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon for chronic syndesmosis injury showed a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The interosseous ligament could be an appropriate reconstruction target in the treatment of chronic syndesmosis injury.
Collapse
|
|
32
|
Del Rio A, Bewsher SM, Roshan-Zamir S, Tate J, Eden M, Gotmaker R, Wang O, Bedi HS, Rotstein AH. Weightbearing Cone-Beam Computed Tomography of Acute Ankle Syndesmosis Injuries. J Foot Ankle Surg 2021; 59:258-263. [PMID: 32130987 DOI: 10.1053/j.jfas.2019.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 02/03/2023]
Abstract
Syndesmotic injuries are common, but only a subset of these injuries are unstable. A noninvasive tool for identifying instability would aid in the selection of patients for surgery. Weightbearing computed tomography (CT) data have been reported for healthy patients, but there are limited data on unstable syndesmoses. We evaluated the syndesmotic area of arthroscopically proven unstable ankles after acute injury. This is a prospective comparative study of consecutive patients recruited to a weightbearing CT database. Thirty-nine patients were included for analysis with arthroscopically proven unstable syndesmoses and an uninjured contralateral ankle. The syndesmosis area was measured for both ankles, in non-weightbearing and weightbearing positions, and compared. Syndesmosis area of the unstable ankle was significantly greater than the uninjured ankle of the same patient, by a mean of 22.9 ± 10.5 mm2. This was a significantly greater difference than that observed with non-weightbearing CT (9.8 ± 10.2 mm2, p < .001). Dynamic change in area, from non-weightbearing to weightbearing, of the unstable ankle (13.7% [16.6 ± 9.9 mm2]) was significantly greater than that of the uninjured ankle (3.1% [3.4 ± 6.7 mm2], p < .001). The intraobserver and interobserver correlations were good with intraclass correlation coefficients of 0.983 and 0.970, respectively. Weightbearing CT demonstrated significantly greater diastasis in unstable ankles than did conventional non-weightbearing CT. Syndesmosis area measurement was reliable and reproducible. Dynamic change in area and weightbearing comparison with the contralateral uninjured ankle are 2 parameters that may prove useful in the future for predicting syndesmotic instability.
Collapse
Affiliation(s)
- Andres Del Rio
- Radiologist, Victoria House Medical Imaging, South Yarra, Victoria, Australia
| | | | - Sasha Roshan-Zamir
- Surgeon, St Vincent's Private Hospital East Melbourne, East Melbourne, Victoria, Australia
| | - Julie Tate
- Radiographer, Victoria House Medical Imaging, South Yarra, Victoria, Australia
| | - Maggie Eden
- Radiographer, Victoria House Medical Imaging, South Yarra, Victoria, Australia
| | - Robert Gotmaker
- Anaesthetist, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Otis Wang
- Surgeon, St Vincent's Private Hospital East Melbourne, East Melbourne, Victoria, Australia
| | - Harvinder S Bedi
- Surgeon, Epworth Richmond Hospital, Richmond, Victoria, Australia
| | - Andrew H Rotstein
- Radiologist, Victoria House Medical Imaging, South Yarra, Victoria, Australia.
| |
Collapse
|
|
33
|
Chen KH, Chen CH, Huang YM, Lee HH, Tsuang YH. Injury mechanism affects the stability of suture-button syndesmosis fixation. J Orthop Surg Res 2020; 15:599. [PMID: 33302992 PMCID: PMC7731085 DOI: 10.1186/s13018-020-02141-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure syndesmosis injury, Weber-B, and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation. METHODS We retrospectively reviewed 63 patients with ankle syndesmosis injury who underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope was evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure syndesmosis injury, Weber-B, and Weber-C type fractures were performed. RESULTS Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 to 4.04 mm, the tibiofibular overlap was increased from 3.05 to 6.44 mm, and the medial clear space was reduced from 8.12 to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS 3.82 to 4.45 mm, p < 0.01 and TFO 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05). CONCLUSIONS Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored. TRIAL REGISTRATION This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Kuan-Hao Chen
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.,Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chih-Hwa Chen
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan. .,Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan. .,Research Center of Biomedical Device, Taipei Medical University, Taipei, Taiwan.
