Syndesmotic Screw Research Articles

Assessing the Need for Additional Syndesmotic Stabilization in Open Reduction of the Posterior Malleolus: A Biomechanical Study.

The treatment of ankle fractures involving the posterior malleolus (PM) has changed in favor of open reduction and internal fixation (ORIF), and the need for additional syndesmotic stabilization has decreased; however, there are still doubts regarding the diagnosis and treatment of residual syndesmotic instability. The aim of the present study was to evaluate the effect of fixation of the PM and to assess the need for additional stabilization methods. We hypothesized that ORIF of the PM would not sufficiently stabilize the syndesmosis and that additional syndesmotic reconstruction would restore kinematics. Eight unpaired, fresh-frozen, cadaveric lower legs were tested in a 6-degrees-of-freedom robotic arm with constant loading (200 N) in the neutral position and at 10° dorsiflexion, 15° plantar flexion, and 30° plantar flexion. The specimens were evaluated in the following order: intact state; osteotomy of the PM; transection of the anterior inferior tibiofibular ligament (AITFL) and interosseous ligament (IOL); ORIF of the PM; additional syndesmotic screw; combination of syndesmotic screw and AITFL augmentation; and AITFL augmentation. A complete simulated rupture of the syndesmosis (PM osteotomy with AITFL and IOL transection) caused translational (6.9 mm posterior and 1.8 mm medial displacement) and rotational instability (5.5° external rotation) of the distal fibula. ORIF of the PM could eliminate this instability in the neutral ankle position, whereas sagittal and rotational instability remained in dorsiflexion and plantar flexion. The remaining instability could be eliminated with an additional procedure, without notable differences between screw and AITFL augmentation. In our model, isolated PM osteotomy and isolated AITFL and IOL rupture (after PM refixation) only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of PM osteotomy and AITFL and IOL rupture resulted in an unstable syndesmosis in all planes. In complex ankle fractures, ORIF of the PM is essential to restore syndesmotic stability; however, residual syndesmotic instability can be detected by a specific posterior shift of the fibula on stress testing. In these cases, anatomical AITFL augmentation is biomechanically equivalent to the use of a syndesmotic screw.

Syndesmotic Screw Fixation Versus Suture Button Versus Tibiotalocalcaneal Nail Treatment in Syndesmotic Ankle Fractures: A Meta-Analysis.

Syndesmotic ankle fractures occur when damage to the syndesmosis complex is combined with a malleolar fracture. This can result in severe pain, weakness, and instability. Surgical interventions include syndesmotic screw fixation (SS), suture button fixation (SB), and tibiotalocalcaneal nail (TTC). This meta-analysis aims to compare the outcomes of these treatment methods for syndesmotic ankle fractures. A literature search was conducted on PubMed and Embase for comparison studies that included at least 2 surgical interventions and at least one of the relevant functional outcomes and/or complication metrics until June 2024. The Olerud-Molander Ankle Score (OMAS) was used to compare functional outcomes, and it is a self-reported outcome measure that evaluates the symptoms and function of those with ankle fractures, while infections and reoperations were reported to compare complication outcomes. Statistical analyses were performed using Review Manager 5.4. A P-value ≤ .05 was considered statistically significant. The risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale. A total of 18 studies with a total of 1,040 patients were ultimately included in this study. The SS had a significantly higher OMAS 2-year follow-up compared to TTC. The TTC had a significantly lower infection rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than SS. The SB had a significantly lower reoperation rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than TTC. The SB had a significantly lower infection rate compared to TTC. The SB emerges as the preferred treatment method for syndesmotic ankle fractures, while TTC stands as a viable alternative. The SB is recommended as the primary surgical intervention for patients with syndesmotic ankle fractures due to its superior clinical benefits when compared to TTC and SS. 3.

Comparison between Suture-Button Technique with Syndesmotic Repair and Screw Fixation Technique for Complete Ankle Syndesmotic Injury: Biomechanical Cadaveric Study.

