Distal Tibiofibular Diastasis Research Articles

COMPARISON OF FIXATION USING SCREWS AND SUTURE BUTTONS IN THE TREATMENT OF DISTAL TIBIOFIBULAR DIASTASIS ASSOCIATED WITH ANKLE FRACTURES

Purpose: We aimed to compare the treatment results of fixation using screws and a suture button when treating distal tibiofibular joint diastasis combined with ankle fractures Materials and Methods: A retrospective study was conducted on 30 patients with ankle fractures who were treated with screws and 34 patients who were treated with suture buttons for distal tibiofibular joint diastasis. Postoperative clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) score, and radiologic outcomes were evaluated by measuring tibiofibular clear space, tibiofibular overlap, and medial clear space on pre- and post-operative radiographs. The average length of hospital stay, whether surgery was performed to remove the internal fixation, the time of weight bearing, and whether the internal fixation was damaged were investigated. Results: One year after surgery, the average AOFAS score showed no statistically significant difference between the screw surgery group and the suture button surgery group. The averages of tibiofibular clear space, tibiofibular overlap, and medial clear space measured immediately postoperatively did not show statistically significant differences between the screw surgery group and the suture button surgery group, but the measurements taken 1 year after surgery were significantly different statistically. Screw removal surgery was performed in all cases in the screw surgery group. In the screw surgery group, there were 3 cases of screw breakage and 3 cases of surgical wound infection, and the length of hospitalization and the postoperative weight-bearing start time in the screw surgery group were longer. Conclusion: When treating distal tibiofibular joint diastasis, the screw surgery group and the suture button surgery group showed no statistically significant difference in clinical outcomes measured by AOFAS 1 year after surgery, but the suture button surgery group had better results in radiological evaluation and in complication frequency.

Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair.

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.

Avoiding the Removal of Syndesmotic Screws after Distal Tibiofibular Diastasis Repair: A Benefit or a Drawback?

There is still no general agreement about the most effective form of syndesmosis fixation with syndesmotic screws for patients affected by ankle fractures that are accompanied by syndesmotic injuries. In the same manner, no consensus has been reached yet on whether or not the tibiofibular syndesmotic screw is more beneficial if removed or not, as well as the exact timing of removal if this proves superiority. The purpose of this research was to verify whether or not removing syndesmotic screws reduces the risk of developing a diastasis and compare outcomes in patients whose syndesmotic screw was or was not removed at all. A retrospective observational study was carried out to cover a period of five years and a computed sample size of almost 300 cases. Patients were included in the current study if their history was positive for ankle fracture with distal tibiofibular diastasis repair with syndesmotic screws. Loss of reduction was more frequent after screw removal (8.5% vs. 2.1%), although the quality of reduction was generally excellent in both groups. The mean AOFAS score was significantly better in patients who had their tibiofibular screw removed (92.6 vs. 88.4), but the tibiofibular clear space and incisura fibularis depth widened more following the second intervention (3.8 mm vs. 3.6 mm, and, respectively, 4.3 vs. 4.1). Lastly, the same patients with tibiofibular screw removal had a significantly higher cost of total interventions and more days of medical leave (21 vs. 15 days on average). It seems that a strong conclusion in favor of removing or not removing syndesmotic screws after distal tibiofibular diastasis repair cannot be given. However, several radiographic findings lean toward the benefit of those patients whose tibiofibular screws were not removed, although mobility was notably better after the screw was removed. Furthermore, treatment expenses are greatly lowered if a subsequent operation for screw removal is avoided, as well as if individuals who have a single surgery take a shorter medical leave.

Syndesmosis Changes before and after Syndesmotic Screw Removal: A Retrospective Radiographic Study.

Background and Objectives: In patients with ankle fractures complicated by syndesmotic injuries, no consensus has been reached on the best method of syndesmosis fixation using syndesmotic screws. One previous study revealed no difference in the tibiofibular overlap between two groups with or without syndesmotic screw removal. Other studies have indicated that distal tibiofibular diastasis exists after the removal of syndesmotic screws. In this study, we aimed to confirm the effect of syndesmotic screw removal on diastasis occurrence. We further analyzed the risk factors that may contribute to the widening of the tibiofibular syndesmosis. Materials and Methods: This retrospective study involved a review of the records of 63 patients with ankle fractures accompanied by syndesmosis injuries that required syndesmotic screw fixation. Anteroposterior radiographs were analyzed for each patient at various time points, from syndesmotic screw fixation to outpatient department follow-ups after screw removal. The changes in tibia–fibula overlap (OL), tibia–fibula clear space (CS), and medial clear space (MCS) were analyzed. Further analysis was performed to reveal potential factors that may have contributed to radiographic differences. Results: Compared with the postoperation radiographs following syndesmotic screw fixation, OL decreased (2.0 mm) and CS increased (0.8 mm) in the anteroposterior radiographs from outpatient department follow-ups. No significant changes were noted in OL or CS after syndesmotic screw removal. However, OL decreased (1.8 mm) and CS increased (0.5 mm) before syndesmotic screw removal. No significant change in MCS occurred during the whole observation period. Linear regression analysis did not reveal any significant correlations between potentially related factors and radiographic changes. Conclusions: Marked diastasis had occurred at final follow-up. Notably, the diastasis occurred before rather than after screw removal. This implies that screw removal does not significantly influence the radiographic outcomes of rotational ankle fractures.

