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Tucker S, Milne I, Pitcher M, Benedict C, N Olson S, MacDonald A, Aynardi M. A Review of Syndesmosis Injuries and Preferred Treatment in Football Players. Curr Rev Musculoskelet Med 2025; 18:190-200. [PMID: 39951239 PMCID: PMC12014971 DOI: 10.1007/s12178-025-09954-x] [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] [Accepted: 01/29/2025] [Indexed: 04/23/2025]
Abstract
PURPOSE OF REVIEW Syndesmotic injuries are common football injuries. The unique demands of football athletes create large magnitude rotational moments about the ankle, even during low impact maneuvers. This review explores the structure and function of the syndesmosis, assesses recent data in football athletes at the professional and collegiate levels regarding epidemiology, describes available treatment options, and provides example cases from the authors' institution. The review concludes with clinical and surgical pearls for the evaluation and treatment of syndesmotic injury. RECENT FINDINGS In general, flexible syndesmotic fixation has demonstrated similar clinical outcome scores as rigid fixation. Flexible fixation has demonstrated benefit over rigid fixation in terms of implant failure, hardware removal, and local irritation. Both flexible and rigid fixation remain viable options for treatment of syndesmotic injuries yet the indications for selecting a construct are often subjective. Certain cases of high-risk football players such as linemen may warrant careful consideration of rigid fixation options despite the clinical advantages of flexible fixation. During fixation, direct visualization techniques with open or arthroscopic assistance for reduction of the syndesmosis remain superior and enable diagnosis of chondral defects. Flexible and rigid syndesmotic fixation techniques are viable for treatment of unstable syndesmotic injuries in athletes. Recent literature favors flexible fixation. However, at-risk football athletes or those with length unstable fibula fractures may benefit from rigid or supplemental flexible fixation as opposed to traditional flexible fixation. We recommend direct visualization of reduction at the syndesmosis during surgical treatment of unstable ankle injuries.
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Affiliation(s)
- Scott Tucker
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA.
- Department of Orthopaedics and Rehabilitation, 500 University Drive, Hershey, PA, 17033, USA.
| | - Indigo Milne
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Michaela Pitcher
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Christian Benedict
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Samantha N Olson
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Ashlee MacDonald
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
| | - Michael Aynardi
- Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA, 17033, USA
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Liu K, Ji X, Su P. Advancements in minimally invasive treatment of deltoid ligament injuries combined with distal tibiofibular syndesmosis injuries. BMC Surg 2025; 25:50. [PMID: 39881270 PMCID: PMC11776317 DOI: 10.1186/s12893-025-02779-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Accepted: 01/13/2025] [Indexed: 01/31/2025] Open
Abstract
The deltoid ligament (medial collateral ligament) and the syndesmosis (a composite ligamentous structure at the distal tibiofibular junction) are critical for maintaining ankle stability. In cases of high-energy ankle fractures, these structures are often injured simultaneously, leading to instability and potential long-term complications such as post-traumatic arthritis. This review aims to explore advancements in minimally invasive techniques for the treatment of combined deltoid ligament and syndesmosis injuries, with a focus on optimizing surgical outcomes and reducing patient morbidity. Current treatment strategies primarily involve cortical screws for syndesmosis stabilization and anchor fixation for deltoid ligament repair. Recent innovations, such as bioabsorbable screws, suture-button devices with elastic micromotion, and syndesmotic plates, have demonstrated potential in improving biomechanical stability while minimizing complications. Furthermore, minimally invasive techniques, including arthroscopic repairs with suture anchors, as well as ligament reconstruction using autografts, allografts, or synthetic ligaments, are becoming increasingly popular. By incorporating these advancements, the field is moving toward more effective and patient-centered approaches to achieve anatomical and functional restoration under minimally invasive principles. Future research should focus on further validating these techniques and identifying the most effective strategies for complex injuries.
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Affiliation(s)
- Kun Liu
- Department of Gynaecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaoyan Ji
- Department of Hand and Foot Surgery, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China.
| | - Peng Su
- Department of Hand and Foot Surgery, Shandong Provincial Hospital, Shandong First Medical University, Jinan, China
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Bhagat SK, Regmi A, Niraula BB, Sah SP, Kunwar BB, Yadav R, Maheshwari V, Meena PK. Computed tomography-based morphometric analysis of normal distal tibiofibular syndesmosis in the Indian population. Foot Ankle Surg 2024; 30:681-687. [PMID: 38851941 DOI: 10.1016/j.fas.2024.05.015] [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: 11/11/2023] [Revised: 03/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND In suspected Ankle Instability, the parameters that can be defined in the X-ray have their limitation owing to their variability in positioning and rotation of the tibiofibular joint. This inaccuracy further increases due to variability in morphometric parameters of distal tibiofibular syndesmosis among different populations based on race and sex. This research aims to study morphometry of normal distal tibiofibular syndesmosis based on computed tomography imaging in the Indian population. METHODS An Prospective observational study was performed from December 2020 to October 2022 on normal ankle CT scans of 100 Indian population using axial, sagittal, and coronal CT images. Anterior and posterior tibiofibular distance, Morphology of the incisura fibularis based on depth, Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO), Transverse and longitudinal length of the fibula, and Relationship between the center of the talus and the center of a line joining the outer aspect of malleoli in the coronal plane were measured and analyzed by two different observers. RESULTS Out of the 100 participants, 77 (77 %) were male, and 23 (23 %) were female. The overall mean age of participants was 34.69 ± 9.7 years. The incisura fibularis was concave in 54 %, and shallow in 46 %. Anterior tibiofibular distance, Posterior tibiofibular distance, and Tibiofibular overlap were significantly different in comparison to the male with female populations (p-value < 0.05). CONCLUSION This study gives the indices that describe normal variations in the anatomical relationship between the fibula and fibular incisure in the Indian population, which will be helpful for improving the diagnostic accuracy of distal tibiofibular syndesmoses and providing optimal treatment in order to improve functional outcomes and reduce the risk of complications. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Saroj Kumar Bhagat
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Anil Regmi
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Bishwa Bandhu Niraula
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Saroj Prasad Sah
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Bom Bahadur Kunwar
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Robin Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Vikas Maheshwari
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
| | - Pradeep Kumar Meena
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh, India.
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Rajeev A, Krishnan S, Koshy G, Mariam Baby M, Devalia K. Tibialis Posterior Tendon Dysfunction Due to Syndesmotic Fixation Using Non-absorbable Suture Button Device Following Fracture-Dislocation of the Ankle: A Case Report. Cureus 2024; 16:e72442. [PMID: 39588440 PMCID: PMC11588346 DOI: 10.7759/cureus.72442] [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: 10/26/2024] [Indexed: 11/27/2024] Open
Abstract
Fracture-dislocation of the ankle is a common lower limb injury, often associated with syndesmotic damage. While CT and MRI scans are more sensitive than plain radiographs in diagnosing syndesmotic injuries, treatment typically involves either static stabilization using metallic screws or dynamic stabilization with a suture button device. The primary advantage of dynamic stabilization is that it eliminates the need for a second surgery to remove screws. However, chronic syndesmotic injuries can lead to significant morbidity, including pain and impaired function. In patients with inflammatory conditions, such as rheumatoid arthritis, dynamic stabilization may result in loosening and migration of the suture button, potentially causing tendon degeneration and rupture. We present the case of a 63-year-old woman with rheumatoid arthritis who sustained a fracture-dislocation of the ankle. She was treated with open reduction and internal fixation, using a plate, screws, and a suture button device for syndesmotic stabilization. Postoperatively, she developed a plano-valgus deformity due to migration of the suture button into the tibialis posterior tendon and degenerative arthritis of the syndesmosis joint.