The tibiofibular syndesmosis is essential for preserving the stability of the ankle. Acute syndesmotic injuries with evident or latent instability usually warrant surgical interventions. This cadaveric study examines and compares biomechanical characteristics between the following treatments for syndesmosis injuries: suture-button fixation plus syndesmotic repair and screw fixation. The lower extremities of 10 cadavers disarticulated at the knee joints were used, yielding 20 feet. Ten feet underwent surgery using the suture-button fixation with syndesmotic repair, while the remaining 10 feet underwent surgery using screw fixation. Before surgical treatment of syndesmosis injuries, each cadaveric lower limb underwent preliminary physiological cyclic loading, which was followed by a series of postfixation cyclic loading tests after the surgical procedure. Our principal finding is that suture-button fixation with syndesmotic repair provided torsional strength comparable to that of screw fixation. The mean failure torque did not differ between the 2 groups, but the rotational stiffness was significantly lower in the suture-button fixation/augmentation group. Suture-button fixation/augmentation facilitates flexible (physiological) syndesmosis movement and may be a useful alternative treatment for ankle syndesmosis injury.

Mini Fragment and Small Fragment Screws are Comparable in Acute Syndesmotic Injury.

Mini Fragment and Small Fragment Screws are Comparable in Acute Syndesmotic Injury.

Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?

Submission Type: Ankle Fractures Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Various techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, recent techniques including the Syndesmosis TightRope® XP (TightRope, Arthrex) and InternalBrace™ (IB, Arthrex) have been developed to optimize natural flexibility and movement of the syndesmosis. It remains unclear whether syndesmotic fixation technique impacts complication rates and outcomes. This study aims to determine which repair technique results in the fewest complications and best functional outcomes as measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). To our knowledge, this is the largest retrospective study comparing PROMIS scores between these syndesmotic fixation techniques. We hypothesized that Tightrope and IB would reduce complications and improve PROMIS scores compared to screws. Methods: 782 patients who underwent ankle fracture surgery at a single institution between January 2016-December 2021 were reviewed retrospectively. Two foot and ankle fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. 328 patients with syndesmotic ruptures were sent post-operative questionnaires. 159 patients with minimum one-year follow-up were analyzed for complications. 70 patients who completed PROMIS CATs were analyzed for functional outcomes. Due to rarity of complications and perfect separation in the data, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS scores across repair types. Analysis of PROMIS scores had 80% power to detect large effect sizes (Cohen’s f = 0.40) with a 0.05 significance level but was underpowered for small and medium effects. PROMIS scores were modeled by repair technique using linear regression. Results: 62/159 patients underwent syndesmotic fixation with screw placement, 59/159 with Tightrope, and 38/159 with IB. Overall complication rates with syndesmotic screw fixation were 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 0% end-stage arthritis, 1.6% (1/62) syndesmotic malreduction, 4.8% (3/62) syndesmotic malunion. Overall complication rate in Tightrope was 1.7% (1/59): 1.7% (1/59) DJD. IB had no radiographic complications. Mean PF was 50.38±9.39 screw, 53.87±9.70 Tightrope, and 52.18±13.08 IB (p=0.71). Mean PI was 49.28±8.22 screw, 47.91±8.80 Tightrope, and 49.15±10.46 IB (p=0.79). Compared to screws, adjusted models demonstrated mean PF 4.00 points greater for Tightrope (p=0.17) and 2.94 points greater for IB (p=0.34). Adjusted models for PI revealed mean scores of 2.05 points less for Tightrope (p=0.42) and 1.23 points less for IB (p=0.65) compared to screws. Conclusion: Our findings indicate that syndesmotic fixation with the Tightrope and IB reduce radiographic complications compared to screws. While this study was underpowered to detect small or medium effect sizes and thus was unable to demonstrate statistically significant differences in PROMIS scores, the higher PF and lower PI for Tightrope and IB compared to screws may reach statistical significance in larger sample sizes. Nevertheless, differences in PF scores in the adjusted model suggest that Tightrope and IB improve PF compared to screw, reaching the lower end range of the minimal clinically important difference for this outcome measure reported in the literature.

Ankle syndesmotic injury repair with tightrope versus syndesmotic screw fixation

Ankle syndesmotic injury repair with tightrope versus syndesmotic screw fixation

A Single-Center Retrospective Study on the Clinical Outcomes of TightRope Fixation Versus Syndesmotic Screw Fixation in the Management of Acute Traumatic Ankle Syndesmotic Injuries.

