Syndesmosis Injury Research Articles

Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study

BackgroundAnkle syndesmosis injuries are common and range in severity from subclinical to grossly unstable. Definitive diagnosis of these injuries can be made with plain film radiographs, but are often missed when severity or image quality is low. Computed tomography (CT) and magnetic resonance imaging (MRI) can provide definitive diagnosis, but are costly and introduce the patient to radiation when CT is used. Ultrasonography may circumvent many of these disadvantages by being inexpensive, efficient, and able to detect injuries without radiation exposure. The purpose of this study was to evaluate the ability of ultrasonography to detect early stage supination-external rotation (SER) ankle syndesmosis injuries with a dynamic external rotational stress test.MethodsNine, all male, fresh frozen specimens were secured to an ankle rig and stress tested to 10 Nm of external rotational torque with ultrasonography at the tibiofibular clear space. The ankles were subjected to syndesmosis ligament sectioning and repeat stress measurements of the tibiofibular clear space at peak torque. Stress tests and measurements were repeated three times and averaged and analyzed using a repeated one-way analysis of variance (ANOVA). There were six ankle injury states examined including: Intact State, 75% of AITFL Cut, 100% of AITFL Cut, Fibula FX - Cut 8 cm proximal, 75% PITFL Cut, and 100% PITFL Cut.ResultsDynamic external rotation stress evaluation using ultrasonography was able to detect a significant difference between the uninjured ankle with a tibiofibular clear space of 4.5 mm and the stage 1 complete injured ankle with a clear space of 6.0 mm (P < .02). Additionally, this method was able to detect significant differences between the uninjured ankle and the stage 2–4 injury states.ConclusionDynamic external rotational stress evaluation using ultrasonography was able to detect stage 1 Lauge-Hansen SER injuries with statistical significance and corroborates criteria for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening.

The Diagnostic Value of MRI for High Ankle Sprains with an Unstable Syndesmosis: Time to Scan Matters

Category:Ankle, Arthroscopy, Sports, TraumaIntroduction/Purpose:Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. The aims of the current study were to describe MRI characteristics associated with diagnosed syndesmosis instability, and to assess if MRI characteristics change as the injury becomes chronic.Methods:Patients with a high ankle sprain and proven syndesmosis instability at arthroscopy were retrospectively identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. Patients were excluded if they had a distal fibula fracture or absence of an MRI report by a consultant radiologist. Associations between MRI characteristics and time from injury to MRI scan, categorised as acute (< 6 weeks), intermediate (6-12 weeks) and chronic (> 12 weeks) were examined using the Pearson’s chi-squared or Fisher’s exact tests (significance set at p<0.05).Results:Of the 164 patients, 108 had an MRI scan in the acute period, 32 were classified as intermediate and 24 as chronic. A posterior syndesmosis injury was detected in 93.5% of acute patients, 87.5% of intermediate patients and 54.2% of chronic patients. In the acute group, PITFL injury was detected in 78.7% of patients, posterior malleolus bone oedema in 60.2% and posterior malleolus fracture in 15.7%. The proportion of patients with injury to the PITFL in intermediate patients was 59.4% and 29.2% in chronic patients which was significantly lower than in acute patients (p<0.001). Twenty eight patients with posterior malleolus bone oedema had an apparently normal PITFL. The proportion of patients with posterior malleolus bone oedema or fracture were not significantly different between groups.Conclusion:The most important finding of the current study is that in acute high ankle sprains with syndesmosis instability, MRI detected a posterior syndesmosis injury in 93.5% of patients. Posterior malleolus bone oedema appears to be a marker of an unstable syndesmosis injury, regardless of time from injury to the MRI scan. The ability of MRI to detect a posterior syndesmosis injury reduces significantly if delayed more than 12 weeks. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries, as the ability of MRI to detect posterior injuries reduces over time.

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.

How Should We Evaluate Syndesmosis Reduction on CT Scan?