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Affiliation(s)
- Aysha Rajeev
- Trauma and Orthopaedics, Gateshead Health Foundation NHS Trust, Gateshead, GBR
| | - Saurav Krishnan
- General Medicine, Gateshead Health Foundation NHS Trust, Gateshead, GBR
| | - George Koshy
- Trauma and Orthopaedics, Gateshead Health Foundation NHS Trust, Gateshead, GBR
| | - Mintu Mariam Baby
- Trauma and Orthopaedics, Gateshead Health Foundation NHS Trust, Gateshead, GBR
| | - Kailash Devalia
- Trauma and Orthopaedics, Gateshead Health Foundation NHS Trust, Gateshead, GBR
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Çalışkan G, Elmas Y, Çelik O. Trans-syndesmotic fixation in supination external rotation type 4 injuries: Are intraoperative tests reliable? ULUS TRAVMA ACIL CER 2024; 30:754-760. [PMID: 39382367 PMCID: PMC11622706 DOI: 10.14744/tjtes.2024.37225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2024] [Revised: 08/11/2024] [Accepted: 08/16/2024] [Indexed: 10/10/2024]
Abstract
BACKGROUND Ankle fractures occur due to a rotational mechanism. According to the Lauge-Hansen classification, supination-external rotation (SER) injuries are the most common type. Following osseous fixation, the evaluation and treatment of syndesmotic injuries in these injuries are controversial. This study aimed to evaluate the clinical, functional, and radiological results of trans-syndesmotic fixation using intraoperative tests in SER type 4 ankle injuries. METHODS Ankle syndesmosis was intraoperatively evaluated using cotton/hook and manual external rotation stress tests in 64 patients with SER type 4 fracture dislocation injuries. These patients were divided into two groups: those treated with and without trans-syndesmotic fixation in addition to open reduction and internal fixation of the fractures. Ankle range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Olerud-Molander Ankle Score (OMAS), tibiofibular overlap, tibiofibular clear space, and joint arthritis based on the Kellgren-Lawrence (K-L) scale were evaluated. RESULTS Median values of OMAS (Z=-3.92, p<0.001), AOFAS (Z=-4.31, p<0.001), and ROM (Z=-2.95, p=0.003) were higher in Group 1. There were no differences between the groups regarding tibiofibular overlap median values (Z=-0.59, p=0.0554), tibiofibular clear space (Z=-1.13, p=0.258), and Kellgren-Lawrence arthritis scale. Lack of posterior malleolus fixation was found to increase the risk of arthritis by 18.197 times, despite having trans-syndesmotic fixation, which was statistically significant (Confidence Interval, CI: 2.482-133.417, p=0.004) (Table 4). CONCLUSION Median values of OMAS, AOFAS, and ROM in patients without trans-syndesmotic fixation were lower. These results indicate that intraoperative tests may not provide entirely accurate results in SER type 4 injuries. Failure to detect a syndesmotic injury timely can result in instability. Therefore, we think that routine trans-syndesmotic fixation, as well as posterior malleolus fixation in SER type 4 ankle injuries, may improve outcomes.
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Affiliation(s)
- Gürkan Çalışkan
- University of Health Sciences Istanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul-Türkiye
| | - Yunus Elmas
- University of Health Sciences Istanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul-Türkiye
| | - Orhun Çelik
- University of Health Sciences Istanbul Kanuni Sultan Suleyman Training and Research Hospital, İstanbul-Türkiye
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Butler JJ, Randall GW, Dalmau-Pastor M, Lin CC, Schoof L, Kennedy JG. A hypertrophic distal fascicle of the anterior tibiofibular ligament is associated with a high rate of osteochondral lesions of the talus. Knee Surg Sports Traumatol Arthrosc 2024; 32:2452-2462. [PMID: 39033348 DOI: 10.1002/ksa.12360] [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: 03/30/2024] [Revised: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE The purpose of this retrospective review was to determine the prevalence of osteochondral lesions (OCLs) of the lateral talar dome in patients with anterior ankle impingement with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament. METHODS Retrospective chart review identified 40 patients who underwent anterior ankle arthroscopy for the management of anterior ankle impingement. Clinical outcomes assessed included pre- and postoperative foot and ankle outcome score (FAOS), visual analogue scale (VAS), complications, failures, secondary surgical procedures, return-to-work data and return-to-sport data. RESULTS Thirty-two patients with a mean follow-up time of 29.3 ± 10.4 months were included. The hypertrophic distal fascicle of the anterior tibio-fibular ligament was hypertrophic in 29 patients (90.6%), with a mean thickness of 2.5 ± 0.4 mm on MRI. There were 22 OCLs of the lateral talar dome (75.9%) with an associated hypertrophic distal fascicle of the anterior tibio-fibular ligament visualized during arthroscopy. The international cartilage repair society gradings of the lesions included 3 (13.6%) grade I lesions, 15 (68.1%) grade II lesions, 3 (13.6%) grade III lesions, and 1 (4.6%) grade IV lesion. There was a statistically significant improvement in mean FAOS and VAS scores from preoperative to postoperative (p < 0.001). No cases of syndesmotic instability were observed following resection of hypertrophic distal fascicle of the anterior tibio-fibular ligament. CONCLUSION This retrospective case series demonstrated that a hypertrophic distal fascicle of the anterior tibio-fibular ligament was associated with an OCL of the lateral talar dome identified during arthroscopic evaluation. In addition, preoperative MRI demonstrated poor sensitivity for the detection of these OCLs. Heightened awareness is warranted for potential lateral talar dome OCLs in patients presenting with anterolateral ankle impingement with a hypertrophic ATiFLdf identified on preoperative MRI in the absence of an associated OCLs. LEVEL OF EVIDENCE Level IV, Retrospective case series.
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Affiliation(s)
- James J Butler
- Department of Orthopaedic Surgery, Foot and Ankle Division, NYU Langone Health, New York City, New York, USA
| | - Grace W Randall
- Department of Orthopaedic Surgery, Foot and Ankle Division, NYU Langone Health, New York City, New York, USA
| | - Miki Dalmau-Pastor
- Human Anatomy and Embryology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
- MIFAS by GRECMIP (Minimally Invasive Foot and Ankle Society), Merignac, France
| | - Charles C Lin
- Department of Orthopaedic Surgery, Foot and Ankle Division, NYU Langone Health, New York City, New York, USA
| | - Lauren Schoof
- Department of Orthopaedic Surgery, Foot and Ankle Division, NYU Langone Health, New York City, New York, USA
| | - John G Kennedy
- Department of Orthopaedic Surgery, Foot and Ankle Division, NYU Langone Health, New York City, New York, USA
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Sun S, Tang T, Shi P, Yang C, Wang W, Chen L, Wei M. Standing on single foot-binding test yields satisfactory results as a novel method for the diagnosis of distal tibiofibular syndesmosis instability: a prospective, cross-sectional diagnostic-accuracy study. BMC Musculoskelet Disord 2024; 25:53. [PMID: 38216973 PMCID: PMC10785373 DOI: 10.1186/s12891-023-07155-6] [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: 11/27/2022] [Accepted: 12/26/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury. METHODS 85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests. Sensitivity, specificity, PPV, NPV, LR+, LR - and their 95% CIs were calculated for each of the clinical tests as well as for the positive clinical diagnosis. RESULTS The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR- (0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test. According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical practice for the prediction of DTSI. CONCLUSION This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal tibiofibular syndesmosis instability (DTSI). LEVEL OF EVIDENCE II.
