Malreduction Of Syndesmosis Research Articles

Open Reduction and Fixation of Lateral Malleolus and Syndesmosis for Ankle Re-Fracture

Rotational ankle fractures are often accompanied with a syndesmotic injury. Furthermore, malreduction of syndesmosis and fibular shortening are frequent errors observed in these cases and often lead to poor functional outcomes. We present a case of Weber C lateral malleolus fracture and distal tibiofibular syndesmotic injury in an active 23-year-old patient. Various techniques for syndesmotic reduction and restoration of fibular length are discussed and demonstrated.

Comparison of Syndesmotic Malreduction Rate following Trans-Syndesmotic Screw Fixation in SER versus PER Type Ankle Fracture: A Prospective Analytic Study

Category:Ankle; TraumaIntroduction/Purpose:Syndesmotic injury frequently presents in severe rotational ankle fracture and a trans-syndesmotic screws fixation is commonly used technique. Bases on previous literatures, syndesmotic malreduction rate can occur between 20- 70 percent following traditional trans-syndesmotic screw fixation in all type of ankle fracture. However, there is a little evidence regarding the malreduction rate in each type of ankle fractures. The purpose of this study is to demonstrate malreduction rate of syndesmosis using simultaneously bilateral post-operative CT measurement after trans-syndesmotic screw fixation between supination external rotation and pronation external rotation type ankle fracture.Methods:A prospective comparative study of patients who had acute ankle fracture with syndesmotic injury between January 2015 and December 2017 were enrolled. Lague-Hansen classification was used to classify all patient into 2 groups: SER and PER based on mechanism of injury. Syndesmotic injury was confirmed by ankle arthroscopic examination in all patients and they were treated with ORIF distal fibula using either 1/3 tubular plate or anatomical locking plate under direct visualization of syndesmosis. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. The accuracy of syndesmotic reduction was evaluated by simultaneously bilateral post-operative CT scan. Syndesmotic reduction was measured using anterior to posterior distance (AP) and medial to lateral distance (ML). A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis.Results:There were 67 patients were enrolled in this study (SER=48 and PER=15). The syndesmotic injury was present 60% (48/70) in SER and 100% (15/15) in PER group respectively. The malreduction was significant higher in PER than SER (2.1% in SER vs 20% in PER). Operative time was 58.2 and 79.2 minutes in SER and PER. The tibiofibular clear space was 4.0mm versus 4.8mm in SER and PER. The AP distance was -0.33mm and -0.51mm and ML distance was 1.91 mm and 1.59mm for SER compared to normal side and 0.19 mm and -0.21 and ML distance was 2.59mm and 1.63mm for PER compared to normal side. There were significant improvements of functional outcomes (FAAM, SF-36, and VAS) but no significant different between the two groups.Conclusion:The incidence of concomitant syndesmotic injury and syndesmotic malreduction rate following trans-syndesmotic screw fixation was significantly higher in PER type compared SER type ankle fracture. The malposition of distal fibula was displaced anteriorly and laterally (undercompression) compared to uninjured side.

Syndesmotic malreduction may decrease fixation stability: a biomechanical study

BackgroundThis study aims to investigate the malreduction of syndesmosis and its effects on stability.MethodsThe 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.ResultsIn 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.ConclusionsMalreduction 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 evidenceIII

Dynamic Fixation versus Static Fixation in Treatment Effectiveness and Safety for Distal Tibiofibular Syndesmosis Injuries: A Systematic Review and Meta-Analysis.