| | - Yu-Min Huang
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.,Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Hsieh-Hsing Lee
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yang-Hwei Tsuang
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
|
34
|
Pollizzi AA, Herman DC, Berlet GC, Reb CW. Reliability of the "Clinical Tibiofibular Line" Technique for Open Syndesmosis Reduction Assessment. Foot Ankle Spec 2020; 13:516-521. [PMID: 32781838 DOI: 10.1177/1938640020948667] [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: 11/17/2022]
Abstract
BACKGROUND When intraoperative computed tomography (CT) is unavailable, open syndesmosis assessment is a universally available, safe alternative that is more accurate than radiographic assessment. However, it has a documented malreduction rate of up to 16%. This may be improved upon with a validated technique for assessing the accuracy of open syndesmosis reductions. The "tibiofibular line" (TFL) is a CT-based technique found to be sensitive for malreduction. The purpose of this study was to assess the feasibility of adapting the CT-TFL method into a reliable intraoperative open technique by refining the methodology of previous work exploring the clinical TFL technique. METHODS Three observers were instructed to clinically simulate the TFL on cadaveric lower limbs. For each specimen, observers repeated and recorded 3 clinical TFL measurements for each of 4 measurement series representing different degrees of fibula reduction. Intraclass correlation was used to assess intra- and interobserver reliabilities. RESULTS Mean intraobserver reliability was .88. Mean interobserver reliability was .75. Both intra- and interobserver reliabilities were highest for anatomic syndesmosis reduction. CONCLUSION The findings of excellent to near perfect intraobserver and good to excellent interobserver reliability indicate the feasibility of translating the CT-TFL into a reliable open technique. LEVELS OF EVIDENCE Level III: Diagnostic study.
Collapse
Affiliation(s)
- Anthony A Pollizzi
- College of Medicine, University of Florida, Gainesville, Florida (AAP).,Department of Physical Medicine and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (DCH).,Orthopedic Foot and Ankle Center, Westerville, Ohio (GCB).,OhioHealth Grant Medical Center, Columbus, Ohio (GCB).,Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (CWR)
| | - Daniel C Herman
- College of Medicine, University of Florida, Gainesville, Florida (AAP).,Department of Physical Medicine and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (DCH).,Orthopedic Foot and Ankle Center, Westerville, Ohio (GCB).,OhioHealth Grant Medical Center, Columbus, Ohio (GCB).,Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (CWR)
| | - Gregory C Berlet
- College of Medicine, University of Florida, Gainesville, Florida (AAP).,Department of Physical Medicine and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (DCH).,Orthopedic Foot and Ankle Center, Westerville, Ohio (GCB).,OhioHealth Grant Medical Center, Columbus, Ohio (GCB).,Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (CWR)
| | - Christopher W Reb
- College of Medicine, University of Florida, Gainesville, Florida (AAP).,Department of Physical Medicine and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (DCH).,Orthopedic Foot and Ankle Center, Westerville, Ohio (GCB).,OhioHealth Grant Medical Center, Columbus, Ohio (GCB).,Department of Orthopaedics and Rehabilitation, College of Medicine, University of Florida, Gainesville, Florida (CWR)
| |
Collapse
|
|
35
|
Behery OA, Mandel J, Solasz SJ, Konda SR, Egol KA. Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures. Foot Ankle Int 2020; 41:1065-1072. [PMID: 32691617 DOI: 10.1177/1071100720935119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome. METHODS A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS). RESULTS A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger (P = .002) and predominantly male (P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) (P = .25), but with similar ankle ROM and MFS (P > .07). CONCLUSION Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal. LEVEL OF EVIDENCE Level III, retrospective case-control study.