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Affiliation(s)
- Shouqi Sun
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Tianshi Tang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Pengtao Shi
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Chen Yang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Wenjuan Wang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
| | - Lei Chen
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
| | - Min Wei
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
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Elsenosy AM, Mansy IH, Hassan E, Muthian S. Comparison of Two Different Methods to Evaluate Ankle Syndesmosis on Lateral Ankle Radiographs. Cureus 2023; 15:e51070. [PMID: 38146335 PMCID: PMC10749521 DOI: 10.7759/cureus.51070] [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: 12/25/2023] [Indexed: 12/27/2023] Open
Abstract
Background Ankle sprains and fractures rank among the most commonly occurring musculoskeletal injuries and hold significant relevance in current medical practice. Accurate information regarding these injuries is crucial for their effective treatment. This study aimed to explore the viability of utilizing ankle lateral radiographs to evaluate syndesmosis in both emergency settings and operating theatres. Methods This randomized retrospective clinical study involved the analysis of 150 ankle lateral radiographs (54 males and 96 females) from patients who presented at our emergency department with suspected ankle injuries. Two authors jointly examined these radiographs and reached a consensus. The anterior tibiofibular (ATF) ratio and anterior-posterior tibiofibular (APTF) ratio were computed. Patients requiring syndesmotic fixation were classified as having experienced a genuine syndesmotic injury. Participants were randomly divided into two equal groups: Group I (normal group) without fractures and Group II (abnormal group) with fractures. Comprehensive patient data, including medical history and clinical examinations, were recorded. Results Gender distribution within the studied population consisted of 54.67% males (n=41) and 45.33% females (n=34) in the abnormal group, while the normal group comprised 37.33% males (n=28) and 62.67% females (n=47). Both APTFR and ATFR methods were found to be inconclusive and unreliable for syndesmosis assessment in ankles. The sensitivity of APTFR stood at 21.33%, with a specificity of 86.67%, a positive predictive value (PPV) of 61.5%, and a negative predictive value (NPV) of 52.4%. Meanwhile, the sensitivity of ATFR was 32%, with a specificity of 80%, a PPV of 61.5%, and an NPV of 54.1%. Conclusions Both techniques demonstrated low sensitivity when ankle fractures were present, indicating their unsuitability for routine clinical diagnosis of syndesmotic disruption via lateral ankle radiographs.
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Affiliation(s)
| | - Islam H Mansy
- General Surgery and Surgical Oncology, Maadi Armed Forces Medical Complex, Cairo, EGY
| | - Eslam Hassan
- Trauma and Orthopaedics, Poole General Hospital, Poole, GBR
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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.
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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;
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Yang Z, Chen J, Liu X, Wang B, Zhao X, Guan P. Clinical study of a steel cable fixation for distal tibiofibular syndesmosis injury. Medicine (Baltimore) 2023; 102:e35691. [PMID: 37861530 PMCID: PMC10589572 DOI: 10.1097/md.0000000000035691] [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: 05/25/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND In order to overcome the shortcomings of common surgical fixation methods for Distal Tibiofibular Syndesmosis (DTS) injuries, which include the inability to exercise early, significant surgical trauma, and the risk of loosening and breakage of implants, we have designed and implemented a new technique using steel cable fixation to treat DTS injuries. METHODS Twenty-six patients treated with steel cable fixation for DTS injury between March 2013 and March 2019 in the Second Hospital of Tangshan City trauma department were followed up to monitor the efficacy of treatment. There were 16 males and 10 females between the ages of 19 and 64, with a mean age of 41.81 ± 9.54 years. All patients were examined by X-ray and CT for 3 days before and after surgery. The patients were then reexamined by X-ray 6 and 9 weeks postoperatively, and by CT 1 year later. The treatment results were evaluated by comparing the distal tibiofibular anterior, middle, and posterior gap changes and the Baird-Jackson score. RESULTS The 26 patients attained good postoperative repositioning, with a fracture healing time of 2.5 to 3 months. and the Baird-Jackson score was 96 ± 2.78. After surgery, the DTS gaps observed in the CT scans taken 3 days and 1 year postoperatively in all patients were significantly reduced compared to the preoperative measurements, with statistical significance (P < .05). However, when comparing the CT scans taken 1 year postoperatively to those at 3 days postoperatively, there was no significant change in the anterior gap. The middle and posterior gaps of DTS showed a slight increase with statistical significance (P < .05), but all measurements remained within the normal range. CONCLUSION Steel cable fixation for DTS injury has the advantages of reliable fixation, early functional exercise, and reduction in the number of operations, and no adverse effects or complications were found.
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Affiliation(s)
- Zuoming Yang
- Department of Orthopaedic Trauma, The Second Hospital of Tangshan, Tangshan, China
| | - Junfei Chen
- Department of Orthopaedic Trauma, The Second Hospital of Tangshan, Tangshan, China
| | - Xiaoming Liu
- Department of General Medicine, Tangshan Gongren Hospital, Tangshan, China
| | - Bin Wang
- Department of Orthopaedic Trauma, The Second Hospital of Tangshan, Tangshan, China
| | - Xiaoming Zhao
- Department of Orthopaedic Trauma, The Second Hospital of Tangshan, Tangshan, China
| | - Pengfei Guan
- Department of Orthopaedic Trauma, The Second Hospital of Tangshan, Tangshan, China
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11
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Chen J, Peng X, Yang Y, Tang X, Yang S, Liu T, Shi H, Zhang L. In Different Gender Groups, What Is the Impact of the Fibular Notch on the Severity of High Ankle Sprain: A Retrospective Study of 360 Cases. Orthop Surg 2023; 15:2557-2565. [PMID: 37537373 PMCID: PMC10549795 DOI: 10.1111/os.13833] [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: 02/10/2023] [Revised: 06/21/2023] [Accepted: 06/24/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVES The role of the distal tibiofibular ligament in the occurrence of high ankle sprain (HAS) has been widely studied. But previous studies have overlooked the physiological and anatomical differences between males and females and have not further refined gender. Therefore, the impact of the anatomical morphology of fibular notch (FN) on HAS in different genders is still unclear. This study aimed to explore the impact of different types of FN on the severity of HAS and to estimate the prognosis of patients with HAS while excluding anatomical differences caused by gender. METHODS One hundred and eighty patients with HAS were included in this study as the experimental group (i.e., HAS group). They were further divided into four groups according to gender and FN depth, with deep concave FN ≥ 4 mm and shallow flat FN < 4 mm. Another 180 normal individuals were set as the control group. The FN morphological indicators, tibiofibular distance (TFD), and ankle mortise indexes were measured and compared with those in HAS group. The independent t-test was used to compare continuous variables between groups, the intraclass correlation coefficient (ICC) was used to analyze the reliability of intra-observer measurement, and the Pearson correlation coefficient was used to verify the correlation between FN and the severity of HAS. RESULTS In males with shallow flat type, the measurements of anterior tibiofibular distance (aTFD), middle tibiofibular distance (mTFD), posterior tibiofibular distance (pTFD), front ankle mortise width (fAMW), middle ankle mortise width (mAMW), posterior ankle mortise width (pAMW), and depth of ankle mortise (DOAM) in HAS group were significantly larger than those in normal group (p < 0.05). In male patients with deep concave type, the measurements of aTFD, mTFD, fAMW, mAMW, and DOAM were significantly larger than those in normal group (p < 0.05). Among female patients with shallow flat type, the measurements of aTFD, mTFD, pTFD, fAMW, mAMW, pAMW, and DOAM were found to be significantly larger than those in normal group (p < 0.05). Among female patients with deep concave type, the measurements of mTFD, pTFD, fAMW, mAMW, and DOAM were found to be significantly larger than those of the normal group (p < 0.05). The depth of FN was negatively correlated with TFD, and the AOFAS score of patients with shallow flat type was significantly lower than that of patients with deep concave type after treatment (p < 0.05). CONCLUSIONS In different gender groups, compared with the normal controls, the TFD and partial ankle mortise indices were significantly different in HAS patients. Moreover, FN depth was negatively correlated with TFD, and the AOFAS score of shallow flat patients was significantly lower than that of deep concave patients. These suggested that shallow flat FN may be associated with more severe distal tibiofibular ligament injury and ankle mortise widening, leading to poorer prognosis. This should be taken seriously in clinical practice.