Category:Ankle, Sports, Trauma, Syndesmosis.Introduction/Purpose:Accurate reduction of the syndesmosis is essential to the restoration of normal ankle mechanics, but radiographic evaluation of reduction quality has been demonstrably unreliable. CT imaging has traditionally been considered the gold standard, but there is no uniformly accepted method by which to assess syndesmotic reduction on CT. The aim of this study was to evaluate intra- and interobserver reliability of published measurements for evaluation of syndesmosis reduction using weight-bearing CT scan.Methods:Medical records were reviewed to identify patients who underwent surgical stabilization of a unilateral syndesmotic injury. Exclusion criteria included patients less than 18 years old, ipsilateral pilon fracture, history of contralateral ankle or pilon fracture or syndesmosis injury, BMI >40, and any neurological impairment. Twenty eligible patients were recruited to participate in the study and underwent weight-bearing CT evaluation for both ankles simultaneously. The quality of syndesmotic reduction was evaluated using axial CT images at a level 1 cm proximal to the tibial plafond using nine published radiological measurements (Figure 1). Inter- and intraobserver reliability were assessed for each evaluation method. Side by side method (qualitatively observing the repaired laterality side by side with the contralateral control) was assessed using Kappa interrater agreement, while the reliabilities for all other continuous methods were assessed with interclass correlation coefficients (ICC).Results:The study cohort consisted of ten males and ten females with mean age of 43 years (range, 23-67 years). The intraobserver reliability of the side by side method was 0.49 and 0.24 for the first and second observers respectively, and the interobserver reliability was 0.24. The syndesmotic area showed the highest interobserver reliability (0.96), the highest intraobserver reliability for observer 2 (0.97), and the second highest intraobserver reliability for observer 1 (0.92). Fibular rotation had the second highest interobserver reliability in our results (0.84), with high intraobserver reliability of 0.91 and 0.8 for first and second observers, respectively. The other six radiological measurements had interobserver reliability that ranged between 0.62 and 0.83.Conclusion:Qualitatively assessing syndesmotic reduction via side by side comparison with the uninjured ankle had the least intra- and interobserver reliability and should not be relied upon to determine syndesmotic reduction quality. In contradistinction, syndesmotic area calculation showed the highest reliability for evaluating syndesmosis reduction, followed by fibular rotation. Additional efforts should be considered to standardize such measurements within CT image viewers, so they become seamlessly accessible in the clinical setting.

Screw Versus Suture Button in Treatment of Syndesmosis Instability: Clinical and Radiographic Outcomes Using PROMIS and Weight Bearing CT Scan

Category:Ankle, Sports, Trauma, SyndesmosisIntroduction/Purpose:Traumatic injuries to the distal tibiofibular syndesmosis are relatively common and can be associated with ankle fractures or occur as purely ligamentous injuries. Unstable syndesmotic injuries require surgical repair, generally performed using either screw or suture button fixation. The superiority of either fixation method remains a subject of ongoing debate. The aim of this study is to compare both clinical and radiographic outcomes of screw and suture button fixation of syndesmosis instability using Patient-Reported Outcomes Measurement Information System (ROMIS) and weight bearing CT scan (WBCT).Methods:Medical records were reviewed to identify patients who had a unilateral syndesmotic injury requiring surgical stabilization and who were at least one year out from injury. Exclusion criteria included patients less than 18 years old, ipsilateral pilon fracture, history of contralateral ankle or pilon fracture or syndesmosis injury, BMI >40, and any neurological impairment. Twenty eligible patients were recruited to complete PROMIS questionnaires and undergo bilateral WBCT scan of both ankles, divided into two groups. In the first group (n=10) the patients had undergone screw fixation of the syndesmosis, while in the second group (n=10) the syndesmosis was fixed using a suture button construct. All patients completed PROMIS questionnaires for pain intensity, pain interference, physical function and depression. Radiographic assessment was performed using axial images of WBCT scan of both the injured ankle and the contralateral normal side at a level one cm proximal to the tibial plafond (Figure 1).Results:At an average follow up of three years, none of the recruited patients required a revision surgery. There was no significant difference between the two groups in terms of the four PROMIS questionnaires (P values ranged from 0.17 to 0.43). In the suture button group, the measurements of the injured side were significantly different from the normal side for the syndesmotic area (P=0.003), fibular rotation (P=0.004), anterior difference (P=0.025) and direct anterior difference (P=0.035). Other measurements of posterior difference, middle difference, direct posterior difference and fibular translation were not significantly different (P values ranged from 0.36 to 0.99). In the screw fixation group, the syndesmotic area was the only significantly different measurement in the injured side as compared to the normal side (P=0.006).Conclusion:Screw and suture button fixation for syndesmotic instability have similar clinical outcomes at average three years follow up as measured by PROMIS scores. Both screw and suture button did not entirely restore the syndesmotic area as compared to the contralateral normal ankle, suggesting some residual diastasis on weight bearing CT. In addition, as compared to screw fixation, the suture button did not seem to restore the normal fibular rotation, with residual external rotation of the fibula noted. Longer clinical follow up is necessary to understand the clinical implication of such malreduction.