Collapse
Affiliation(s)
- Omar A Behery
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Jessica Mandel
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Sara J Solasz
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Sanjit R Konda
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Kenneth A Egol
- Department of Orthopedic Surgery, Division of Orthopedic Trauma, NYU Langone Orthopedic Hospital, New York, NY, USA
| |
Collapse
|
|
36
|
Cassinelli SJ, Harris TG, Giza E, Kreulen C, Matheny LM, Robbins CM, Clanton TO. Use of Anatomical Landmarks in Ankle Arthroscopy to Determine Accuracy of Syndesmotic Reduction: A Cadaveric Study. Foot Ankle Spec 2020; 13:219-227. [PMID: 31113242 DOI: 10.1177/1938640019846972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The aim of this study was to determine the accuracy of ankle arthroscopy as a means for diagnosing syndesmotic reduction or malreduction and to determine anatomical landmarks for diagnosis. Methods. Six matched-pair cadavers (n = 12) with through-knee amputations were studied. Component parts of the syndesmosis and distal 10 cm of the interosseous membrane (IOM) were sectioned in each. The 12 specimens were divided into 2 groups: 6 specimens in the in-situ group fixed with suture button technique and 6 specimens in the malreduced group rigidly held with a 3.5-mm screw. Specimens were randomized to undergo diagnostic arthroscopy by 3 fellowship-trained foot and ankle orthopaedic surgeons in a blinded fashion. Surgeons were asked to determine if the syndesmosis was reduced or malreduced and provide arthroscopic measurements of their findings. Results. Of 36 arthroscopic evaluations, 34 (94%) were correctly diagnosed. Arthroscopic measurement of 3.5 mm diastasis or greater at the anterior aspect of the distal tibiofibular syndesmosis correlated with a posteriorly malreduced fibula. Arthroscopic evaluation of the Anterior inferior tibiofibular ligament (AITFL), IOM, Posterior inferior tibiofibular ligament (PITFL), lateral fibular gutter, and the tibia/fibula relationship were found to be reliable landmarks in determining syndesmotic reduction. An intraclass correlation coefficient (ICC) for interrater reliability of 1.00 was determined for each of these landmarks between 2 surgeons (P < .001). The ICCs between 2 surgeons' measurements and the computed tomography measurements were found to be 0.896 (P value < .001). Conclusions. Ankle arthroscopy is a reliable method to assess syndesmotic relationship when reduced in situ or posteriorly malreduced 10 mm. Levels of Evidence: Level V: Cadaveric.
Collapse
Affiliation(s)
- Spenser J Cassinelli
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Thomas G Harris
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Eric Giza
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Christopher Kreulen
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Lauren M Matheny
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Colin M Robbins
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| | - Thomas O Clanton
- Harbor-UCLA Medical Center, Torrance, California (SJC, TGH).,Congress Orthopedic Associates, Pasadena, California (TGH).,UC Davis Medical Center, Sacramento, California (EG, CK).,Steadman Philippon Research Institute, Center for Outcomes-Based Orthopaedics, Vail, Colorado (LMM).,Steadman Philippon Research Institute, Vail, Colorado (CMR).,The Steadman Clinic, Vail, Colorado (TOC)
| |
Collapse
|
|
37
|
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.
Collapse
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
| |
Collapse
|
|
38
|
Dynamic fixation is superior in terms of clinical outcomes to static fixation in managing distal tibiofibular syndesmosis injury. Knee Surg Sports Traumatol Arthrosc 2020; 28:270-280. [PMID: 31422424 DOI: 10.1007/s00167-019-05659-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE To analyze the current randomized controlled trials (RCTs) of dynamic fixations (DFs) and static fixations (SFs) in treating distal tibiofibular syndesmosis injuries (DTSIs). METHODS The Cochrane Central Register of Controlled Trials, PubMed, and EMBASE were systematically searched according to the PRISMA guidelines to identify RCTs comparing the DFs and SFs for DTSIs. Included studies were assessed using the Cochrane Risk of Bias Tool. Postoperative functional scores, range of motion (ROM), complication rate, and incidence of reoperation were statistically analyzed using review manager software, and a p value of < 0.05 was considered statistically significant. RESULTS Five RCTs with a total of 282 patients were included. Analysis revealed statistically significant differences in favor of DFs with regard to American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score at a follow-up less than 6 months (MD 5.29; 95% CI 0.99-9.59; p = 0.02; I2 = 0%) and at a follow-up more than 2 years (MD 7.53; 95% CI 3.30-11.76; p = 0.0005; I2 = 0%), Olerud-Molander ankle (OMA) score at 1 year follow-up (MD 4.62; 95% CI 0.91-8.32; p = 0.01; I2 = 14%), and overall postoperative complication rate (RR 0.22; 95% CI 0.07-0.77; p = 0.02; I2 = 73%). There was no significant difference between the DFs and SFs regarding ROM and incidence of reoperation. CONCLUSIONS The DF procedure leads to significantly improved functional scores as well as lower rate of overall postoperative complications when compared with SF procedure. On the basis of results of this meta-analysis, the DF should be recommended for managing the DTSI. LEVEL OF EVIDENCE I.
Collapse
|
|
39
|
Abstract
The distal tibiofibular joint is a fibrous joint that plays a crucial role in the stability of the ankle joint. It is stabilized by three main ligaments: the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the interosseous tibiofibular ligament, which are well delineated on magnetic resonance imaging. Pathology of the distal tibiofibular joint is mostly related to trauma and the longer-term complications of trauma, such as soft tissue impingement, heterotopic ossification, and synostosis. This review article outlines the MRI anatomy and pathology of this joint.