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Affiliation(s)
- Junyao Chen
- School of Clinical MedicineSouthwest Medical UniversityLuzhouChina
| | - Xiaoyao Peng
- School of Clinical MedicineSouthwest Medical UniversityLuzhouChina
| | - Yuening Yang
- School of Clinical MedicineSouthwest Medical UniversityLuzhouChina
| | - Xiangyu Tang
- School of Clinical MedicineSouthwest Medical UniversityLuzhouChina
| | - Siyi Yang
- School of Integrated Traditional Chinese and Western MedicineSouthwest Medical UniversityLuzhouChina
| | - Tianyu Liu
- School of Clinical MedicineSouthwest Medical UniversityLuzhouChina
| | - Houyin Shi
- Department of OrthopedicsThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhouChina
| | - Lei Zhang
- Department of OrthopedicsThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhouChina
- Center for Orthopedic Diseases ResearchThe Affiliated Traditional Chinese Medicine Hospital of Southwest Medical UniversityLuzhouChina
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12
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Ataoğlu MB, Tokgöz MA, Özer M, Köktürk A, Yaka H, Ergişi Y. Radiological Evaluation of Distal Tibiofibular Joint Anatomy Variations in Patients with and Without Syndesmotic Injury. Indian J Orthop 2023; 57:1473-1477. [PMID: 37609029 PMCID: PMC10441950 DOI: 10.1007/s43465-023-00952-0] [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: 11/20/2021] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
Introduction Syndesmosis injuries are a common and debilitating problem affecting the ankle joint, but the precise causes of these injuries remain unclear. In the current retrospective study, it was aimed to investigate the relationship between variations in the distal tibiofibular syndesmosis and surgically proven syndesmosis injuries. Patients and Method A total of 57 patients with surgically proven syndesmosis injuries and 51 patients without syndesmosis injuries were included as the control group. Computed tomography (CT) scans were used to measure six anatomical features 1 cm proximal to the tibiotalar joint, including the anterior facet length (a), posterior facet length (b), angle between the anterior and posterior facets (c), fibular incisura depth (d), tibia thickness (e), and fibula thickness (f). Results Comparing the measurements of the patients with and without syndesmosis injury, it was demonstrated that the anterior facet length (a) (p = 0.022) was shorter and the a-b difference (anterior facet length-posterior facet length difference) (p = 0.010) tended toward negative values. Pearson correlation analysis demonstrated that a (r = - 0.211, p < 0.033) and a-b (r = - 0.254, p = 0.010) measurements were strongly negatively correlated with syndesmosis injury. Discussion Our study findings suggest that the shortness of the anterior facet and the difference in length are related to syndesmosis injuries. To the best of our knowledge, this is the first study to report this relationship with syndesmosis. This study sheds light on the underlying mechanisms of syndesmosis injury, which could help clinicians in the diagnosis, treatment, and prevention of this common ankle injury.Level of evidence: Level 4: case-control study.
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Affiliation(s)
- Muhammet Baybars Ataoğlu
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mh. Gazi Üniversitesi Tıp Fakültesi, Ankara, 06560 Turkey
| | - Mehmet Ali Tokgöz
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mh. Gazi Üniversitesi Tıp Fakültesi, Ankara, 06560 Turkey
| | - Mustafa Özer
- Department of Orthopaedics and Traumatology, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Anıl Köktürk
- Department of Orthopaedics and Traumatology, Medical Park Ankara Hospital, Ankara, Turkey
| | - Haluk Yaka
- Department of Orthopaedics and Traumatology, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Yılmaz Ergişi
- Department of Orthopaedics and Traumatology, Karabuk University Faculty of Medicine, Karabük, Turkey
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Yoon SJ, Yeo ED, Jung KJ, Hong YC, Hong CH, Won SH, Lee KJ, Ji JY, Byeon JY, Lee DW, Kim WJ. Evaluating the Efficacy of Tension Band Wiring Fixation for Chaput Tubercle Fractures. J Clin Med 2023; 12:5490. [PMID: 37685557 PMCID: PMC10488479 DOI: 10.3390/jcm12175490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Chaput tubercle fractures, located at the attachment site of the anterior inferior tibiofibular ligament (AITFL) on the distal tibia, have the potential to destabilize the syndesmosis joint. This study aims to assess the effectiveness of tension band wiring (TBW) as a surgical intervention for managing Chaput fractures and the consequent syndesmosis instability. METHODS A retrospective review of patient charts was undertaken for those who had undergone ankle fracture surgery from April 2019 through May 2022. The surgical procedure involved direct fixation of the Chaput fractures using the TBW method. Radiological assessments were performed using postoperative simple radiographs and computed tomography (CT) scans, while clinical outcomes were evaluated using the Olerud-Molander Ankle Score (OMAS) and the visual analog scale (VAS). RESULTS The study included 21 patients. The average OMAS improved significantly, rising from 5.95 preoperatively to 83.57 postoperatively. Similarly, the average VAS score dropped from 7.95 before the surgery to 0.19 thereafter. Minor wound complications were reported by three patients, and one case of superficial infection was resolved with antibiotic therapy. CONCLUSIONS Our findings suggest that the TBW technique is an effective surgical approach for treating Chaput fractures and associated syndesmosis instability. It provides reliable fixation strength and leads to improved long-term functional outcomes. Further research is needed to compare the TBW technique with alternative methods and optimize the treatment strategies for these complex ankle fractures.
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Affiliation(s)
- Sung-Joon Yoon
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Eui-Dong Yeo
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul 05368, Republic of Korea;
| | - Ki-Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Yong-Cheol Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Chang-Hwa Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Sung-Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea;
| | - Kyung-Jin Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170, Jomaru-ro, Bucheon-si 14584, Republic of Korea;
| | - Jae-Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Je-Yeon Byeon
- Department of Plastic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Dhong-Won Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, Seoul 05030, Republic of Korea;
| | - Woo-Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
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Lei Q, Chen P, He X, Xu Z, He W. Preoperative CT parameters to predict tibiofibular syndesmosis injury associated with ankle fracture: a propensity score-matched analysis. Eur J Trauma Emerg Surg 2023; 49:1883-1890. [PMID: 37072565 DOI: 10.1007/s00068-023-02256-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/24/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Untreated ankle fractures with concomitant tibiofibular syndesmosis injury often lead to postoperative pain and early traumatic arthritis. CT has advantages in the preoperative diagnosis of combined ankle injuries. However, a few studies have investigated the best preoperative CT parameters to predict tibiofibular syndesmosis injuries associated with ankle fractures. This study aimed to identify and evaluate the optimal preoperative CT parameters for predicting tibiofibular syndesmosis injuries associated with ankle fractures. METHODS We retrospectively analyzed 129 patients who underwent preoperative CT of an ankle fracture treated between January 2016 and April 2022 at a tertiary A hospital. All patients underwent open reduction and internal fixation and intraoperative stability testing. Based on the Cotton test, the patients were divided into the stable group (n = 83, 64.3%) and unstable group (n = 46, 35.7%). After 1:1 propensity score matching, the general conditions, anterior tibiofibular distance (TFD), posterior TFD, maximum TFD, tibiofibular syndesmosis area, sagittal fracture angle, Angle-A, and Angle-B were compared between the stable and unstable groups. RESULTS The propensity score-matched cohort comprised 82 patients. There were no significant differences between the stable and unstable groups in sex, age, affected side, operation interval, injury mechanism, Lauge-Hansen classification, sagittal fracture angle, and Angle-A (all P > 0.05). Compared with the stable group, the unstable group had a significantly greater aTFD, pTFD, maxTFD, and area (all P < 0.05). PTFD, maxTFD, and area were positively correlated with joint instability. Angle-B was smaller in the unstable group (57.13°) than the stable group (65.56°). ROC analysis showed that Area (AUC 0.711) and maxTFD (AUC 0.707) had the highest diagnostic efficacy. CONCLUSION MaxTFD and Area were the best predictive parameters; a larger Area was associated with a higher likelihood of instability of the tibiofibular syndesmosis after ankle fracture fixation.