Background Ankle fractures are one of the most commonpresentations in orthopaedic surgery and represent the third most frequent musculoskeletal injury in the elderly population. Syndesmotic injuries can be associated with ankle fractures, and surgical intervention is critical in these injuries to restore stability and prevent long-term disability. Traditionally, syndesmotic screw fixation has been the standard treatment for acute traumatic syndesmotic injuries, but controversies regarding this fixation method remain. Over recent years, the TightRope system (Arthrex,Florida, US)has gained popularity as a dynamic alternative, offering the advantage of restoring anatomical function while maintaining reduction. The optimal surgical fixation method for managing syndesmotic injuries remains a topic of ongoing debate withinorthopaedic practice. Therefore, this study aims to compare the clinical outcomes of these two fixation methods to provide further guidance on their use in managing acute traumatic syndesmotic injuries. Methods A retrospective cohort study was performed for all patients with ankle syndesmotic injuries who underwent surgical fixation using either TightRope devices or syndesmotic screws at Buckinghamshire Healthcare NHS Trust between June 2020 and June 2023, identified through the BlueSpier electronic record system (Bluespier, Droitwich, United Kingdom). Data on demographics and surgical details were extracted from electronic medical recordswhile radiographic images were systematically reviewed to confirm eligibility for inclusion. Clinic letters were also reviewed for complications and reasons for metalwork removal. Results A total of 217 patients met the eligibility criteria for this study, with 132 (61%) females and 85 (39%) males, aged between 13 and 93 years (mean age: 49 years). Of the cohort, 28 (13%) underwent syndesmotic fixation with TightRope deviceswhile 189 (87%) were treated with syndesmotic screws. Metalwork removal was required in 11% of TightRope cases (3 patients) and 28% of syndesmotic screw cases (52 patients). The most commonreason for metalwork removal in our study cohort was for broken or loosened screw(s), followed by discomfortand patient preferences. The metalwork removal rates in our study cohort are consistent with those reported in the current literature. Conclusion In conclusion, our study found that the use of TightRope devices is associated with lower removal rates in comparison to syndesmotic screws. This finding is consistent with those reported in the current literature. The most commondocumented reason for metalwork removal in our study cohort was due to screw breakage or loosening. Although emerging evidence suggests that routine removal of syndesmotic screws may not be necessary, given the lack of consensus regarding the routine removal of syndesmotic screws, decisions for metalwork removal should be tailored by clinical judgement and individual patient needs. Despite its limitations, this study contributes valuable insights into the outcomes and metalwork removal rates associated with syndesmotic fixation methods in the management of acute ankle fractures with syndesmotic injuries.

Syndesmotic Screws, Is Routine Removal Necessary? A Systematic Review and Meta-Analysis