Collapse
|
|
40
|
Fan X, Zheng P, Zhang YY, Hou ZT. Dynamic Fixation versus Static Fixation in Treatment Effectiveness and Safety for Distal Tibiofibular Syndesmosis Injuries: A Systematic Review and Meta-Analysis. Orthop Surg 2019; 11:923-931. [PMID: 31823499 PMCID: PMC6904666 DOI: 10.1111/os.12523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 07/11/2019] [Accepted: 07/28/2019] [Indexed: 12/26/2022] Open
Abstract
To compare the effectiveness and safety of dynamic fixation (DF) and static fixation (SF) in distal tibiofibular syndesmosis injuries (DTSI) by a system review and meta-analysis. PubMed, Cochrane, and EMBASE were systematically searched by computer to select clinical randomized controlled trials (RCT) and cohort trials comparing DF and SF in treating patients with DTSI. RCT and cohort trials comparing DF and SF for patients with DTSI were included. Inclusion criteria: (i) prospective or retrospective study of patients with DTSI; (ii) patients were diagnosed as having DTSI by imageology and only received DF treatment or SF treatment; (iii) the study compared DF and SF in DTSI; and (iv) one or more of the following outcomes were reported: ankle joint functional score, surgical complications, malreduction of syndesmosis, and second operations. Exclusion criteria: (i) non-human studies; (ii) DTSI patients accompanied with other complications or other joints injuries; and (iii) full text unavailable. RevMan V5.3 software was used to perform the statistical analysis. Outcomes analyzed by Revman software showed that there were no statistically significant differences between DF and SF in the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score (MD, 1.90; 95% CI, -0.23 to 4.03; P = 0.08; I2 = 0%), Olerud-Molander (OM) score (MD, 1.92; 95% CI, -7.96 to 11.81; P = 0.70; I2 = 55%), incidence of syndesmotic malreduction (RR, 0.19; 95% CI, 0.03 to 1.09; P = 0.06; I2 = 0%), and overall postoperative complication rate (RR, 0.30; 95% CI, 0.09 to 0.99; P = 0.05, I2 = 75%) and the rate of second procedure was significantly lower with DF (RR, 0.17; 95% CI, 0.07 to 0.43; P = 0.0002, I2 = 54%). Compared to SF, DF has an advantage, with a low rate of second procedures to treat DTSI.
Collapse
Affiliation(s)
- Xiao Fan
- Traditional Chinese Medicine Department, Qingdao Municipal Hospital, Qingdao, Shandong Province, China
| | - Peng Zheng
- Orthopaedic Department, Traditional Chinese Medicine Hospital of Qingdao West Coast New Area, Qingdao, Shandong Province, China
| | - Ying-Yu Zhang
- Traditional Chinese Medicine Department, Qingdao Municipal Hospital, Qingdao, Shandong Province, China
| | - Zeng-Tao Hou
- Orthopaedic Department, Qingdao Municipal Hospital, Qingdao, Shandong Province, China
| |
Collapse
|
|
41
|
Chang AL, Mandell JC. Syndesmotic Ligaments of the Ankle: Anatomy, Multimodality Imaging, and Patterns of Injury. Curr Probl Diagn Radiol 2019; 49:452-459. [PMID: 31668368 DOI: 10.1067/j.cpradiol.2019.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/13/2019] [Accepted: 09/03/2019] [Indexed: 12/17/2022]
Abstract
Injuries to the syndesmotic ligaments of the ankle or "high ankle sprains" are common in acute ankle trauma but can be difficult to diagnose both clinically and on imaging. Missed injuries to the syndesmosis can lead to chronic ankle instability, which can cause persistent pain and lead to early osteoarthritis. This review will illustrate the anatomy of the syndesmotic ligamentous complex, describe radiographic, CT, and MR imaging of the syndesmosis, demonstrate typical mechanisms of injuries and associated fracture patterns, and provide an overview of important management considerations.
Collapse
Affiliation(s)
- Andrew L Chang
- Long Beach Veteran Affairs, Imaging Service, Long Beach, CA.