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Affiliation(s)
- Qinliang Lei
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Pinhua Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China
| | - Xueyi He
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China
| | - Zhixian Xu
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China.
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China.
| | - Wubing He
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Emergency Trauma Surgery, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Fujian Trauma Medicine Center, Fuzhou, 350001, Fujian, China.
- Fujian Key Laboratory of Emergency Medicine, Fuzhou, 350001, Fujian, China.
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15
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Lin X, Tu C, Lin W, Xie W, Guo X, Liu Q. Comparison the treatment of anterior inferior tibiofibular ligament anatomical repair and syndesmosis screw fixation for syndesmotic injuries in ankle fracture. BMC Surg 2023; 23:80. [PMID: 37038119 PMCID: PMC10084683 DOI: 10.1186/s12893-023-01982-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 03/31/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND The fixation method of syndesmotic injuries in ankle fractures remains controversial. The goal of the study was to compare radiographic and clinical outcomes between anterior inferior tibiofibular ligament (AITFL) anatomical repair with syndesmosis screw fixation in syndesmotic injuries. METHODS We analyzed 62 patients who were treated with AITFL anatomical repair or syndesmosis screw fixation for syndesmotic injuries in an advanced teaching hospital between March 2016 and March 2019. Fixation was performed with AITFL anatomical repair in 30 patients (AAR group) and syndesmosis screw in 32 patients (SS group). Radiographic evaluations were the differences in mean anterior and posterior (A difference and P difference) tibiofibular distance between injured and uninjured ankle computed tomography (CT) scan at 6 months postoperatively. Clinical evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score, the Olerud-Molander Ankle (OMA) score and visual analogue scale (VAS) score at 1, 3, 6 months and 1, 2 years postoperatively. RESULTS The A difference and P difference on CT was no differences (1.6 ± 0.8 mm, 1.3 ± 0.7 mm vs. 1.5 ± 0.7 mm, 1.2 ± 0.7 mm) between the two groups (All of P > 0.05). The AAR group had higher mean AOFAS score (65.6 ± 5.9, 82.3 ± 4.2, 87.6 ± 5.6 vs. 61.8 ± 5.2, 79.1 ± 4.0, 83.8 ± 4.9; P = 0.008, 0.003, 0.007) and higher mean OMA score (45.7 ± 8.7, 79.2 ± 6.5, 84.1 ± 5.3 vs. 40.4 ± 7.3, 74.8 ± 6.3, 80.3 ± 5.8; P = 0.012, 0.009, 0.010)) at 1, 3 and 6 months postoperatively. The AAR group had lower mean VAS scores (2.6 ± 1.2, 1.7 ± 0.7 vs. 3.4 ± 1.2, 2.2 ± 1.1; P = 0.018, 0.038) at 1 and 3 months postoperatively. CONCLUSIONS The results of this study suggest that the AITFL anatomical repair technique could effectively improve ankle function during daily activity. Therefore, AITFL anatomical repair technique is expected to become a better fixation method for syndesmotic injuries.
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Affiliation(s)
- Xuping Lin
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, 363000, Fujian Province, China
- School of Medicine, Xiamen University, Xiamen, 361005, China
| | - Chengquan Tu
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, 363000, Fujian Province, China
- School of Medicine, Xiamen University, Xiamen, 361005, China
| | - Weihuang Lin
- Department of Orthopedic Surgery, Xiamen Haicang Hospital, Xiamen, 361100, China
| | - Weina Xie
- Department of Anesthesiology, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, 363000, China
| | - Xiaowei Guo
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, 363000, Fujian Province, China
| | - Qingjun Liu
- Department of Orthopedic Surgery, The Affiliated Dongnan Hospital of Xiamen University, Zhangzhou, 363000, Fujian Province, China.
- School of Medicine, Xiamen University, Xiamen, 361005, China.
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A Tension-Band Wiring Technique for Direct Fixation of a Chaput Tubercle Fracture: Technical Note. Medicina (B Aires) 2022; 58:medicina58081005. [PMID: 36013472 PMCID: PMC9412543 DOI: 10.3390/medicina58081005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Few reports have described direct fixation of the Chaput tubercle; screw fixation is usually employed. Herein, we introduce a novel technique for Chaput tubercle fixation using tension-band wiring. This technique is applicable to fractured tubercles of various sizes and has the advantage that the fragment breakage that may occur during screw fixation is impossible. In addition, our technique increases fixation strength.
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17
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Lu C, Fan Y, Yu G, Chen H, Sinclair J, Fan Y. Asymptomatic foot and ankle structural injuries: a 3D imaging and finite element analysis of elite fencers. BMC Sports Sci Med Rehabil 2022; 14:50. [PMID: 35346343 PMCID: PMC8962477 DOI: 10.1186/s13102-022-00444-y] [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] [Received: 04/28/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Fencing is a highly asymmetrical combat sport, that imposes high mechanical demands over repeated exposures on the musculoskeletal structures, a primary cause of injuries in fencers. However, there are limited epidemiological studies on the structural injuries of the foot and ankle in fencers. This study aimed to investigate foot and ankle structural injuries, and explore how metatarsophalangeal joint structural changes may affect the mechanisms of foot and ankle injuries in asymptomatic fencers. METHODS 3D images of foot and ankle morphology using computed tomography were obtained from ten elite fencers. We then constructed finite element models of the first metatarsophalangeal joint in the foot of their trail legs. The validated models were used to simulate stress distribution changes from different ankle joint angles during lunging. RESULTS The findings showed that stress distribution changes at the medial and lateral sesamoid may have caused sesamoid fractures, and that habitual and concentrated stress on the metatarsal bones might have flattened the sesamoid groove. This process may damage the integrity of the first metatarsophalangeal joint, and consequently affect the efficiency of the windlass mechanism in fencers. During lunging, different ankle joint angles of the trail foot increased the total stress difference of the medial and lateral foot, and thus influenced the lunging quality and its stability. CONCLUSIONS Our findings revealed that the asymmetric nature of fencing might have caused asymptomatic foot and ankle structural injuries, and finite element analysis results indicated that this might increase the incidence of the serious injuries if unattended. Regular computed tomography examination should be introduced to monitor elite fencers' lower limb alterations, permitting unique angle adjustments in the trail foot without sacrificing technical or physiologic properties based on the exam results and reduce the lower limb injury risk.
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Affiliation(s)
- Congfei Lu
- Foot Research Laboratory, Key Laboratory of Sport and Health Science of Fujian Province, School of Physical Education and Sport Science, Fujian Normal University, Fuzhou, 350117, China
| | - Yuxuan Fan
- Foot Research Laboratory, Key Laboratory of Sport and Health Science of Fujian Province, School of Physical Education and Sport Science, Fujian Normal University, Fuzhou, 350117, China
| | - Genyu Yu
- Foot Research Laboratory, Key Laboratory of Sport and Health Science of Fujian Province, School of Physical Education and Sport Science, Fujian Normal University, Fuzhou, 350117, China
| | - Hua Chen
- Foot Research Laboratory, Key Laboratory of Sport and Health Science of Fujian Province, School of Physical Education and Sport Science, Fujian Normal University, Fuzhou, 350117, China
| | - Jonathan Sinclair
- Research Centre for Applied Sport, Physical Activity and Performance, School of Sport and Health Sciences, University of Central Lancashire, Lancashire, Preston, PR1 2HE, UK
| | - Yifang Fan
- Foot Research Laboratory, Key Laboratory of Sport and Health Science of Fujian Province, School of Physical Education and Sport Science, Fujian Normal University, Fuzhou, 350117, China.
