Tibiofibular Syndesmosis Research Articles

The Effect of Stabilization Procedures on Sports Discipline and Performance Level in Non-Elite Athletes after Acute Syndesmotic Injury: A Prospective Randomized Trial.

Background: Suture button devices for tibiofibular syndesmosis injuries provide semirigid dynamic stabilization. The effect of stabilization procedures on sports discipline and performance level in non-elite athletes after acute syndesmotic injury has not been clarified in sports medicine research to date. Methods: A total of 47 of 56 eligible patients were analyzed and completed the 1-year follow-up. The average age was 35.5 years (range, 18–60 years). The screw fixation and knotless suture button groups comprised 26 and 21 patients, respectively. Nine patients were lost to follow-up. Patients underwent clinical and radiological evaluations preoperatively and twice during the 1-year postoperative follow-up. Function was measured using the FADI sports scale, the FAAM sports module, and a visual analogue scale for pain and function in sports. Questionnaires were completed to assess preoperative and postoperative sports levels and to evaluate the sports discipline. Results: All scores increased during the follow-up, but no significant differences were found in the FADI score, the FAAM sports module score and or the VAS score for pain and function during sport (p ≤ 0.05). Using Spearman’s rank correlation coefficient, we found no significant correlation between the groups for age, injury mechanism, or body mass index. Differences were identified in sports discipline and performance level between the groups during the follow-up period. Conclusion: No statistically significant differences could be demonstrated between the two stabilization methods in terms of return to previous sport level and return to the original sport discipline, so both procedures can be regarded as equivalent at present.

Functional Characterization of Posttraumatic Heterotopic Ossification of Tibiofibular Syndesmosis with Dynamic Bone Scan and Single-Photon Emission Computed Tomography/Computed Tomography.

A 53-year-old man was investigated for ongoing right ankle pain and lateral malleolus swelling following a traumatic inversion injury 12 weeks prior. The initial ankle radiograph was normal with no evidence of fracturing. The follow-up radiograph showed bridging ossification in the distal tibiofibular syndesmosis. As the pain did not subside, posttraumatic heterotopic ossification (HO) was suspected, and triple-phase dynamic bone imaging with technetium 99m-methylene diphosphonate was performed to guide further management. The bone scan revealed intense focal tracer activity centered on the HO of the tibiofibular syndesmosis, with no evidence of occult fracturing confirming HO as a pain generator.

Paper 97: Defining Normal Values for Distal Tibiofibular Syndesmotic Space with and without External Rotation Stress: A Prospective Study with Volunteer Controls

Objectives:The diagnosis and treatment of distal tibiofibular syndesmosis (DTFS) injury can be challenging, especially in cases of subtle instability that may be masked on two-dimensional conventional radiographs. Weightbearing computed tomography (WBCT) has recently emerged as a useful diagnostic tool allowing direct assessment of distal tibiofibular widening. Area measurements of the distal tibiofibular incisura assessed one centimeter proximal to the ankle joint have been proposed as an accurate diagnostic tool to differentiate stable and unstable DTFS, however the literature lacks information regarding normal DTFS area measurements in asymptomatic ankles. The purpose of the current study was to examine and report normal threshold values for DTFS area measurements in a cohort of healthy volunteers, assessing the ankles in natural weightbearing position and under external rotation stress.Methods:In this prospective study, we enrolled twenty-five healthy volunteers without a history of DTFS injury or high ankle sprain, previous foot and ankle surgery, or current ankle pain. Study participants underwent bilateral standing non-stress and external rotation stress WBCT scans. On non-stress WBCT scans, subjects stood with feet shoulder width apart in a natural, upright position with body weight evenly distributed. For external rotation stress images, patients were instructed to position their lower extremity in maximal internal rotation while the foot was held in a fixed plantigrade position. The DTFS area (mm2) was semi-automatically quantified on axial-plane WBCT images one centimeter proximal to the apex of the talar dome using dedicated software (Figure 1). Syndesmosis area values were compared between non-stressed and stressed ankles, as well as left and right ankles. Statistical analysis was performed utilizing independent t-tests/Wilcoxon analysis with statistical significance defined as p<0.05.Results:The study cohort consisted of 50 ankles in 25 patients (12 males, 48%) with a mean age of 28.7+9.3 years. In the unstressed ankle, the mean pooled DTFS area was determined to be 99.1+2.8 mm2. The mean syndesmosis area of unstressed left ankles in the cohort was 96.5+4.0 mm2, while unstressed right ankles had a mean area of 101.6 mm2 (p=0.378). With external rotation stress, the DTFS area of left ankles (mean difference 1.2 mm2; CI: -9.8-11.8; p=0.765), right ankles (mean difference -3.1 mm2; CI: -16.1-6.6; p=0.453), and all ankles (mean difference -1.2 mm2; CI: -12.4-9.3; p=0.775) remained similar.Conclusions:This is the first study to assess standing WBCT DTFS area measurements in a cohort of volunteer controls, with and without external rotation stress. We found a mean DTFS value of 99 mm² ± 18.8. We also observed that in normal ankles with expected intact ligaments, external rotation stress did not result in significant widening of the DTFS space. The results of this study can be utilized in the literature as normal threshold values for DTFS area measurements, fostering additional investigations with patients with suspected and confirmed DTFS instability.