| | - Jacob C Mandell
- Brigham and Women's Hospital, Division of Musculoskeletal radiology imaging and intervention, Boston, MA
| |
Collapse
|
|
42
|
Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med 2019; 47:2764-2771. [PMID: 30475639 DOI: 10.1177/0363546518804804] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Operative treatment is indicated for unstable syndesmosis injuries, and approximately 20% of all ankle fractures require operative fixation for syndesmosis injuries. PURPOSE To perform a meta-analysis of randomized controlled trials evaluating clinical outcomes between suture button (SB) and syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. STUDY DESIGN Meta-analysis. METHODS A literature search was performed according to the PRISMA guidelines to identify randomized controlled trials comparing the SB and SS techniques for syndesmosis injuries. Level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine. Statistical analysis was performed with RevMan, and a P value ≤.05 was considered statistically significant. RESULTS Five clinical studies were identified, allowing comparison of 143 patients in the SB group with 142 patients in the SS group. Patients treated with the SB technique had a higher postoperative American Orthopaedic Foot & Ankle Society score at a mean 20.8 months (95.3 vs 86.7, P < .001). The SB group resulted in a lower rate of broken implants (0.0% vs 25.4%, P < .001), implant removal (6.0% vs 22.4%, P = .01), and joint malreduction (0.8% vs 11.5%, P = .05) as compared with the SS group. CONCLUSION The SB technique results in improved functional outcomes as well as lower rates of broken implant and joint malreduction. Based on the findings of this meta-analysis, the SB technique warrants a grade A recommendation by comparison with the SS technique for the treatment of syndesmosis injuries.
Collapse
Affiliation(s)
- Yoshiharu Shimozono
- Hospital for Special Surgery, New York, New York, USA
- Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Eoghan T Hurley
- Hospital for Special Surgery, New York, New York, USA
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - C Lucas Myerson
- Hospital for Special Surgery, New York, New York, USA
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | | | | |
Collapse
|
|
43
|
Lamer S, Hébert-Davies J, Dubé V, Leduc S, Sandman É, Ménard J, Nault ML. Effect of a Controlled Ankle Motion Walking Boot on Syndesmotic Instability During Weightbearing: A Cadaveric Study. Orthop J Sports Med 2019; 7:2325967119864018. [PMID: 31457067 PMCID: PMC6702776 DOI: 10.1177/2325967119864018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Syndesmotic injuries can lead to long-term complications; hence, they require careful management. Conservative treatment is adequate when 1 syndesmotic ligament is injured, but surgery is often necessary to achieve articular congruity when 3 syndesmotic ligaments are ruptured. However, there is some controversy over the best treatment for 2-ligament injuries. Purpose: To evaluate the effect of a controlled ankle motion (CAM) walking boot on syndesmotic instability following iatrogenic isolated anterior inferior tibiofibular ligament (AiTFL) injury and combined AiTFL/interosseous ligament (IOL) injuries in a cadaveric simulated weightbearing model. Study Design: Controlled laboratory study. Methods: Ten cadaveric specimens were dissected to expose the tibial plateau and syndesmosis. The specimens were fitted to a custom-made device, and a reproducible axial load of 750 N was applied. Iatrogenic rupture of the syndesmotic ligaments (AiTFL + IOL) was done sequentially. Uninjured syndesmoses, isolated AiTFL rupture, and combined AiTFL/IOL rupture were compared with and without axial loading (AL) and CAM boot. The distal tibiofibular relationship was evaluated using a previously validated computed tomography scan measurement system. Wilcoxon tests for paired samples and nonparametric data were used. Results: The only difference noted in the distal tibiofibular relationship during AL was an increase in the external rotation of the fibula when using the CAM boot. This was observed with AiTFL rupture (8.40° vs 11.17°; P = .009) and combined AiTFL/IOL rupture (8.81° vs 11.97°; P = .005). Conclusion: AL did not cause a significant displacement between the tibia and fibula, even when 2 ligaments were ruptured. However, the CAM boot produced a significant external rotation with 1 or 2 injured ligaments. Clinical Relevance: Further studies are needed to assess the capacity of the CAM walking boot to prevent malreduction when external rotation forces are applied to the ankle. Moreover, special care should be taken during the fitting of the CAM boot to avoid overinflation of the cushions.