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic injuries are commonly treated with syndesmotic screws, with subsequent screw removal routinely scheduled during the postoperative period. Recent studies have raised doubts about the necessity of routine removal, highlighting the lack of change in functional outcomes and the risks posed by a second surgery. Previous systematic reviews on this topic have not limited their inclusion criteria to Randomized Controlled Trials (RCTs), consequently lowering their level of evidence (LOE). Our study aimed to compare the functional outcomes and complication rates in patients undergoing routine syndesmotic screw removal versus those managed with an on-demand approach while providing a higher LOE than previous studies. Methods: In accordance with the guidelines on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) we conducted a systematic search of seven databases (MEDLINE, Embase, Cochrane CENTRAL, CINAHL, Web of Science, PubMed, and ClinicalTrials.gov) for comparative studies on routine syndesmotic screw removal versus an on-demand approach to removal following acute ankle fractures or isolated syndesmotic injuries. Only prospective RCTs were considered for inclusion. Data reported by at least 2 studies were pooled for meta-analysis using Review Manager Software (RevMan 5.4.1). Mean differences were calculated for continuous outcomes while risk ratios were calculated for dichotomous outcomes; all measures were calculated with their respective 95% confidence intervals (CIs). Two-tailed tests of significance were performed with a value of 0.05. Heterogeneity was calculated using I2 index, Random-effect models were used for groups with high heterogeneity (I2 > 51%) while common-effect models were used for groups with low heterogeneity (I2 < 50%). Results: Of 630 potential articles, only 3 studies were ultimately chosen for inclusion. Pooled data analysis showed no significant difference in Olerud-Molander ankle scores (mean difference [MD] -2.36, 95% confidence interval [CI] -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (mean difference 2.20, 95% CI -0.50 to 4.89, p = 0.11) between the routine removal and on-demand removal groups at the one-year mark postoperatively. However, routine removal was associated with a significantly higher rate of overall complications compared to on-demand removal (risk ratio 3.02, 95% CI 1.64 to 5.54, p = 0.0004). Respectively, none of the included studies reported a significant difference in pain scores or range of motion. Conclusion: Our results did not show any significant difference in functional outcome scores between routine removal and on-demand removal of syndesmotic screws at 1-year postoperatively, suggesting that neither removal strategy significantly impacts functional recovery. However, the significantly higher incidence of complications in the routine removal group, raises important considerations regarding the potential disadvantages of this approach. Consequently, given the elevated risk of complications associated with routine removal and the lack of superior functional outcomes, we recommend adopting an as-needed approach to syndesmotic screw removal.

The Kinematic Effect of Anatomic Deep Deltoid Ligament Stabilization in a Cadaveric Model of Syndesmotic Instability with Deep Deltoid Ligament Instability

Category: Trauma; Sports Introduction/Purpose: The objective of this work was to investigate the utility of a suture augmented deep deltoid ligament (DDL) stabilization with different accepted treatments of distal tibiofibular syndesmosis injuries. We hypothesized that adding DDL stabilization would improve the rotational stability of the ankle. Also, that flexible syndesmotic stabilization using suture button fixation, AITFL suture stabilization, with DDL stabilization would restore the kinematics of an intact ankle most closely during external rotation stress (ERS). Methods: Ten matched pairs of through-the-knee cadaveric ankle specimens were mechanically tested in 5 Nm of ERS under 750 N of axial load. Specimens were tested intact, after transection of all the syndesmotic and deep deltoid ligaments and after each iteration of one of two stabilization sequences: 1) AITFL + suture button (SB) stabilization; AITFL+SB + DDL suture stabilization; syndesmotic screw with or without DDL stabilization; or 2) AITFL+SB+DDL; AITFL+SB; syndesmotic screw with or without DDL stabilization. Optical motion tracking was used to capture the kinematics of the tibia, fibula, and talus. CT scans of each specimen with markers were used to transform kinematic data into an anatomic coordinate system. Individual bony kinematics were extracted by decomposing the transformation matrices needed to align the starting test position to the ending test position and tracking points on the anterior medial and anterior lateral talus. Results: The average axial rotation of the talus was significantly increased after destabilization from 5.15 to 9.02 as compared to the intact state (P< 0.001). All the four fixation constructs reduced the axial rotation of the talus without significant difference when compared to intact (figure 1). Addition of DDL stabilization reduced the talar axial rotation with both screw and flexible stabilization. The axial plane translation direction changed from 16.22 degrees in intact stage to 53.21 after destabilization (P=0.044). The range of axial plane translation direction after all stabilizations was 35.02 to 44.43, however, they were not significantly different as compared to the intact state. Conclusion: DDL stabilization improved rotational stability of the talus. Although there were no significant changes in the axial plane translation direction of the talus after any stabilizations, there was a 19 to 28 degree difference as compared to the intact stage. This could be clinically significant over the course of years since the latency period of posttraumatic ankle arthritis is known to be approximately 20 years. The apparent over-tightening of both flexible and screw stabilization of syndesmosis with DDL stabilization should be thought of as time zero due to creep of flexible fixation that was observed at the conclusion of testing.