To compare the effectiveness and safety of dynamic fixation (DF) and static fixation (SF) in distal tibiofibular syndesmosis injuries (DTSI) by a system review and meta‐analysis. PubMed, Cochrane, and EMBASE were systematically searched by computer to select clinical randomized controlled trials (RCT) and cohort trials comparing DF and SF in treating patients with DTSI. RCT and cohort trials comparing DF and SF for patients with DTSI were included. Inclusion criteria: (i) prospective or retrospective study of patients with DTSI; (ii) patients were diagnosed as having DTSI by imageology and only received DF treatment or SF treatment; (iii) the study compared DF and SF in DTSI; and (iv) one or more of the following outcomes were reported: ankle joint functional score, surgical complications, malreduction of syndesmosis, and second operations. Exclusion criteria: (i) non‐human studies; (ii) DTSI patients accompanied with other complications or other joints injuries; and (iii) full text unavailable. RevMan V5.3 software was used to perform the statistical analysis. Outcomes analyzed by Revman software showed that there were no statistically significant differences between DF and SF in the American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score (MD, 1.90; 95% CI, −0.23 to 4.03; P = 0.08; I 2 = 0%), Olerud–Molander (OM) score (MD, 1.92; 95% CI, −7.96 to 11.81; P = 0.70; I 2 = 55%), incidence of syndesmotic malreduction (RR, 0.19; 95% CI, 0.03 to 1.09; P = 0.06; I 2 = 0%), and overall postoperative complication rate (RR, 0.30; 95% CI, 0.09 to 0.99; P = 0.05, I 2 = 75%) and the rate of second procedure was significantly lower with DF (RR, 0.17; 95% CI, 0.07 to 0.43; P = 0.0002, I 2 = 54%). Compared to SF, DF has an advantage, with a low rate of second procedures to treat DTSI.

Functional and Radiographic Outcomes after the Removal of Suture-Button Fixation Device in the Treatment of Syndesmosis Diastasis

Category:TraumaIntroduction/Purpose:Suture-button fixation device (TightRope, Arthrex, Naples, Florida) is devised to obviate the need for second operation for removal in the treatment of syndesmosis diastasis, but considerable removal rate has been reported.Nevertheless, functional and radiographic outcomes after suture-button fixation device removal has not yet been well documented. Therefore, the purpose of this study is to investigate the functional and radiographic outcomes of syndesmosis fixation treated with suture-button device before and after device removal.Methods:The records of 30 patients with syndesmosis injury who underwent suture-button fixation and later device removal between August 2009 and September 2017 were investigated. The mean postoperative time to device removal was 11.9 months (range, 7-19). In plain radiograph, tibiofibula clear space (TFCS), tibiofibula overlap (TFO), and medial clear space (MCS) were measured at three specific follow-up period; immediate postoperative (F1), just before device removal (F2), and at least three months after device removal (F3). For subgroup of 18 patients with CT scans, the Anterior to posterior (A/P) ratio (Normal range: 0.8 -1.2) was measured to investigate malreduction of syndesmosis and they were divided into two groups according to their accuracy of reduction. Additionally, functional outcomes were recorded and compared using American Orthopedic Foot and Ankle (AOFAS) score. Repeated measurement analysis of variance was performed to statistically compare the data and statistical significance was set at P < 0.05.Results:In plain radiographs, TFCS, TFO, MCS at three specific follow-up period showed no significant differences. In CT analysis at immediate postoperative period, 6 cases (30%) revealed malreduction, but 5 of them showed spontaneous reduction at follow- up just before device removal. Malreduced patients (n = 6) had a mean A/P ratio of 1.28 (range, 0.78 -1.52) at F1, 1.08 (range, 0.81- 1.21) at F2, and 1.08 (range, 0.83 -1.22) at F3 (F1, F2: p = 0.021, F1, F3: p = 0.032, F2, F3: p > 0.05). Patients with initial adequate reduction (n = 12) continued to have a reduced syndesmosis during the follow-up period and after the device removal. The AOFAS score did not change significantly before and after removal.Conclusion:Our investigation showed that the removal of suture-button device for syndesmosis fixation at average 1-year postoperative time does not bring out reduction loss or functional changes. Thus, removal is advisable for the patients with irritation or discomfort related to device. Furthermore, malreduced syndesmosis after tightrope fixation may have possibility of spontaneous reduction during the follow-up period.