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Clinical outcomes of isolated acute instability of the syndesmosis treated with arthroscopy and percutaneous suture-button fixation. Arch Orthop Trauma Surg 2021; 141:1567-1574. [PMID: 33580342 DOI: 10.1007/s00402-021-03813-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 02/01/2021] [Indexed: 01/17/2023]
Abstract
INTRODUCTION To present the short- to midterm clinical outcomes of a series of patients with isolated acute syndesmosis instability treated with arthroscopy and percutaneous suture-button fixation. MATERIALS AND METHODS A review of 17 patients treated through the arthroscopic approach. The mean age of the patients was 27.8 years and the mean follow-up was 31.5 months. Clinical and functional evaluations were based on the VAS, AOFAS ankle-hindfoot score and time of return to preinjury level of activities. Imaging analysis was performed with stress radiographs, MRI and CT scan with stress. RESULTS The average VAS was 0.5 and the mean AOFAS score was 95.5. Out of the 17 patients, 15 were able to return to their preinjury level of activities. The mean time of return to activities was 5.06 months. CONCLUSION Arthroscopic approach and percutaneous suture-button fixation provided satisfactory clinical and functional results for selected patients with ASI at short- to midterm follow-up. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Alastuey-López D, Seral B, Pérez MÁ. Biomechanical evaluation of syndesmotic fixation techniques via finite element analysis: Screw vs. suture button. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106272. [PMID: 34293494 DOI: 10.1016/j.cmpb.2021.106272] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/01/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Tibiofibular syndesmotic injuries may cause degenerative changes, reduction in ankle function and compromising ankle stability. Different fixation techniques try to restore its functionality. Screw-fixation is the gold-standard. Recently, suture-button fixation has aroused the attention because it allows for physiologic micromotion while maintaining an accurate reduction. The aim of this study is to compare the biomechanical behaviour of both fixation techniques using the finite element method. METHODS A three-dimensional finite element model of the tibiofibular joint was reconstructed simulating the intact ankle and the injured syndesmosis. Then, different methods of syndesmosis fixation were analysed: screws (number of cortices, number of screws and distance between screws) and suture buttons (single, double parallel and double divergent with a sensitivity analysis on the pretension forces) configuration. Ligaments and cartilages were included and simulated as spring elements. Physiological loads during stance phase were simulated. RESULTS Syndesmosis widening and von Mises stresses were computed. Syndesmosis widening in the injured configuration compromised joint stability (2.06 mm), whereas using a single quadricortical screw (0.18 mm) stiffened the joint. Syndesmosis widening using suture-buttons were closer to syndesmosis widening of the intact ankle configuration (0.97 mm). Von Mises stresses were higher for the titanium screws than for the suture buttons. CONCLUSIONS A detailed biomechanical comparison among different syndesmotic fixation was performed. Suture buttons have advantages with regard to syndesmosis widening in comparison to screw fixation. This fact supports the good long-term clinical results obtained with suture buttons fixation. The proposed methodology could be an efficient tool for preoperative planning.
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Affiliation(s)
- Diego Alastuey-López
- M2BE-Multiscale in Mechanical and Biological Engineering, Instituto de Investigación en Ingeniería de Aragón (I3A), Aragón Institute of Health Science (IACS), Universidad de Zaragoza, Campus Río Ebro, c/María de Luna s/n, 50018-Zaragoza, España, Spain.
| | - Belén Seral
- Hospital Universitario "Lozano Blesa", Aragón Institute of Health Science (IACS), University of Zaragoza,, Zaragoza, Spain.
| | - Mª Ángeles Pérez
- M2BE-Multiscale in Mechanical and Biological Engineering, Instituto de Investigación en Ingeniería de Aragón (I3A), Aragón Institute of Health Science (IACS), Universidad de Zaragoza, Campus Río Ebro, c/María de Luna s/n, 50018-Zaragoza, España, Spain.
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20
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Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: A cadaveric study. Injury 2021; 52 Suppl 3:S84-S88. [PMID: 34088466 DOI: 10.1016/j.injury.2021.02.017] [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: 01/17/2021] [Revised: 02/06/2021] [Accepted: 02/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In surgically treated rotational malleolar fractures, residual syndesmotic instability is typically assessed following fixation with the widely used intraoperative Cotton test. However, due to its dynamic nature, there are inconsistencies of the magnitude and direction of the distraction force when attempting to pull the fibula away from the tibia using a bone hook. The novel Tap test advances a cortical tap through a drilled hole in the fibula with a stable, unidirectional distraction force applied to the tibia. The objective of this cadaveric study was to compare the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability. METHODS Tibiofibular Clear Space (TFCS) of 10 cadaveric specimens was measured for: intact, non-stressed; intact, stressed; injured, non-stressed; and injured, stressed (Tap and Cotton tests). In injured conditions, the syndesmotic ligamentous complex was sectioned using an anterolateral longitudinal approach. Perfect fluoroscopic Mortise images were acquired for all conditions. Two independent and blinded Orthopaedic Foot and Ankle Surgeons measured TFCS 1 cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient. Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed using a relative increase of TFCS > 2 mm when comparing intact stressed and injured stressed conditions. P-values <0.05 were considered significant. RESULTS The intraclass correlation coefficient for intraobserver and interobserver reliability was respectively 0.96 and 0.79. TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non-stressed conditions, with mean values and 95% Confidence Intervals of: intact non-stressed, 3.5 mm; intact stressed, 3.6 mm (Cotton test) and 4.0 mm (Tap test); injured non-stressed, 3.8 mm. The Cotton test and Tap test had, respectively, 73.3% and 70% sensitivity, 100% and 90% specificity, 86.7% and 80% diagnostic accuracy. CONCLUSIONS Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in the TFCS measurements in stressed injured conditions when compared to intact non-stressed and stressed conditions, as well as injured non-stressed conditions.
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21
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Pogliacomi F, De Filippo M, Casalini D, Longhi A, Tacci F, Perotta R, Pagnini F, Tocco S, Ceccarelli F. Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts. World J Orthop 2021; 12:270-291. [PMID: 34055585 PMCID: PMC8152437 DOI: 10.5312/wjo.v12.i5.270] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
| | - Massimo De Filippo
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Daniele Casalini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Alberto Longhi
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Fabrizio Tacci
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Rocco Perotta
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Francesco Pagnini
- Department of Medicine and Surgery, University of Parma, Parma 43126, Italy
| | - Silvio Tocco
- Centro Riabilitativo della Mano e Arto Superiore, Parma 43121, Italy
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22
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Rellensmann K, Baumbach SF, Polzer H. [28/f-Ankle sprains: not always are the lateral ligaments injured : Preparation for the medical specialist examination: part 64]. Unfallchirurg 2021; 124:179-183. [PMID: 33620519 DOI: 10.1007/s00113-021-00961-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Kathrin Rellensmann
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland
| | - Sebastian F Baumbach
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland
| | - Hans Polzer
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Universität München, LMU München, Nussbaumstr. 20, 80336, München, Deutschland.
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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.
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Huang H, Yang Y. [Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1346-1351. [PMID: 33063503 DOI: 10.7507/1002-1892.201911090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the research progress in the diagnosis and treatment of distal tibiofibular syndesmosis injury. Methods The recent literature about distal tibiofibular syndesmosis injury was reviewed and analyzed. Results Distal tibiofibular syndesmosis injury is commonly seen in ankle joint injury, the anatomical complexities make diagnosis and treatment difficult. Preoperative physical examination, radiologic evaluation, and intraoperative stress-testing are important for the diagnosis. Aggressive treatment is also recommended for these injuries to prevent long-term chronic instability. Internal fixation is the main treatment, including metal screw, degradable screw, elastic fixation, and hybrid techniques. Metal screw fixation is still the current mainstream, but elastic fixation represented by Suture-button is more in line with the physiological characteristics of ankle joint, and the rate of secondary operation is low while the clinical outcome is satisfactory. The application prospect of elastic fixation is worthy of expectation. Conclusion It's crucial for patient with ankle fracture to repair the distal tibiofibular syndesmosis injury. How to diagnose the injury more accurately and simply, how to increase the success rate of reduction, and how to reduce the complications of surgery are still worthy for further exploration.