Clinical Significance of Ankle Arthroscopy in the Diagnosis of Type B Ankle Fracture Associated with the Distal Tibiofibular Syndesmosis Injury

Category:Arthroscopy, TraumaIntroduction/Purpose:To investigate clinical significance of ankle arthroscopy in the diagnosis of type B ankle fracture associated with the distal tibiofibular syndesmosis injury.Methods:From February 2014 to December 2016, the authors diagnosed and treated 35 cases of type B ankle fractures. including 23 males and 12 females; with an average age of (43.05±12.480) years.Each patient underwent preoperative assessment: according to the patient’s clinical manifestations and imaging examination, and before the operation and after internal fixation of ankle fracture, the Cotton test and the external rotation test were done in the C arm X-ray, the initial diagnosis whether there is the distal tibiofibular syndesmosis injury.When the Cotton test and the external rotation test was used, Ankle arthroscopy was used to observe and evaluate whether there is the distal tibiofibular syndesmosis injury.For patients with the distal tibiofibular syndesmosis injury, In addition to the internal fixation of the ankle fracture, the TightRope was used to repair the injury. And observation of repair effect by ankle arthroscopy.Results:After internal fixation of ankle fracture, the Cotton test and the external rotation test was performed under the C arm X-ray, there were no the distal tibiofibular syndesmosis injury in 22 patients. Preoperative CT showed 6 cases of combined the distal tibiofibular syndesmosis injury, Preoperative MRI showed 13 cases of combined the distal tibiofibular syndesmosis injury. Ankle arthroscopy confirmed 11 cases of combined the distal tibiofibular syndesmosis injury. The sensitivity of ankle arthroscopy and MRI diagnosis combined with the distal tibiofibular syndesmosis injury was higher than that of CT sensitivity(P<0.05). The sensitivity of ankle arthroscopy for the diagnosis of the distal tibiofibular syndesmosis injury was weaker than that of MRI in the diagnosis of the distal tibiofibular syndesmosis injury (P<0.05). MRI diagnosis of the distal tibiofibular syndesmosis injury can be false positive.Conclusion:Ankle arthroscopy can directly observe the medial triangle ligament of the ankle, the distal tibiofibular syndesmosis injury, which provides the basis for correct diagnosis and treatment of Type B ankle fracture with the distal tibiofibular syndesmosis injury. And it can evaluate the stability of ankle after repairing the distal tibiofibular syndesmosis injury.

Epidemiology of injuries due to ankle sprain diagnosed in an orthopedic emergency room.

ABSTRACTObjective To use magnetic resonance imaging to assess the prevalence of foot and ankle ligament injuries and fractures associated with ankle sprain and not diagnosed by x-ray.Methods We included 180 consecutive patients with a history of ankle sprain, assessed at a primary care service in a 12-month period. Magnetic resonance imaging findings were recorded and described.Results Approximately 92% of patients had some type of injury shown on the magnetic resonance imaging. We found 379 ligament injuries, 9 osteochondral injuries, 19 tendinous injuries and 51 fractures. Only 14 magnetic resonance imaging tests (7.8%) did not show any sort of injury. We observed a positive relation between injuries of the lateral complex, syndesmosis and medial ligaments. However, there was a negative correlation between ankle ligament injuries and midfoot injuries.Conclusion There was a high rate of injuries secondary to ankle sprains. We found correlation between lateral ligament injuries and syndesmosis and deltoid injuries. We did not observe a relation between deltoid and syndesmosis injuries or between lateral ligamentous and subtalar injuries. Similarly, no relation was found between ankle and midfoot injuries.

Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model

BackgroundThe effect of syndesmotic fixation on restoration of pressure mechanics in the setting of a syndesmotic injury is largely unknown. The purpose of this study is to examine the contact mechanics of the tibiotalar joint following syndesmosis fixation with screws versus a flexible fixation device for complete syndesmotic injury. MethodsSix matched pairs of cadaveric below knee specimens were dissected and motion capture trackers were fixed to the tibia, fibula, and talus and a pressure sensor was placed in the tibiotalar joint. Each specimen was first tested intact with axial compressive load followed by external rotation while maintaining axial compression. Next, syndesmotic ligaments were sectioned and randomly assigned to repair with either two TightRopes® or two 3.5 mm cortical screws and the protocol was repeated. Mean contact pressure, peak pressure, reduction in contact area, translation of the center of pressure, and relative talar and fibular motion were calculated. Specimens were then cyclically loaded in external rotation and surviving specimens were loaded in external rotation to failure. ResultsNo differences in pressure measurements were observed between the intact and instrumented states during axial load. Mean contact presure relative to intact testing was increased in the screw group at 5 Nm and 7.5 Nm torque. Likewise, peak pressure was increased in the TightRope group at 7.5 Nm torque. There was no change in center of pressure in the TightRope group at any threshold; however, at every threshold tested there was significant medial and anterior translation in the screw group relative to the intact state. ConclusionEither screws or TightRope fixation is adequate with AL alone. With lower amounts of torque, the TightRope group appears to have contact and pressure mechanics that more closely match native mechanics.

High Ankle Sprains in Professional Ice Hockey Players: Prognosis and Correlation Between Magnetic Resonance Imaging Patterns of Injury and Return to Play.

Background:Hockey players sustain a greater incidence of ankle syndesmosis injuries than other athletes. These injuries have a higher morbidity and more unpredictable recovery than lateral ankle sprains. Magnetic resonance imaging (MRI) has been used to establish the diagnosis but has not been evaluated for its ability to predict return to play.Hypothesis:We hypothesized that patterns of injury defined on MRI could be used to predict return to play in a cohort of professional hockey players with syndesmosis sprains.Study Design:Cohort study; Level of evidence, 3.Methods:A prospectively collected National Hockey League (NHL) database was analyzed from the 2006-2007 to 2011-2012 seasons to assess return to play after an injury. A separate retrospective review of ankle MRI scans from professional hockey players with a documented high ankle sprain sustained between 2007 and 2012 was performed. Injuries were classified on MRI as complete or partial tears of the anterior-inferior tibiofibular ligament (AITFL), posterior-inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL), calcaneofibular ligament (CFL), and deltoid ligament. Fractures, bone contusions, and osteochondral lesions were also recorded.Results:A total of 105 NHL athletes sustained high ankle sprains over the 5 seasons studied. Of these athletes, 85 were unable to play and missed a median of 8 games (range, 0-65 games). A retrospective MRI evaluation of 21 scans identified complete AITFL tears in 13 (62%) and high-grade partial tears in 5 (24%) cases. In contrast, the PITFL was partially torn in 9 (43%) and normal in 12 (57%) cases. Bone contusions were seen in 71% of cases and lacked a consistent pattern. The most commonly associated ligamentous injury was of the ATFL, which was injured in 52% of cases (11/21; 3 complete and 8 partial). There was no difference in the mean number of days lost when players were stratified by patterns of injury (incomplete/complete AITFL tear ± additional ligamentous injury, bone contusion, syndesmosis width).Conclusion:A high ankle sprain resulted in significant variations in time of recovery among professional hockey players. A torn AITFL and bone bruising were the most common patterns of injury. Although MRI can be used to confirm the diagnosis of a syndesmosis injury, it did not predict return to play in this population.