Syndesmotic Screw Angle in Lateral Fibular Pre-Contoured Plates Impacts Quality of Syndesmotic Reduction: A Cadaveric Study

Category: Ankle; Trauma Introduction/Purpose: Achieving adequate reduction of ankle syndesmosis after syndesmotic injury is critical as malreduction can lead to accelerated arthritis, pain, and instability. Static fixation with syndesmotic screw is the gold standard where 1-2 syndesmosis screws are placed obliquely at a 25-30° angle from posterolateral to anteromedial, parallel to the joint line. While retrospective studies have been conducted on screw level and extreme angle changes, it is unclear how changes in screw angle impacts rates of malreduction. We sought to assess the effect of syndesmotic screw angle within lateral fibular pre-contoured plates on the quality of syndesmotic reduction. We hypothesize that greater deviations from the 30° screw angle would cause malreduction of the syndesmosis, particularly as the screw head engaged with the pre-contoured plate at sharper angles. Methods: Twelve cadaveric legs were used for this study. All legs were CT scanned pre- and post-simulated syndesmosis injury, with the uninjured serving as the controls. Six pairs of legs were split into 3 groups of 4, (20, 30, and 40 degree screw angles). Each specimen was confirmed to have no prior syndesmosis injury prior to conducting the simulated syndesmosis injury. Syndesmotic screw angle was determined by 3D-printed custom drill guides with drilling performed by a fellowship-trained trauma surgeon, tricortical screws were placed and scanned, then repeated with quad-cortical screws. Syndesmosis reduction was assessed via pre- and post-injury CT scans, we compared the following measures at 1 cm above the tibial plafond: anterior and posterior tibiofibular distance, anteroposterior fibular translation, and fibular rotation. Malreduction was defined as any significant deviation of the 4 measurements compared to pre-injury. Pre-injury K-wire tracks served as additional verification of translation or rotation. Results: In total, 24 reductions were measured and analyzed for malreduction. Measurements, grouped by screw angle, of post injury CT scan at 1 cm above the tibial plafond showed malreductions as follows: 3 of 8 at 20°, 0 of 8 at 30°, and 6 of 8 at 40°. Fischer’s exact demonstrated a significant change between angle and presence of malreduction (p = 0.009). Syndesmotic screw angle significantly impacted change in anteroposterior fibular translation with positive changes indicating posterior translation and negative, anterior translation (20°: 0.98 mm, 30°: 0.068 mm, 40°: -1.91 mm, p= 0.0094). Syndesmotic screw angle did not impact change in anterior or posterior tibiofibular distance or fibula angle. Malreduction did not differ between tri and quad cortical screws (p = 0.5). Conclusion: Our study shows evidence that deviation of syndesmotic screw angle within a pre-contoured lateral fibula plate significantly impacts malreduction rates and anteroposterior fibular translation regardless of tri- or quad-cortical fixation. While our study does not support our hypothesis that plate-screw interaction is responsible for malreduction in syndesmosis fixation, it does support that the ideal syndesmotic screw angle is approximately 30 degrees and that deviation from this angle risks anteroposterior fibular translation and malreduction.

Ankle Fractures Treated With Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique.

To describe and report outcomes of a minimally invasive open fibular intramedullary (IM) nailing technique for fixation of ankle fractures. Case Series. Urban Level 1 trauma center. Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing through a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Quality of reduction, complications, and patient-reported outcomes. A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean body mass index was 30.6 ± 7.4 kg/m 2 . Ninety-three (62%) patients were female, and 78 (52%) patients were White. Seventy-two (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients had diabetes, and 23 (15.3%) patients had open fractures. Thirty-seven (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65 (43.3%) had trimalleolar fractures. One hundred and twenty-three (82%) patients had 2 syndesmotic screws placed, 26 patients (17.3%) had 1 screw, and 1 patient (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan criteria. One hundred thirteen patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months. One hundred and ten patients (97.3%) went on to successful clinical and radiographic union after the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. Three patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). Nine (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9 degrees (0-40) of dorsiflexion, 39.6 degrees (10-70) of plantar flexion, 23.5 degrees (5-40) of inversion, and 18.2 degrees (5-50) of eversion. Mean PROs at final follow-up visit were Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72), and Mobility: 36.9 (16-65.3). Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient-reported outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparative Study between Syndesmotic Rupture Treated by Suture-Button and Syndesmosis Screw

