An Accuracy of Syndesmotic Reduction by Direct Visualization Technique

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Category: Trauma Introduction/Purpose: Syndesmotic injury is commonly seen associated with acute ankle fracture. Syndesmotic malreduction was proven be a poor prognostic factor. Many methods have been purposed to assess the quality of reduction such as direct visualization, comparing radiographic parameters to contralateral ankle fluoroscopy, and intra-operative computed tomography. In this study, we demonstrated syndesmotic malreduction rate using bilateral CT after using direct visualization technique for syndesmotic fixation. Methods: A prospective case series of 34 patients (13 left and 21 right sides) with an average age of 42 years who had rotational ankle fractures with syndesmotic injury confirmed by arthroscopic examination. All patients were treated with an open reduction and internal fixation of distal fibula using either 1/3 tubular plate or distal anatomical locking plate. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. Before syndesmotic fixation, syndesmotic reduction is made by using a large point reduction clamp and quality of the reduction was checked by direct visualization at anterior tibiofibular line. The accuracy of syndesmotic reduction is then evaluated by post-operative bilateral CT. A widening of distance between anterior tibia and fibular at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: The accuracy of syndesmotic reduction was 97.1 percent (33/34) compare to contralateral ankle. An average of BMI was 27.2 and an average of operative time was 98.2 minutes. One malreduction, was diagnosed on the criteria of a 2 mm difference from the contralateral side occurred due to a small fragment interposition at the syndemosis. This patient underwent revision surgery to remove the fragment and then fixation of syndesmosis with same manner to achieve anatomical reduction. In all cases, the screws are removed at 12 weeks. Neither breakage nor migration of screws is observed and no wound or nerve complications following this technique. Conclusion: A syndesmotic fixation using direct visualization technique demonstrate lower rate of malreduction as demonstrated by poster-operative bilateral CT scan and no complications. This technique is effective, safe, and should be considered for treatment of syndesmotic injury associated ankle fracture.