CASE REPORT OF A VERY RARE TRAUMA COMBINATION: CONCOMITANT COMPLEX IPSILATERAL ANKLE FRACTURE ASSOCIATED WITH TIBIA SHAFT FRACTURE

There is a relationship between tibial shaft fractures and ankle injuries. Complex ankle injuries including fractures and syndesmosis injuries associated with ipsilateral tibial fractures are uncommon.&nbsp; In this case report, a four-combination injury including oblique-spiral tibial shaft fracture [TSF], posterior malleolar fracture [PMF], lateral malleolar fracture [LMF], and anteroinferior tibiofibular ligament [AITFL] avulsion in ankle are presented. A 45-year-old female patient was reported to the Department of Orthopedics with the diagnosis of tibia fracture by the emergency department. Ankle injury was noted during clinical examinationa and evaluation of xray. CT study used determine the components of ankle injury and to plan surgery showed distal third oblique-spiral TSF, LMF, PMF, and AITFL avulsion. The next day, the patient underwent open reduction and internal fixation with the fluoroscopic guidance, for all fractures. Only the screw to the posterior malleolus was sent percutaneously under fluoroscopy. No complication and untoward event developed during and after the operation. The fractures reached both radiological and clinical bony union at 4 months. Ankle injuries such as LM fractures, PM fractures and AITFL avulsion fractures, which may be associated with oblique spiral type TSFs, are rarely seen or neglected. It is clinically important to recognize the four-combination injury preoperatively as unsuccessful reduction or fixing of the four-combination injury in the anatomic position may increase the risk of posttraumatic arthritis. Therefore, ankle fracture and syndesmosis injuries which is associated with tibia shaft fracture should not be missed and should treated appropriately.

Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review.

Tibiofibular syndesmosis injury leads to ankle pain and dysfunction when ankle injuries are not treated properly. Despite several studies having been performed, many questions about diagnosis and treatment remain unanswered, especially in ankle syndesmosis injury with interosseous membrane injury. Therefore, the purpose of this study was to help guide best practice recommendations. This review explores the mechanism of injury, clinical features, diagnosis methods, and the treatment strategy for ankle syndesmosis injury with interosseous membrane injury to highlight the current evidence in terms of the controversies surrounding the management of these injuries. Radiological and CT examination are an important basis for diagnosing ankle syndesmosis injury. Physical examination combined with MRI to determine the damage to the interosseous membrane is significant in guiding the treatment of ankle syndesmosis injury with interosseous membrane injury. In the past, inserting syndesmosis screws was the gold standard for treating ankle syndesmosis injury. However, there were increasingly more controversies regarding loss of reduction and broken nails, so elastic fixation has become more popular in recent years. Anatomical reduction and effective fixation are the main aspects to be considered in the treatment of ankle syndesmosis injury with interosseous membrane injury and are the key to reducing postsurgery complications.

Prevalence and associated factors of intra-articular lesions in acute ankle fractures evaluated by arthroscopy and clinical outcomes with minimum 24-month follow-up.