Collapse
Affiliation(s)
- Stéphanie Lamer
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | | | - Vincent Dubé
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Stéphane Leduc
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Émilie Sandman
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
| | - Jérémie Ménard
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
| | - Marie-Lyne Nault
- Hôpital du Sacré-Cœur de Montréal, Montréal, Quebec, Canada
- Department of Surgery, Université de Montréal, Montréal, Quebec, Canada
- Harborview Medical Center, Seattle, Washington, USA
- Marie-Lyne Nault, MD, PhD, CHU Ste-Justine, 7905- 3175 chemin de la Côte Ste-Catherine, Montréal, QC H3T1C5, Canada ()
| |
Collapse
|
|
44
|
Amin A, Janney C, Sheu C, Jupiter DC, Panchbhavi VK. Weight-Bearing Radiographic Analysis of the Tibiofibular Syndesmosis. Foot Ankle Spec 2019; 12:211-217. [PMID: 29607668 DOI: 10.1177/1938640018766631] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Diagnosis of distal tibiofibular syndesmotic injuries includes assessment of radiographs; however, there exist no agreed on standard diagnostic criteria. Previous studies lack consistency with radiographic evaluation methods. The dynamic nature of the ankle joint supports analyzing anatomical parameters using weight-bearing films to assess for tibiofibular syndesmotic integrity. Methods: Weight-bearing tibiofibular syndesmosis radiographs of 39 male and 40 female patients were retrospectively analyzed by 3 investigators, at different levels of orthopaedic training. Measurements 1 cm above the tibial plafond for the anterior tibiofibular overlap (TFO) and tibiofibular clear space (TCS) were recorded and standardized by the fibular width (FW) at 2 time points. Data were compared to check for agreement between the sets of measurements for each rater and agreement between investigators, and to ascertain underlying gender differences. Results: There was good intraobserver correlation (intraclass correlation coefficient [ICC] > 0.90) among investigators for each parameter. A significant difference in the TFO was noted between genders (P < .05). We establish the following radiographic (anteroposterior view) parameters for an intact syndesmosis: male patients, TCS <4.57 mm or TCS/FW <29% and TFO >9.29 mm or TFO/FW > 57%; female patients, TCS <4.28 mm or TCS/FW <30% and TFO >7.41 mm or TFO/FW >51%. Conclusions: Our study provides a more objective approach by utilizing weight-bearing radiographs and performing all measurements 1 cm above the tibial plafond. Levels of Evidence: Level IV.
Collapse
Affiliation(s)
- Arsalan Amin
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas (AA, CJ, VKP).,United States Navy, Washington, DC (CJ).,Skagit Regional Health, Mount Vernon, Washington (CS).,Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (DCJ)
| | - Cory Janney
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas (AA, CJ, VKP).,United States Navy, Washington, DC (CJ).,Skagit Regional Health, Mount Vernon, Washington (CS).,Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (DCJ)
| | - Christopher Sheu
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas (AA, CJ, VKP).,United States Navy, Washington, DC (CJ).,Skagit Regional Health, Mount Vernon, Washington (CS).,Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (DCJ)
| | - Daniel C Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas (AA, CJ, VKP).,United States Navy, Washington, DC (CJ).,Skagit Regional Health, Mount Vernon, Washington (CS).,Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (DCJ)
| | - Vinod K Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, Texas (AA, CJ, VKP).,United States Navy, Washington, DC (CJ).,Skagit Regional Health, Mount Vernon, Washington (CS).,Preventative Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas (DCJ)
| |
Collapse
|
|
45
|
Lopes R, Orhant E, Guillo S, Bouvard M, Brasseur J, Brunot S, Collado H, Frey A, Guillodo Y, Kuentz P, Maillet P, Tamalet B, Rousseau R. La cheville du footballeur : résumés des communications de la 1re journée francophone des fédérations de la Société française de traumatologie du sport (SFTS) en partenariat avec la Fédération française de football (FFF). JOURNAL DE TRAUMATOLOGIE DU SPORT 2019; 36:120-137. [DOI: 10.1016/j.jts.2019.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
46
|
Gan K, Zhou K, Hu K, Lu L, Gu S, Shen Y. Dynamic Fixation Versus Static Fixation for Distal Tibiofibular Syndesmosis Injuries: A Meta-Analysis. Med Sci Monit 2019; 25:1314-1322. [PMID: 30776287 PMCID: PMC6392477 DOI: 10.12659/msm.913324] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Ankle sprains with distal tibiofibular syndesmosis injuries (DTSIs) require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint. In the last decade, dynamic fixation (DF) for DTSIs using a suture-button device has gained popularity because of its advantages over static fixation (SF). Material/Methods The present meta-analysis was conducted to compare clinical outcomes between DF and SF of DTSIs. PubMed, Cochrane Central Register of Controlled Trials, and Embase were systematically searched. Three randomized controlled studies and 7 cohort studies, with a total of 420 patients, were involved in this study. DTSIs patients treated with DF were assigned to the experimental group, and patients treated with SF were assigned to the control group. Outcomes were evaluated and analyzed by using review-manager software. Mean difference (MD) or risk ratio (RR) with 95% confidence interval (95% CI) was analyzed and calculated by utilizing the random effects models. Results Analysis revealed no statistically significant differences between DF and SF in American Orthopedic Foot and Ankle Society Ankle-Hindfoot score (MD, 1.90; 95% CI, −0.23–4.03; p=0.08; I2=0%), Olerud-Molander score (MD, 1.92; 95% CI, −7.96–11.81; p=0.70; I2=55%), incidence of syndesmotic malreduction (RR, 0.19; 95% CI, 0.03–1.09; p=0.06; I2=0%), and overall postoperative complication rate (RR, 0.30; 95% CI, 0.09–0.99; p=0.05, I2=75%). The rate of second procedure was significantly lower compared with DF (RR, 0.17; 95% CI, 0.07–0.43; p=0.0002, I2=54%). Conclusions The dynamic fixation and static fixation methods are equal in clinical outcomes, with dynamic fixation needing fewer second interventions for DTSIs.