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Affiliation(s)
- Hui Huang
- Department of Orthopaedics, Tongji Hospital, Tongji University, Shanghai, 200065, P.R.China
| | - Yunfeng Yang
- Department of Orthopaedics, Tongji Hospital, Tongji University, Shanghai, 200065, P.R.China
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25
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Abstract
Optimal healing for fractures requires anatomic reduction and stable fixation. This optimizes not only bone healing, but optimal function within the limb including joint functioning. Proper ligamentous healing is also crucial for optimal functioning. In patients with injuries around the ankle involving distal tibiofibular syndesmotic injuries of the ankle, malreduction of the syndesmosis is a potential consequence that can lead to chronic pain and functional limitations. This article discusses proper ways of evaluating reduction of the syndesmosis and surgical revision for the chronic injury.
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Gräff P, Alanazi S, Alazzawi S, Weber-Spickschen S, Krettek C, Dratzidis A, Fleischer-Lueck B, Hawi N, Liodakis E. Screw fixation for syndesmotic injury is stronger and provides more contact area of the joint surface than TightRope®: A biomechanical study. Technol Health Care 2020; 28:533-539. [PMID: 32280069 DOI: 10.3233/thc-191638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The rupture of syndesmotic ligaments is treated with a screw fixation as the gold standard. An alternative is the stabilization with a TightRope®. A couple of studies investigated the different clinical outcome and some even looked at the stability in the joint, but none of them examined the occurring pressure after fixation. OBJECTIVE Is there a difference in pressure inside the distal tibiofibular joint between a screw fixation and a TightRope®? Does the contact area differ in these two treatment options? METHODS This biomechanical study aimed to investigate the differences in fixation of the injured syndesmotic ligaments by using a fixation with one quadricortical screw versus singular TightRope® both implanted 1 cm above the joint. By using 12 adult lower leg cadaveric specimens and pressure recording sensor, we recorded the pressure across the distal tibiofibular joint. Additionally we measured the contact surface area across the joint. RESULTS The mean of the pressure across the distal tibiofibular joint from the start of the insertion of the fixation device to the complete fixation was 0.05 Pascal for the TightRope® and 0.1 for the screw (P= 0.016). The mean of the maximum pressure across the joint (after completion of fixation and releasing the reduction clamp) was 1.750 mega Pascal with the screw fixation and 0.540 mega Pascal with TightRope® (P= 0.008). The mean of the measured contact area of the distal tibiofibular joint after fixation was 250 mm2 in the TightRope® group and of 355 mm2 in the screw fixation (P= 0.123). CONCLUSIONS The screw fixation is stronger and provides a larger surface contact area, which leads us to the conclusion that it provides a better stability in the joint. While previous clinical studies did not show significant clinical difference between the two methods of fixation, the biomechanical construct varied. Long term clinical studies are required to establish whether this biomechanical distinction will contribute to various clinical outcomes.
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Affiliation(s)
- Pascal Gräff
- Trauma Department, Hannover Medical School, Hannover, Germany
| | | | | | | | | | | | - Benjamin Fleischer-Lueck
- Laboratory for Biomaterials and Biomechanics, Orthopaedic Surgery Department, Hannover Medical School, Hannover, Germany
| | - Nael Hawi
- Trauma Department, Hannover Medical School, Hannover, Germany
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Accuracy of cone-beam computed tomography for syndesmosis injury diagnosis compared to conventional computed tomography. Foot Ankle Surg 2020; 26:265-272. [PMID: 30992183 DOI: 10.1016/j.fas.2019.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 03/15/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Syndesmosis injury can lead to ankle mortise instability and early osteoarthritis. Several multiple detector computed tomography (MDCT) methods for measurement have been developed. Weight-bearing cone beam CT (WB CBCT) is an emerging technique that offers the possibility of upright-position scanning and lower doses. This study sought to assess the diagnostic accuracy of WB CBCT in syndesmose injury compared to MDCT, with instability confirmed via manual testing upon arthroscopic examination. METHODS Three musculoskeletal radiologists with different levels of expertise prospectively analyzed 11 MDCT and eight WB CBCT scans of the same trauma-afflicted ankles with clinical suspicion of syndesmosis lesion over a period of 5 months. They evaluated 10 methods of measurement in both sides. Syndesmosis was considered pathological on arthroscopic examination in four patients. Correlation between readers was evaluated with intra-class correlation testing (p < 0.05 was considered significant). Capacity of discrimination was assessed by area under the curve (AUC) for all methods. RESULTS Inter-observer agreement was near excellent for both WB CBCT and MDCT for the anterior tibio-fibular (TF) distance (ICC = 0.781 and 0.831, respectively), posterior TF distance (ICC = 0.841 and 0.826), minimal TF distance (ICC = 0.899 and 0.875), and TF surface (ICC = 0.93 and 0.84). AUC were better for MDCT than WB CBCT in assessing syndesmosis instability for: anterior TF distance (ROC = 0.869 vs. 0.555, p = 0.01), minimal TF distance (ROC = 0.883 vs. 0.608, p = 0.02) and antero-posterior fibular translation (ROC = 0.894 vs. 0.467, p = 0.006). CONCLUSIONS MDCT demonstrated better ability to distinguish pathological syndesmosis than WB CBCT, with the antero-posterior fibular translation the best discriminating measurement. The physiological widening of the contralateral syndesmosis occurring with the WB CBCT upright position may explain these results.
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Bai L, Zhang W, Guan S, Liu J, Chen P. Syndesmotic malreduction may decrease fixation stability: a biomechanical study. J Orthop Surg Res 2020; 15:64. [PMID: 32085779 PMCID: PMC7035663 DOI: 10.1186/s13018-020-01584-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/07/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This study aims to investigate the malreduction of syndesmosis and its effects on stability. METHODS The biomechanical tests, including the three-dimensional (3D) displacement of the syndesmotic incisura, fibular rotation angle, and torque resistance, were performed on six cadaver legs. These specimens were first tested intact (intact group), then cut all the syndesmotic ligaments and fixed in anatomical position (anatomical model group) and test again. After that, syndesmosis was fixed in 1 cm malreduction (anterior and posterior displacement group) to do the same test. RESULTS In internal or external load, there were significant differences in torque resistance and fibular rotation angle (internal t = 2.412, P = 0.036; external t = 2.412, P = 0.039) between the intact and post-malreduction groups. In internal rotation load, there were significant differences in sagittal displacement between the intact and post-malreduction groups (P = 0.011), and between the anatomical and post-malreduction groups (P = 0.020). In external rotation load, significant differences existed between the intact and ant-malreduction group (P = 0.034) in sagittal (anterior-posterior) displacement. Significant differences also existed between the intact and post-malreduction groups (P = 0.013), and between the anatomical and post-malreduction groups (P = 0.038) in coronal (medial-lateral) displacement. CONCLUSIONS Malreduction in different conditions does affect the stability of the syndesmotic fixation. The result of the study may reveal the biomechanical mechanism of poor clinical outcome in syndesmosis malreduction patients and pathological displacement patterns of the ankle under syndesmotic malreduction conditions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lu Bai
- Department of Sports Medicine, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China
- National and Local Joint Engineering Research Center of Orthopaedic Biomaterials, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China
| | - Wentao Zhang
- Department of Sports Medicine, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China.
| | - Siyao Guan
- Department of Sports Medicine, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China
| | - Jianxin Liu
- Department of Rehabilitation, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China
| | - Peng Chen
- Department of Sports Medicine, Peking University Shenzhen Hospital, #1120 Lianhua Road, Shenzhen, Guangdong Province, China
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Abstract
Foot and ankle injuries account for a significant volume of primary care office visits each year. Given the incidence of injury and concern for long-term sequelae, it is imperative that primary care physicians familiarize themselves with commonly encountered foot and ankle injuries. Coupling a sound understanding of key anatomic structures with an appropriately gathered history can help to quickly narrow the differential diagnosis in this clinical presentation. This article focuses on key elements from the history and physical examination as well as provides a concise review of imaging modalities and recommended treatment strategies.