Background:Acute ankle fractures can lead to high rate of concomitant intra-articular lesions which may compromise clinical results. The purpose of this study was to evaluate the incidence of concomitant intra-articular lesions in acute ankle fractures with arthroscopy. We also sought to analyze the relationship between intra-articular lesions and the fracture type, as well as the severity of the fracture.Methods:It was a retrospective cohort study. From April 2014 to December 2015, we have chosen arthroscopy-assisted open reduction and internal fixation (AORIF) for the treatment of unstable acute ankle fractures. All concomitant intra-articular lesions were assessed and documented carefully and prospectively, such as ligament injuries, osteochondral lesions, and tibiofibular syndesmosis injuries. All fractures were classified according to the Lauge-Hansen classification system. The American Orthopedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale was used to assess post-operative function. Statistical comparisons between the intra-articular lesions, the fracture type, and the severity of the presenting fracture were performed using a Chi-squared analysis.Results:Data of 36 patients were analyzed in the study, including 23 supination-type fractures and 13 pronation-type fractures. The incidence of tibiofibular syndesmosis injuries, chondral lesions, and loose bodies were 92%, 72%, and 39%, respectively. Avulsion fractures of the anterior tibiofibular syndesmosis were more commonly found in supination-type fractures than pronation-type fracture (45% vs. 15%, χ2 = 5.78, P = 0.02), which would cause mechanical blocking in the anterior portion of the ankle. On the contrary, chondral lesions were more commonly found in the more severe fractures than mild fractures (86% vs. 53%, χ2 = 4.57, P = 0.03). A mean 41.7 months (range, 33.0–51.0 months) of follow-up was achieved. A mean AOFAS's ankle-hindfoot scale was 96.9, and 97.2% of the patients were satisfied with the procedure.Conclusions:Acute ankle fractures have a high incidence of concomitant intra-articular lesions. Avulsion fractures of the anterior tibiofibular syndesmosis are more commonly found in supination-type fractures. Chondral lesions are related to the severity of the fractures, but not with the classification of the fractures. AORIF can be one reliable solution in dealing with the associated injuries seen with acute ankle fractures.

Importance of Syndesmotic Reduction on Clinical Outcome After Syndesmosis Injuries.

To evaluate the relationship between syndesmosis reduction and outcome. Retrospective cohort study. One Level 1 and 1 Level 3 Trauma Center. Ninety-seven patients with syndesmosis injury. Stabilization of syndesmosis injury. Open reduction and internal fixation of malleolar fracture, if present. Anterior, central, and posterior measures of syndesmosis width on computed tomography scans, Olerud-Molander Ankle score, American Orthopaedic Foot and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, and range of motion measurements. Eighty-seven patients completed 2 years of follow-up. The difference in anterior tibiofibular distance (aTFD) between the injured and noninjured ankle postoperatively had a significant effect on the Olerud-Molander Ankle score after 6 weeks [b = -2.6, 95% confidence interval (CI), -4.8 to -0.4; P = 0.02], 1 year (b = -2.7, 95% CI, -4.7 to -0.8; P < 0.001), and 2 years (b = -2.6, 95% CI, -4.6 to -0.6; P = 0.009) and on American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score after 6 weeks (b = -2.2, 95% CI, -3.7 to -0.7; P = 0.004), 1 year (b = -1.7, 95% CI, -3.0 to -0.4; P = 0.04), and 2 years (b = -1.9, 95% CI, -3.2 to -0.5; P = 0.006). The effect of computed tomography measurements on range of motion was inconsistent. Receiver operating characteristic (ROC) curves demonstrated that aTFD had adequate discriminatory performance (area under the ROC curve ≥ 0.7) 1 and 2 years after surgery and the central measurement at only 2 years after surgery. ROC analyses indicate a cutoff value for syndesmosis malreduction of 2 mm. The postoperative rate of malreduction was 32%. The aTFD correlated with clinical outcome. A 2-mm difference in aTFD seems to predict poorer clinical outcome. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Internal Tibial Torsion is Related to Syndesmosis Injury in a Large Osteological Collection

Internal Tibial Torsion is Related to Syndesmosis Injury in a Large Osteological Collection

A reliable method for intraoperative detection of lateral malleolar malrotation using conventional fluoroscopy