Collapse
Affiliation(s)
- Kaifeng Gan
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| | - Ke Zhou
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| | - Keqi Hu
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| | - Liangjie Lu
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| | - Shirong Gu
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| | - Yandong Shen
- Department of Orthopaedics, Ningbo Medical Center Lihuili Hospital, Ningbo, Zhejiang, China (mainland)
| |
Collapse
|
|
47
|
Lee JY, Lim JH, Jung GH. Radiological indicator of reduction adequacy during ankle syndesmosis surgery: A computational cadaveric study. Injury 2018; 49:1491-1496. [PMID: 29885964 DOI: 10.1016/j.injury.2018.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 05/30/2018] [Accepted: 06/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE We introduced the intraoperative radiological indicator to assess the reduction adequacy without additional procedure or instrument, and propose the optimal syndesmotic screw trajectory. METHODS Thirty adult cadavers (15 males and 15 females) without ankle problems were enrolled and subjected to continuous 0.75 mm-slice computed tomography (CT) scans. CT images were imported into Mimics® software to reconstruct three-dimensional (3D) model of ankle. Using free 360° rotations with magnification, the 3D mutual relationships of ankle syndesmosis were assessed, and the fibular congruency of incisura was evaluated to determine the optimal screw trajectory. By reformatting the CT scanning plane along the screw direction, the coronal relation of ankle syndesmosis was evaluated to verify the distance between the adjacent bones. RESULTS The fibula was placed in the concentric position of fibular incisura in the 20 models (concentric group) and 40 models, in an eccentric position (eccentric group). Despite this variant, all fibulas were changed into the concentric position in the proximal part of syndesmotic footprint, which might be the ideal height for syndesmotic screw in our study. The fibular bisecting screw trajectory associated with the ideal height of screw was parallel to the ground if the tibial tubercle was directed to the superior and nearly vertical to the ground floor (TT view). Through the reformatted scanning plane parallel to the screw, the lateral border of talus was always placed more medial than the lateral border of distal tibia in the coronal image. All models had a perfectly equidistant and parallel joint space except the medial aspect. CONCLUSION The lateral border of talus in the TT view was intraoperatively used as the radiological indicator for ankle syndesmosis widening because it was always placed more medial than the lateral border of distal tibia. The optimal syndesmotic screw trajectory was placed around the proximal syndesmotic footprint and parallel to the ground via the TT view.
Collapse
Affiliation(s)
- Jun-Young Lee
- Department of Orthopaedic Surgery, Chosun University, Chosun University Hospital, 365 Pilmundae-ro, Dong-gu, Gwangju, 61453, Republic of Korea
| | - Jae Hwan Lim
- Department of Orthopaedic surgery, Gyeongsang National University, College of Medicine, Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Gu-Hee Jung
- Department of Orthopaedic surgery, Gyeongsang National University, College of Medicine, Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea.
| |
Collapse
|
|
48
|
Ntalos D, Rupprecht M, Grossterlinden LG, Hamurcu A, Regier M, Klatte TO, Rueger JM, Spiro AS. Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function -Clinical study and MRI evaluation. Injury 2018; 49:1220-1227. [PMID: 29706250 DOI: 10.1016/j.injury.2018.04.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/18/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up. PATIENTS AND METHODS One hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36. RESULTS No tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups. CONCLUSION Three-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.