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30
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Bae KJ, Kang SB, Kim J, Lee J, Go TW. Reduction and fixation of anterior inferior tibiofibular ligament avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. J Int Med Res 2019; 48:300060519882550. [PMID: 31885342 PMCID: PMC7607056 DOI: 10.1177/0300060519882550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objective We aimed to present the radiographic and functional outcomes of anatomical reduction and fixation of anterior inferior tibiofibular ligament (AITFL) avulsion fracture without syndesmotic screw fixation in rotational ankle fracture. Methods We retrospectively reviewed 66 consecutive patients with displaced malleolar fracture combined with AITFL avulsion fracture. We performed reduction and fixation for the AITFL avulsion fracture when syndesmotic instability was present after malleolar fracture fixation. A syndesmotic screw was inserted only when residual syndesmotic instability was present even after AITFL avulsion fracture fixation. The radiographic parameters were compared with those of the contralateral uninjured ankles. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were assessed 1 year postoperatively. Results Fifty-four patients showed syndesmotic instability after malleolar fracture fixation and underwent reduction and fixation for AITFL avulsion fracture. Among them, 45 (83.3%) patients achieved syndesmotic stability, while 9 (16.7%) patients with residual syndesmotic instability needed additional syndesmotic screw fixation. The postoperative radiographic parameters were not significantly different from those of the uninjured ankles. The mean AOFAS score was 94. Conclusion Reduction and fixation of AITFL avulsion fracture obviated the need for syndesmotic screw fixation in more than 80% of patients with AITFL avulsion fracture and syndesmotic instability.
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Affiliation(s)
- Kee Jeong Bae
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seung-Baik Kang
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jihyeung Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Jaewoo Lee
- Department of Orthopaedic Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Tae Won Go
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Jia Z, Cheng J, Zhong H, Xiao T, Ren J, Lin Y, Huang W, Liang Y, Liu Q, Zhang X. Titanium cable isotonic annular fixation system for the treatment of distal tibiofibular syndesmosis injury. Am J Transl Res 2019; 11:4967-4975. [PMID: 31497213 PMCID: PMC6731404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/02/2019] [Indexed: 06/10/2023]
Abstract
Distal tibiofibular syndesmosis injury (DTS) occurs frequently with ankle sprains. Current treatments pose several limitations including causing soft tissue irritation, bringing damage to fixation secondary to weight-bearing, and requiring follow-up surgeries. Here, we investigated the clinical effects of a new technique, titanium cable isotonic annular fixation, for the treatment of DTS injury. From January 2015 to June 2017, 36 patients with ankle fractures and DTS injuries had their fractures repaired with the titanium cable isotonic annular fixation system. Recovery was scored by the AOFAS ankle function score system. We also assessed the differences in ankle motion between healthy and operative joints, and recorded the complications. All patients recovered from surgery without any serious complications. We followed all the cases for 18-25 months with an average follow-up of 21.26±3.23 months. 12 months after the operation, X-ray images showed that the titanium cables were fixed in the correct position without any fracture or loosening. Additionally, no degeneration or traumatic arthritis was observed in the ankle joint. There were no incision or bone mineral density changes between the titanium fix and tibiofibular bones. Nearly all patients recovered well except for three who developed inflammation and infection. However, these three patients recovered following 1 week of intravenous antibiotics and local radiofrequency physiotherapy. According to the AOFAS scoring system, all patients achieved satisfactory recovery 12 months post operation. Our titanium cable isotonic annular fixation system has both the advantages of elastic and rigid fixations. It can restore isotonic strength of the distal tibiofibular joint, and its biomechanical performance approaches normal physiological function. After the operation, patients tolerated weight-bearing exercise and recovered joint mobility. Finally, there is no need to remove the distal tibiofibular implant after 12 weeks. Overall, it is a highly effective surgical method to treat DTS injury.
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Affiliation(s)
- Zhaofeng Jia
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Jiwu Cheng
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Haiyan Zhong
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Tinghui Xiao
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Jinke Ren
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Yimiao Lin
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Wenjun Huang
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
| | - Yujie Liang
- Department of Chemistry, The Chinese University of Hong KongShatin, Hong Kong SAR, China
| | - Qisong Liu
- Institute for Regenerative Medicine, Texas A&M Health Science Center College of MedicineTemple, TX 76502, USA
| | - Xiaoming Zhang
- Department of Osteoarthropathy, Shenzhen People’s Hospital, The Second Clinical Medical College of Jinan University and The First Affilliated Hospital of Southern University of Science and TechnologyShenzhen 518035, Guangdong Province, China
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Chun DI, Kim J, Kim YS, Cho JH, Won SH, Park SY, Yi Y. Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures. Injury 2019; 50:1382-1387. [PMID: 31174871 DOI: 10.1016/j.injury.2019.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). METHODS All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided. RESULTS A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively. CONCLUSIONS CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.
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Affiliation(s)
- Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Jahyung Kim
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Yoon Seok Kim
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
| | - Jae-Ho Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, College of Medicine, 77, SakJu-Ro, Gyo-dong, Chun-Cheon, 24262, Republic of Korea.
| | - Sung-Hun Won
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Su-Yeon Park
- Department of biostatistics, Soonchunhyang University Hospital, College of medicine, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Young Yi
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
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Kohake MBJ, Wiebking U, O'Loughlin PF, Krettek C, Gaulke R. Mid- to Long-term Outcomes After Weber B-type Ankle Fractures With and Without Syndesmotic Rupture. In Vivo 2019; 33:255-261. [PMID: 30587633 DOI: 10.21873/invivo.11469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIM The aim of the present study was to assess the impact of syndesmotic screw fixation on overall clinical outcomes following Weber B-type ankle fractures. MATERIALS AND METHODS A total of 21 patients with syndesmotic rupture requiring screw fixation were compared to 40 patients with an intact syndesmosis. Olerud-Molander-Ankle-Score, American Orthopedic Foot & Ankle Society ankle hindfoot score, and the Short Form Health Survey-36 were recorded. Weight-bearing plain radiographs were performed to rate post traumatic osteoarthrosis according to the Kellgren-Lawrence score. Pain levels were evaluated with a visual analog scale. RESULTS A total of 61 patients with a mean follow-up of 6.6 years (range=2-12 years) satisfied the inclusion criteria. Pain level, clinical outcome scores, and radiographs did not reveal significant differences between the groups. Ankle joints with syndesmotic rupture showed a significant restriction in dorsiflexion compared to those with an intact syndesmosis (15 vs. 20°, p=0.028). CONCLUSION Syndesmotic rupture does not affect clinical and radiological outcome parameters following Weber B-type ankle fractures, but does lead to a significant restriction in dorsiflexion of the ankle joint.
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Affiliation(s)
- Michael B J Kohake
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany.,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
| | - Ulrich Wiebking
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany.,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
| | | | | | - Ralph Gaulke
- Section Upper Extremity, Foot- and Rheuma Surgery, Trauma Department, Medical School Hanover (MHH), Hanover, Germany .,Trauma Department, Medical School Hanover (MHH), Hanover, Germany
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34
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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.
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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
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