PO 18191 - Congenital distal tibiofibular diastasis

Introduction: Congenital distal tibiofibular diastasis is an extremely rare entity of unknown etiology that compromises the feet and ankles with different degrees of deformity, although in general, the feet show equinovarus deformity, and the talus is proximally dislocated due to the separation of the distal tibial and fibular epiphyses. There are few reports of this disorder in the literature, and most describe cases that ultimately lead to limb amputation. We present the cases of 2 patients treated from birth to skeletal maturity. Methods: Two female patients with clubfoot at birth were diagnosed with congenital distal tibiofibular diastasis. One of them had the deformity of the right foot, and the other had deformity of both limbs. Both patients underwent early distal tibiofibular arthrodesis and serial stretching of the compromised feet and legs. Results: After 20 years of clinical follow-up and after reaching skeletal maturity, both patients had plantigrade feet without significant shortening of the lower limbs or pain, and both performed activities of daily living without restrictions, wearing conventional shoes. Conclusion: Early distal tibiofibular arthrodesis followed by limb stretching was effective for treating congenital distal tibiofibular diastasis and is a good alternative to amputation, which is indicated in the literature.

A Case Report of Deformity Correction of a Limb with Congenital Distal Tibiofibular Diastasis.

Introduction:Congenital distal tibiofibular diastasis is an extremely rare disorder. The main feature at presentation is a clubfoot deformity with leg length discrepancy (LLD) due to a short tibia. Limb lengthening and reconstruction techniques today can correct the deformity, ending with a plantigrade and functional limb.Case Report:We report a patient with congenital tibiofibular diastasis, who was initially treated with series of casts and later with ankle arthrodesis, but the deformity and LLDleg length discrepancy remained. We applied an Ilizarov frame and initially corrected the varus and equinus deformity of the foot. Then, we corrected the LLD leg length discrepancy with limb lengthening with distraction osteogenesis. We achieved a plantigrade stable limb, with a small amount of length inequality.Conclusion:Congenital distal tibiofibular diastasis can be managed with staged correction and lengthening with the Ilizarov method.

Intraoperative Torque Test to Assess Syndesmosis Instability.

In this cadaveric study, a new "torque test" (TT) stressing the fibula posterolaterally under direct visualization was compared with the classical external rotation stress test (ERT) and lateral stress test (LST). The anteroinferior tibiofibular ligament (AiTFL), the interosseous membrane (IOM), and the posteroinferior tibiofibular ligament (PiTFL) were sectioned sequentially on 10 fresh-frozen human ankles. At each stage of dissection, instability was assessed using the LST, ERT, and TT under direct visualization. Anatomical tibiofibular diastasis measurements were taken directly on cadavers and compared using the Wilcoxon signed rank test. All 3 tests showed statistically significant motion in the syndesmosis when at least 2 ligaments were sectioned. The mean increase across diastasis with a 2-ligament section was 3.0 mm ( P = .005), 3.2 mm ( P = .005), and 4.8 mm ( P = .005) for the LST, ERT, and TT, respectively. The largest mean increase in diastasis was obtained with a complete injury using the TT and was 6.2 mm ( P = .008). With the TT, a 3.5-mm tibiofibular diastasis was 90% sensitive and 100% specific when 2 or more syndesmotic ligaments were sectioned. The TT was a more sensitive and specific tool for detecting syndesmosis instability than classic LST and ERT. Stressing the fibula in a posterolateral direction created a larger distal tibiofibular diastasis, which would be easier to detect in the intraoperative setting. The TT was more sensitive and specific to detecting a 2-ligament syndesmotic injury than the classic test and required less force to perform.

Role of the Deltoid Ligament in Syndesmotic Instability.

The deltoid ligament (DL) is the principal ligamentous stabilizer of the medial ankle joint. Little is known, however, about the contribution of the DL toward stabilizing the syndesmosis. The aim of this study was to arthroscopically evaluate whether the DL contributes to syndesmotic stability in the coronal plane. Eight above-knee cadaveric specimens were used in this study. A lateral hook test was performed by applying 100 N of lateral force to the fibula in the intact state and after sequential transection of the DL, anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), and posterior-inferior tibiofibular ligament (PITFL). At each stage, distal tibiofibular diastasis was measured arthroscopically at both the anterior and posterior third of the incisura and compared to stress measurements of the intact syndesmosis. Measurements were performed using probes ranging from 0.1 to 6.0 mm, with 0.1-mm increments. There was no significant increase in diastasis at either the anterior or posterior third of the tibiofibular articulation after isolated DL disruption, nor when combined with AITFL transection. In contrast, a significant increase in diastasis was observed following additional disruption of the IOL (anterior and posterior third diastasis, P= .012 and .026, respectively), and after transection of all 3 syndesmotic ligaments (anterior and posterior third diastasis, P=.001 and .001, respectively). When evaluating the syndesmosis arthroscopically in a cadaveric model under lateral stress, neither isolated disruption of the DL nor combined DL and AITFL injuries destabilized the syndesmosis in the coronal plane. In contrast, the syndesmosis became unstable if the DL was injured in conjunction with partial syndesmotic disruption that included the AITFL and IOL. Disruption of the DL appeared to destabilize the syndesmosis in the coronal plane when associated with partial disruption of the syndesmosis (AITFL and IOL).