An Accuracy of Syndesmotic Reduction by Direct Visualization Technique

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.

Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view

PurposeMalalignment of syndesmosis is generally associated with a poor outcome, yet occurs at a high rate in malleolar ankle fractures. In this study, we examine whether malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber's three indexes in the mortise view. Materials and methodsOf 156 patients with malleolar ankle fracture who underwent surgery from December 2012 to March 2016 at two medical facilities, 24 patients who received syndesmotic screw fixation were included in the study. Fractures were Danis–Weber types B and C in 8 (8/134, 6.0%) and 16 (16/22, 72.7%) patients, respectively. Using axial computed tomography (CT), we calculated the difference between injured and non-injured sides for each of three parameters: tibiofibular clear space (TFCS), anterior tibiofibular interval (ATF), and fibular rotation (θfib). Malreduction was diagnosed if one or more of the three parameters had an abnormal value. Weber's three indexes in the mortise view on the injured side were used to determine whether reduction of syndesmosis was performed successfully. Consistency between the evaluation of reduction of syndesmosis in axial CT images and reevaluation of mortise views was examined by calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ResultsThe rate of malreduction of syndesmosis in axial CT images was 29.2% (7/24). Re-evaluation in the mortise view confirmed malreduction of syndesmosis in six of the seven subjects, all of whom also had malreduction based on axial CT images. The one subject in whom malreduction could not be detected in a mortise view showed an abnormal value only for ATF. Use of the mortise view for perioperative diagnosis had a sensitivity of 0.857, specificity of 1.000, PPV of 1.000, and NPV of 0.944. ConclusionThe results of our study show that malreduction of syndesmosis can be avoided by careful interpretation of intraoperative perspective mortise views based on Weber's three indexes. To increase the diagnostic accuracy further, it is important to detect anteroposterior deviation of the fibula in intraoperative lateral views.

Usefulness of intraoperative three-dimensional imaging in fracture surgery: a prospective study

BackgroundSince its introduction, intraoperative threedimensional (3D) imaging has enabled the analysis of articular fractures and implant positions during fracture surgery. The purpose of this study was to evaluate the usefulness of intraoperative 3D imaging in locating anatomic structures, correcting errors, and preventing revision surgery. MethodsBetween March 2010 and November 2012, intraoperative 3D imaging was used during surgery for 109 fractures in 101 patients. Fluoroscopy was performed with the Iso-C3D™ (Siemens, Erlangen, Germany). We recorded the number of intraoperative revisions for adjustment of fracture reduction and correction of implant position for these fractures. ResultsCases comprised intra-articular fractures (55 %), disruptions of the posterior pelvic ring (33 %), and syndesmotic injury (12 %). The intraoperative revision rate was 9.2 % (10/109). When considered by fracture site, the revision rate was highest for syndesmotic injury (23.1 %), followed by iliosacral fixation (8.3 %) and intra-articular fractures (6.6 %). We changed the implant position in six cases, corrected the articular reduction in one case, and revised the malreduction of syndesmosis in three cases. No postoperative infection occurred in any of these cases. ConclusionsIntraoperative 3D imaging is useful for correcting errors and may prevent a second operation. Three-dimensional imaging may be especially helpful in intra-articular fractures, iliosacral screw fixation, and syndesmotic injury.

Anterior Subluxation of the Talus: A Complication of Malreduction of the Ankle Syndesmosis: A Report of Three Cases.