Background: Syndesmosis injury and rupture is quite common in Lauge-Hansen external-rotation type ankle fractures (ERAF). The injured syndesmosis may remain unstable even the fractures are well reduced and fixed. The aim of this work is to compare between Suture-Button and Syndesmosis Screw as treatment of Syndesmotic Rupture. Methods: This prospective randomized study was conducted on Forty patients with ankle fracture admitted to Orthopedic Surgery unit., at Benha University Hospitals from Jan 2022 to September 2023. Forty Patients were randomly enrolled, the allocation of the patients into each group was done using a 1:1 computer-generated sequencing placed in sealed envelopes into three groups: Group A SS (N=20): patients were treated with Syndesmosis Screw, Group B SB (N=20): patients were treated with Suture-Button. Results: Regarding the mean total score of The American Orthopaedic Foot & Ankle Society (AOFAS), at 3 months, the mean score in group A was 58.5±12.9 and in group B was 64.75±10.9 with p-value 0.05(p-value ≤0.05 is statistically significant). At 6 months, the mean total score in group A was 86.95±11.45 and in group B was 94.15±5.35 with p-value 0.005.Conclusions: The dynamic fixation of acute syndesmosis injuries by tightrope gives better clinical outcomes than static fixation at 3 and 6 months follow up. the implant offers adequate syndesmosis stabilization without the risk of screw breakage. Also, it decreases the reoperation rate.

How has acute syndesmotic injury management evolved over the last decade? Results from a national survey

The management of acute distal tibiofibular syndesmotic injuries has evolved over time and therefore, the aim of this study was to evaluate the use of different methods and the changes regarding management of distal tibiofibular syndesmotic injury among Dutch trauma- and orthopedic surgeons.A digital survey based on a previous survey conducted in 2012 was sent to (orthopedic) trauma surgeons from all different hospitals in the Netherlands.Sixty out of the 68 invited hospitals completed at least one survey (88.2 %). For Weber B or low Weber C fractures, there was a preference for the use of a single syndesmotic screw (SS)(73.6 %), while two screws were mainly used in Maisonneuve fractures (89.3 %). Furthermore, there was a clear preference for 3.5-mm screws, engaging three cortices, 2 to 4-cm above the tibiotalar joint. There is a significant decrease in routine removal of SSs (23.2 % compared to 87.0 % in 2012, p < 0.01). The percentage of hospitals in this survey that used the suture button (SB) was relatively low: 8.3 % for low fibular fractures and 5.0 % in high fibular fractures.In conclusion, the most striking difference compared to 2012 is the large decline in routine removal of the SS, which is in line with current literature. The SS is mainly implanted engaging three cortices, placed 2-4 cm above the tibiotalar joint and 3.5 mm in size and for the treatment of Maisonneuve fractures, two screws are preferred over a single SS. Level of evidenceLevel III

Is There Any Purpose in Routine Syndesmotic Screw Removal? Systematic Literature Review.

Introduction: The aim of this systematic review is to examine the recent evidence comparing the removal and non-removal of syndesmotic screws in tibiofibular syndesmosis injuries in terms of functional, clinical, and radiographic outcomes. Methods: A comprehensive literature review was conducted to identify clinical studies on syndesmotic screw removal and its outcomes, searching the Cochrane Library and PubMed Medline for publications from 1 January 2004 to 12 February 2024. Studies were included if they involved tibiofibular syndesmotic screw fixation, assessed screw removal or retention, described clinical outcomes, and were original research with at least fifteen patients per group. Results: Most reviewed articles (18 out of 27; 67%) found no significant differences between the routine removal and retention of syndesmotic screws post-fixation. Four retrospective studies (15%) suggested that retaining screws might result in worse outcomes compared to removal. Two studies (7%) indicated that removing screws could introduce additional risks. One study (4%) observed that post-removal, there is some fibula-tibia separation without affecting the medial clear space. Another study (4%) noted that intraosseous screw breakage might increase the need for implant removal due to pain. Additionally, no significant differences in ankle function were found among groups with varying intervals of screw removal. Conclusions: The current literature does not definitively support routine removal of syndesmotic screws. Given the potential complications and financial costs, routine removal should not be performed unless specifically indicated.