The Utilization of a Suture Bridge Construct for Tibiofibular Instability During Transtibial Amputation Without Distal Bridge Synostosis Creation

Symptomatic distal tibiofibular instability is a known complication of trauma-related transtibial amputations. Overt proximal tibiofibular dislocations, which are easily recognized on routine radiographs, may occur concurrently with the traumatic injury or amputation. More commonly, however, the proximal tibiofibular joint remains structurally intact in the presence of distal instability due to the loss of the distal syndesmotic structures and damage to the interosseous membrane, resulting in fibular angulation and distal tibiofibular diastasis. Some authors have espoused treating this instability with the creation of a distal tibiofibular bridge synostosis (the so-called Ertl procedure or modifications there of) to prevent potentially painful discordant motion and to minimize the prominence of the residual distal fibula. Recent studies, however, have suggested an increase in complication and reoperation rates in transtibial amputations that received a bridge synostosis compared with standard transtibial amputations. Additionally, although there are several described techniques for bridge synostosis creation, most are dependent on having sufficient remaining fibula to construct the bone bridge without unnecessary shortening of the tibia; however, sufficient residual fibula is not always available after traumatic and trauma-related amputations. We propose a technique utilizing a suture bridge to restore tibiofibular stability when performing transtibial amputations in patients with proximal tibiofibular dislocations or distal diastasis, avoiding the potential need for a distal bridge synostosis.

Long-term follow-up of congenital distal tibiofibular diastasis

Congenital diastasis of the inferior tibiofibular joint is an extremely rare variant of dysplastic tibial anomaly, which is usually associated with significant shortening of the lower leg and ipsilateral foot deformity due to talus incarceration in the distal tibiofibular mortise. The purpose of this study was to present the long-term results of reconstructive treatment and the functional outcome after a follow-up of 11-16 years. The principles of extremity preservation and reconstruction with the Ilizarov frame have shown a stable ankle joint, a plantigrade foot, and fully independent outdoor ambulation in both patients at the final follow-up. We concluded that amputation should not be performed under this condition.

Treatment of the Deltoid Ligament Injury in Ankle Fractures Combined with Distal Tibiofibular Diastasis: retrospective study

Treatment of the Deltoid Ligament Injury in Ankle Fractures Combined with Distal Tibiofibular Diastasis: retrospective study

Distal Tibiofibular Diastasis Secondary to Osteochondroma in a Child

An 18-month-old girl with a distal tibiofibular diastasis secondary to an osteochondroma was seen with a valgus deformity of the ankle. The patient underwent operative excision of the osteochondroma at the age of 2 years. At 13-year followup there was resolution of the diastasis, and the patient was free of symptoms. Early excision obviates the need for complex reconstructive surgery to correct ankle deformity later.

The Effect of Syndesmotic Screw of Ankle Fracture with Distal Tibiofibular Diastasis

The Effect of Syndesmotic Screw of Ankle Fracture with Distal Tibiofibular Diastasis

Fracture-dislocation of the Ankle with Anterior Dislocation of the Fibula

A fracture-dislocation of the ankle with fixed anterior displacement of the proximal fibular fragment is reported. The mechanism of this injury was likely eversion of the foot which produced rupture of the deltoid ligament and distal tibiofibular diastasis, and lateral dislocation of the talus. The proximal fibular fragment was probably displaced laterally and returned to a position anterior to the fibular notch of the tibia. This injury was extremely unstable and required open reduction with internal fixation, not only to reduce the anterior displacement of the fibula but also to repair the associated disruption of the syndesmotic ligament and anterior capsule. The key radiographic finding was anterior displacement of the distal fibula seen on the lateral view.

Congenital aplasia and dysplasia of the tibia with intact fibula. Classification and management.

Congenital aplasia and dysplasia of the tibia with intact fibula. Classification and management.

Diastasis of the Tibiofibular Mortise, Hypoplasia of the Tibia, and Clubfoot, in a Neonate with Cleft Hand and Cardiac Anomalies A Case Report

In a newborn girl diastasis of the distal tibiofibula joint was associated with cleft hand deformity, and cardiac anomalies. While at least 3 cases of congenital distal tibiofibular diastasis have been reported previously, this patient seems to be the first to have had hand and cardiac defects. The diastasis is believed to be secondary to tibial hypoplasia. The initial presentation was that of an apparent clubfoot deformity and emphasizes the point that roentgenograms of all equinovarus deformities in the newborn should be mandatory.