The goal of operative treatment of unstable ankle fractures is to obtain an anatomic reduction of the ankle mortise and provide stable fixation until osseous union and ligamentous healing occur1. The syndesmosis, an important secondary stabilizer of the ankle joint, may be injured in rotational ankle fractures and require stabilization. However, placement of a transsyndesmotic screw is an independent risk factor for inferior outcomes2, which may be caused by the high incidence of syndesmosis malreduction when a closed reduction is attempted3,4. The tibiotalar joint is highly conforming, bearing more weight per unit area than any other joint. Therefore, small changes in the relationship between the tibia and the talus may lead to posttraumatic arthritis5,6. The literature has focused on reduction of the mortise in the coronal plane since l mm of lateral talar translation decreases the tibiotalar contact area by 42%, consequently increasing cartilage pressures7. The clinical relevance of lateral talar shift is corroborated by studies demonstrating poor outcomes in patients with widening of the mortise after an ankle fracture1,8. We report a series of three patients with malreduction of the tibiotalar joint in the sagittal plane after closed reduction of the syndesmosis and placement of transsyndesmotic screws. In all three of these cases, the talus subluxated anteriorly after placement of a syndesmotic screw and was rigidly fixed in the malreduced position. This complication results from avoidable technical errors that result in malreduction of the syndesmosis and secondarily affect the tibiotalar joint. The patients were all informed that data concerning the cases would be submitted for publication, and they all provided consent. We reviewed 364 consecutive cases of operatively treated ankle fractures that included fixation of the syndesmosis. Based on postoperative radiographs …

Fixation of Ankle Syndesmotic Injuries

Background: Ankle syndesmotic injuries are complex and require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint and prevent long-term complications. Purpose: The aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using TightRope versus syndesmotic screw fixation. Study Design: Cohort study; Level of evidence, 2. Methods: This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial computed tomography (CT) scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. A greater than 2-mm widening of syndesmosis compared with the untreated contralateral ankle was considered significant malreduction. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores. Results: Forty-six of 55 eligible patients participated in the study; 23 patients were in the TightRope group and 23 in the syndesmotic screw group. The average age was 42 years in the TightRope and 40 years in the syndesmotic screw group, and the mean follow-up time was 2.5 years (range, 1.5-3.5 years). The average width of normal syndesmosis was 4.03 ± 0.89 mm. In the TightRope group, the mean width of syndesmosis was 4.37 mm (SD, ±1.12 mm) (P = .30, t test) compared with 5.16 mm (SD, ±1.92 mm) in the syndesmotic screw group (P = .01, t test). Five of 23 ankles (21.7%) in the syndesmotic screw group had syndesmotic malreduction, whereas none of the TightRope group showed malreduction on CT scans (P = .04, Fisher exact test). Average time to full weightbearing was 8 weeks in the TightRope group and 9.1 weeks in the syndesmotic screw group. There was no significant difference between the TightRope and syndesmotic screw groups in mean postoperative AOFAS score (89.56 and 86.52, respectively) or FADI score (82.42 and 81.22, respectively). Regression analysis confirmed malreduction of syndesmosis as the only independent variable that affected the clinical outcome (regression coefficient, −12.39; t = −2.43; P = .02). Conclusion: The results of this study indicate that fixation with TightRope provides a more accurate method of syndesmotic stabilization compared with screw fixation. Syndesmotic malreduction is the most important independent predictor of clinical outcomes; therefore, care should be taken to reduce the syndesmosis accurately.

Malreduction of syndesmosis—Are we considering the anatomical variation?

Previous studies have demonstrated the need for accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. A computed tomography (CT) scan allows better visualisation of the transverse relationship between the fibula and incisura fibularis. The difference (‘G’ a term we coined for ease of description) between the fibula and the anterior and posterior facets of the incisura fibularis was compared between normal and injured ankles following syndesmotic fixation in 19 patients. The mean diastasis (MD) was also calculated, representing the average measurement between the fibula and the anterior and posterior incisura. When compared with the normal side, eight out of 19 (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis. However, if a standard value of G (2 mm) was used for the injured leg only, all of the 19 cases would have abnormal values of ‘G’ following reduction. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of ‘G’ of 2 mm as the normal limit cannot be applied universally, as apparent from the data presented in this study.