Post-treatment Functional Outcomes of Distal Tibiofibular Syndesmosis Injuries With Varying Duration and Method of Stabilization

Post-treatment Functional Outcomes of Distal Tibiofibular Syndesmosis Injuries With Varying Duration and Method of Stabilization

Surgical Outcomes of Syndesmotic Fixation of Ankle Fractures Using Syndesmotic Screws Versus Suture Button Devices.

Ankle fractures associated with disruption of the syndesmotic complex could potentially have poorer outcomes if missed or malreduced at the time of surgery.Favourable results have been reported for the suture button (SB) technique and may provide advantages over standard screw fixation of the syndesmosis, although this remains the gold standard method in many units. To compare the outcomes of syndesmotic screws (SS) with SB fixation of the syndesmosis during ankle fracture fixation at a high-volume orthopaedic department of a Scotland trauma unit. A cross-sectional, retrospective study looking at ankle fracture fixations was undertaken at the Clyde Trauma Unit, Paisley. Relevant information was obtained from electronic patient records for 457 ankle fracture patients between August 2019 and February 2022 and followed up for six months. The digital patient archive system (PACS) was used for evaluating radiographs. Patients were divided into two groups depending on whether they had an SS or SB fixation of their syndesmosis. We focused on the surgical and radiological outcomes following syndesmotic fixation as no functional scores following surgery were conducted on the patients. Out of the entire study group, 26.3% (120/457 patients) required syndesmotic fixation. Within the syndesmotic fixation group, 70.8% (85/120 patients) underwent SS fixation, and 29.2% (35/120 patients) had an SB fixation. Both groups were statistically well-matched. Additionally, 21.1% (18/85) of SS fixation went on to have a second surgical procedure (four fixation failures, five planned removals, five for pain/stiffness, two infections, and two metalwork breakage/migration), whereas 8.6% (3/35) of the SB fixation group had a secondary procedure - two for fixation failures and one for infection. We reported a higher incidence of associated syndesmotic injury in our series of 457 ankle fractures than previously described. There were significantly fewer sequelae in the SB group compared to the SS fixation group (P = 0.0464). Although we did not observe a statistically significant difference in the rate of reoperation (P = 0.1184), this is likely due to the small numbers in the SB group.Our study suggests that SB fixation may be associated with a lower rate of reoperation for post-op complications such as metalwork failure, pain, and stiffness (21.1% SS vs 8.6% SB). Regardless of the fixation method used, accurate reduction of the ankle mortice and syndesmosis is a key step to a successful surgical outcome.

Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures

Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures

Syndesmotic fixation in Weber B ankle fractures: A systematic review.

Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.

Comparative Study for Surgical Treatment of Acute Distal Tibiofibular Syndesmotic Lesions Using the Modified Suture-Button Fixation Versus Static Syndesmotic Screw Fixation.

Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation. It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months. Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications. The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up. Level II.

Risk factors associated with breakage of tibio-fibular syndesmotic screws.

This retrospective study aimed to investigate the factors associated with the breakage of tibio-fibular syndesmotic screws (SS). 69 patients with unstable AO-Weber Type 44-B ankle fractures who underwent three cortex SS (3.5mm ø) fixation were included. Patients were followed for at least one year (mean, 18.3 ± 7.6months). At the final follow-up, patients with broken (Group I) and intact (Group II) SS were compared regarding age, gender, height, weight, body mass index, fracture type, SS length, location, and orientation. Multivariate logistic regression was used to identify the independent risk factors associated with SS breakage. The sensitivity, specificity, cut-off value, and area under the ROC curve were analyzed. A stepwise backward logistic regression analysis revealed that age was the only independent predictor for SS breakage (OR = 0.938, 95% CI = 0.904-0.973, R2 = 0.270). ROC curve analysis demonstrated that patients younger than 36years were associated with seven times increased risk of SS breakage [Odds ratio (95% CI), 7.042 (2.251-22.031)]. Age under 36years was the only significant risk factor for SS breakage. The higher incidence of breakage of the syndesmotic screw can be informed to patients younger than 36.