ObjectiveTo introduce a new method for intraoperative detection of rotational malreduction of the lateral malleolus using conventional fluoroscopy. Material and methodsFrom January 2014 to December 2017, 56 Weber type C unstable lateral malleolar fractures with syndesmosis injury were identified. The fibular fracture patterns were simple oblique or transverse in 20, comminuted in 25, and Maisonneuve injury with fibular neck fractures in 11 cases. 47 cases were operated with ORIF, and 9 cases of Maisonneuve fractures were operated with CRIF. The mortise view of the contralateral uninjured ankle was used for intraoperative comparison. Two indexes were applied for fluoroscopic detection of distal fibula malrotation, i.e. the contour profile change in lateral malleolar shape, and the intrinsic structure appearance of lateral malleolar fossa cortex. Postoperative talofibular joint congruency was measured on axial CT scan to confirm the reduction quality. ResultsUsing the two radiographic parameters for intraoperative fluoroscopic evaluation, we finally achieved satisfying reduction and fixation of the lateral malleolus in all 56 cases. A more spoon-shaped fibula profile and disappearance of the lateral fossa cortex shadow indicates an internal rotation, while a more pointed blade-shaped fibula profile and disappearance of lateral fossa cortex shadow indicates an external rotation. Postoperative CT scanning identified distal fibular no rotation in 44 cases (78.6%), mild rotation less than 5° in 12 cases (21.4%), with 7 cases internal rotation (mean 3.1°) and 5 cases external rotation (mean 2.8°). ConclusionUsing conventional intraoperative fluoroscopy on mortise view, new radiographic parameters can provide reliable method to detect rotational malreduction of the lateral malleolus.

Diagnostic Accuracy of Radiologic Methods for Ankle Syndesmosis Injury: A Systematic Review and Meta-Analysis.

Misdiagnosis and inadequate treatment of syndesmosis could result in significant long-term morbidity including pain, instability, and degenerative changes of the ankle joint. The objective of this systematic review and meta-analysis was to determine whether radiologic tests accurately and reliably diagnose ankle syndesmosis injury. Medline, Embase, and Cochrane were searched. The database search resulted in 258 full text articles that we assessed for eligibility, we used eight studies that met all the inclusion criteria. In subgroup meta-analysis, the sensitivity analysis showed significant differences only in the MRI (Magnetic Resonance Imaging), and specificity was not statistically significant. In diagnostic meta-analysis, the pooled sensitivity and specificity were 0.528 and 0.984 for X-rays, 0.669 and 0.87 for CT (Computed Tomography), and 0.929 and 0.865 for MRI, all respectively. For sensitivity, MRI showed significantly sensitivity as higher than the other methods, and we detected no significance for specificity. Syndesmosis injuries differed significantly in the accuracy of radiological methods according to the presence of accompanied ankle fractures. In patients with fractures, simple radiography has good specificity, and CT and MRI have high sensitivity and specificity irrespective of fracture; in particular, MRI has similar accuracy to gold standard arthroscopic findings.

What’s New in Orthopaedic Trauma

What’s New in Orthopaedic Trauma

MRI for high ankle sprains with an unstable syndesmosis: posterior malleolus bone oedema is common and time to scan matters.

Early clinical examination combined with MRI allows accurate diagnosis of syndesmosis instability after a high ankle sprain. However, patients often present late. The aims of the current study were to describe MRI characteristics associated with syndesmosis instability and to test the hypothesis that MRI patterns would differ according to time from injury. Over a 5-year period, 164 consecutive patients who had arthroscopically proven syndesmosis instability requiring fixation were retrospectively studied. Patients with distal fibula fractures were not included. Injuries were classified as acute in 108 patients (< 6weeks), intermediate in 32 (6-12weeks) and chronic in 24 patients (> 12weeks). Posterior malleolus bone oedema was noted in 65 (60.2%), and posterior malleolus fracture in 17 (15.7%) of acute patients, respectively, which did not significantly differ over time. According to MRI, reported rates of posterior syndesmosis disruption significantly differed over time, observed in 101 (93.5%), 28 (87.5%) and 13 (54.2%) of acute, intermediate and chronic patients, respectively (p < 0.001). Apparent rates of PITFL injury significantly reduced with time (p < 0.001). MRI detected a posterior syndesmosis injury in 93.5% of patients acutely but became less reliable with time. The clinical relevance of this study is that posterior malleolus bone oedema may be the only marker of a complete syndesmosis injury and can help clinically identify those injuries which require arthroscopic assessment for instability. If suspicious of a high ankle sprain, we advocate early MRI assessment to help determine stable versus unstable injuries as MRI becomes less reliable after 12weeks. III.

Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared With Screw Fixation: A Meta-analysis of Randomized Controlled Trials

Background: Several devices for obtaining dynamic fixation of the syndesmosis have been introduced in recent years, but their efficacy has been tested in only a few randomized controlled trials (RCTs), without demonstrating any clear benefit over the traditional static fixation with screws. Purpose: To perform a level 1 meta-analysis of RCTs to investigate the complications, subjective outcomes, and functional results after dynamic or static fixation of acute syndesmotic injuries. Study Design: Meta-analysis of RCTs. Methods: A systematic literature search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, and Embase electronic databases, as well as ClinicalTrials.gov for unpublished studies. Eligible studies were RCTs comparing dynamic fixation and static fixation of acute syndesmosis injuries. A meta-analysis was performed, while bias and quality of evidence were rated according to the Cochrane Database questionnaire and the Grading of Recommendations Assessment, Development and Evaluation guidelines. Results: Dynamic fixation had a significantly reduced relative risk (RR = 0.55, P = .003) of complications—in particular, the presence of inadequate reduction at the final follow-up (RR = 0.36, P = .0008) and the clinical diagnosis of recurrent diastasis or instability (RR = 0.10, P = .03). The effect was more evident when compared with permanent screws (RR = 0.10, P = .0001). The reoperation rate was similar between the groups (RR = 0.64, P = .07); however, the overall risk was reduced after dynamic fixation as compared with static fixation with permanent screws (RR = 0.24, P = .007). The American Orthopaedic Foot & Ankle Society score was significantly higher among patients treated with dynamic fixation—6.06 points higher (P = .005) at 3 months, 5.21 points (P = .03) at 12 months, and 8.60 points (P < .00001) at 24 months—while the Olerud-Molander score was similar. The visual analog scale for pain score was reduced at 6 months (–0.73 points, P = .003) and 12 months (–0.52 points, P = .005), and ankle range of motion increased by 4.36° (P = .03) with dynamic fixation. The overall quality of evidence ranged from “moderate” to “very low,” owing to a substantial risk of bias, heterogeneity, indirectness of outcome reporting, and evaluation of a limited number of patients. Conclusion: The dynamic fixation of syndesmotic injuries was able to reduce the number of complications and improve clinical outcomes as compared with static screw fixation—especially malreduction and clinical instability or diastasis—at a follow-up of 2 years. A lower risk of reoperation was found with dynamic fixation as compared with static fixation with permanent screws. However, the lack of patients or personnel blinding, treatment heterogeneity, small samples, and short follow-up limit the overall quality of this evidence.

Epidemiology of syndesmotic fixations in a pediatric center: A 12-year retrospective review.

Syndesmosis injuries need to be accurately diagnosed and managed to avoid chronic pain, early arthritis, and instability. To this end, the present study aimed to analyze the epidemiology of syndesmotic injuries in a pediatric ankle fracture cohort and identify patient and surgery-related characteristics.A retrospective review of all the ankle fractures during a 12-year period at a single pediatric referral center was conducted. Inclusion criteria were: a fractured ankle that underwent a surgical fixation, at least 1 radiograph available for review before fixation, available information regarding surgery, including operative report and fluoroscopic images, and younger than 18 years at the time of surgery. Demographic information, trauma, radiographs, surgical details, clinical examination, follow up, outcomes, and physeal status (skeletally immature, transitional, or mature) were recorded. Finally, patients were divided in 2 groups: with or without syndesmotic fixation. Statistical analysis included descriptive statistics, Mann–Whitney test for nonparametric data to compare continuous parameters, and χ2 test for categorical parameters.A total of 128 patients were included with a mean age of 14.1 years. There were 80 boys and 48 girls. There were 51 skeletally immature patients, 23 with transitional fractures, and 54 that were skeletally mature. The main finding of this study is that only 11 patients from the mature group underwent syndesmotic fixation. There were no cases of syndesmotic fixation in the skeletally immature and transitional groups.This is the first retrospective study to focus specifically on syndesmotic injuries in a pediatric population who underwent ankle fracture fixation. Only 11 skeletally mature patients underwent syndesmotic fixation out of 128 patients in this cohort. This result raises the question of whether there are accurate diagnostic tools to evaluate syndesmosis in children.