Collapse
Affiliation(s)
- D Ntalos
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - M Rupprecht
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L G Grossterlinden
- Department of Orthopaedic, Trauma and Spine Surgery, Asklepios Hospital Altona, Hamburg, Germany
| | - A Hamurcu
- Department of Orthopaedic and Trauma Surgery, Albertinen Hospital, Hamburg, Germany
| | - M Regier
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T O Klatte
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J M Rueger
- Department of Trauma-, Hand-, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A S Spiro
- Department of Pediatric Orthopaedic Surgery, Children's Hospital, Altona, Hamburg, Germany; Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
|
49
|
Krähenbühl N, Weinberg MW, Davidson NP, Mills MK, Hintermann B, Saltzman CL, Barg A. Imaging in syndesmotic injury: a systematic literature review. Skeletal Radiol 2018; 47:631-648. [PMID: 29188345 DOI: 10.1007/s00256-017-2823-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/29/2017] [Accepted: 11/07/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To give a systematic overview of current diagnostic imaging options for assessment of the distal tibio-fibular syndesmosis. MATERIALS AND METHODS A systematic literature search across the following sources was performed: PubMed, ScienceDirect, Google Scholar, and SpringerLink. Forty-two articles were included and subdivided into three groups: group one consists of studies using conventional radiographs (22 articles), group two includes studies using computed tomography (CT) scans (15 articles), and group three comprises studies using magnet resonance imaging (MRI, 9 articles).The following data were extracted: imaging modality, measurement method, number of participants and ankles included, average age of participants, sensitivity, specificity, and accuracy of the measurement technique. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess the methodological quality. RESULTS The three most common techniques used for assessment of the syndesmosis in conventional radiographs are the tibio-fibular clear space (TFCS), the tibio-fibular overlap (TFO), and the medial clear space (MCS). Regarding CT scans, the tibio-fibular width (axial images) was most commonly used. Most of the MRI studies used direct assessment of syndesmotic integrity. Overall, the included studies show low probability of bias and are applicable in daily practice. CONCLUSIONS Conventional radiographs cannot predict syndesmotic injuries reliably. CT scans outperform plain radiographs in detecting syndesmotic mal-reduction. Additionally, the syndesmotic interval can be assessed in greater detail by CT. MRI measurements achieve a sensitivity and specificity of nearly 100%; however, correlating MRI findings with patients' complaints is difficult, and utility with subtle syndesmotic instability needs further investigation. Overall, the methodological quality of these studies was satisfactory.
Collapse
Affiliation(s)
- Nicola Krähenbühl
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Maxwell W Weinberg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Nathan P Davidson
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Megan K Mills
- Department of Radiology and Imaging Sciences, University of Utah, 30 N. 1900 E. No. 1A071, Salt Lake City, UT, 84132, USA
| | - Beat Hintermann
- Department of Orthopaedics, Kantonsspital Baselland, Rheinstrasse 26, 4410, Liestal, Switzerland
| | - Charles L Saltzman
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| |
Collapse
|
|
50
|
Ibnu Samsudin M, Yap MQW, Wei Luong A, Kwek EBK. Slippage of Tightrope Button in Syndesmotic Fixation of Weber C Malleolar Fractures: A Case Series. Foot Ankle Int 2018; 39:613-617. [PMID: 29332433 DOI: 10.1177/1071100717749533] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tightrope fixation is an emerging technique for syndesmotic fixation with promising results. However, our case series highlights the slippage of Tightrope buttons as a complication of suture button syndesmotic fixation of Weber C malleolar fractures using limited contact dynamic compression (LCDCP) plates. METHODS We report a series of cases from our database in which slippage of the Tightrope button through the LCDCP holes in Weber C malleolar fractures was noted. We measured the medial clear space (MCS), tibiofibular clear space (TFCS), and distal tibiofibular overlap (DTFO) and computed the largest change in these measurements from the first postoperative follow-up radiographs. Patient records were reviewed for persistent symptoms that could be attributed to the loss of syndesmotic fixation and stability. RESULTS Follow-up radiographs of 3 patients showed a slippage of the Tightrope button through the LCDCP holes. Two of the patients reported persistent ankle pain and swelling with prolonged activity. The mean increases in MCS and TFCS among these patients were 0.7 (±0.081) mm and 1.5 (±0.798) mm, respectively. The mean decrease in DTFO was 2.2 (±0.864) mm. We next highlight 3 patients with Weber C malleolar fractures who underwent suture button syndesmotic fixation using double-stacked one-third tubular plates instead of the LCDCP. CONCLUSION This case series reported Tightrope button slippage as an early complication of syndesmotic fixation of Weber C malleolar fractures. We propose the use of double-stacked one-third tubular plates instead of the LCDCP to avoid this complication. LEVEL OF EVIDENCE Level V, expert opinion.
Collapse
Affiliation(s)
| | - Ming Quan Wayne Yap
- 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ang Wei Luong
- 2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | |
Collapse
|