Ankle syndesmosis biomechanical evaluation by shear-waves elastography in healthy young adults: Assessment of the reliability and accuracy of the measurements and definition of a corridor of normality

BackgroundAims of this study were: 1/ to evaluate the shear wave speed (SWS) properties of the anteroinferior tibiofibular ligament (AITFL) and the distal interosseous membrane (DIOM) in neutral, dorsal flexion and plantar flexion positions in a cohort of healthy adult volunteers; 2/ to assess the reliability and reproducibility of these measurements. MethodsBoth ankles were analyzed by shear wave elastography (SWE) in 20 healthy patients (10 females/10 males) standing on a hinge support with their ankles in neutral, 20° dorsal flexion and 30° plantar flexion positions. Stiffness of AITFL and DIOM was evaluated by SWS measurement. ResultsThe SWS of AITFL and DIOM were minimal in the plantar flexion position (4.28 m/s [2.65–5.11] and 3.35 m/s [1.69–4.55], respectively). It increased significantly for both ligaments in neutral position (4.69 m/s [3.53–5.71] and 3.81 m/s [1.91–4.74], respectively; p < 0.0001), and reached their maximum values in dorsal flexion (6.58 m/s [5.23–8.34] and 4.79 m/s [3.07–6.19], respectively; p < 0.0001). There was no correlation between each ligament regardless the positions. SWS of AITFL was independent of demographic characteristics analyzed. SWS of DIOM was negatively correlated with height in dorsal flexion (ρ = −0.35; p = 0.03) and in plantar flexion (ρ = −0.37; p = 0.02). Female gender was associated with increased DIOM SWS in neutral (p = 0.005), dorsal flexion (p = 0.003), and plantar flexion (p = 0.001) positions. Moreover, foot morphology (foot arch, hind foot frontal deviation) did not impact AITFL nor DIOM SWS. Inter- and intra-observer measurements were all good or excellent. ConclusionThe AITFL and DIOM, stabilizers of the distal tibiofibular syndesmosis, increase in stiffness while dorsal flexion increases. This study describes a reliable and reproducible protocol to assess their stiffness by SWE, and defines a corridor of normality.

Application of an arched, Ni–Ti shape-memory connector in repairing distal tibiofibular syndesmosis ligament injury

ObjectiveTo investigate the clinical effect of internal fixation of a Ni–Ti arched shape-memory connector in the treatment of distal tibiofibular syndesmosis ligament injury.MethodsFrom January 2013 to January 2016, 108 cases of ankle fracture with distal tibiofibular syndesmosis ligament injury in our hospital were selected, and all of them were fixed with ASCs or screw fixation. The functional evaluation and efficacy evaluation were performed according to the Olerud Molander Ankle Score (Omas) and SF-36. At the same time, follow-ups recorded the incidence of postoperative complications: osteoarthritis, superficial infection, symptomatic hard and soft tissue irritation, early removal and poor reduction of internal fixation, and later loss of reduction.ResultsIn the ASC(Ni–Ti Arched shape-memory Connector) group, the incidence of symptomatic hardware, soft tissue or superficial infection decreased to 2.77%(from 13.8% or 11.1% in SCREW group). The early removal rate(2.77%) of internal fixation was also lower than that of the screw group. While the incidence of osteoarthritis is 13.8% in SCREW group, the incidence of osteoarthritis in the later follow-up was also as low as 1.38% in ASC group. Loss of fracture reduction due to removal of the fixation device for the distal tibiofibular syndesmosis ligament was not observed in the ASC group. With two postoperative scoring systems (OMAS and SF-36), patients in the ASC group significantly get higher score than that in SCREW group.ConclusionThe design of the Ni–Ti arched shape-memory connector can be adapted to the irregular anatomical structure of the malleolus and the ability to continue to contract by body temperature. The use of ASCs in fixation of articular ligaments can preserve a slight range of motion, and the results suggest that ASCs can effectively reduce the incidence of fixation looseness, fracture, infection and other complications.

Traumatic rupture of the midportion of the interosseous membrane: a rare cause of acute lower leg pain in two soccer players kicked in the anterior shin.

The interosseous membrane (IOM) of the leg is a component of the tibiofibular syndesmosis that serves an important role in stabilization, as well as transferring forces to the fibula during weight-bearing. We present two separate cases of acute traumatic rupture of the midportion of the interosseous membrane in high school soccer players with blunt trauma to the anterior shin with MRI and ultrasound confirmation.

Pathomechanics, Diagnosis and Treatment of Traumatic Injuries to the Ankle and Subtalar Joints in the Scientific Achievements of the Department of Trauma Surgery and Orthopaedics at the 5th Military Clinical Hospital with Polyclinic, Independent Public Healthcare Centre in Kraków

Introduction: Traumatic injuries to the ankle and subtalar joints constitute severe damage to the locomotor system, both structural and functional. They most often occur in the form of ankle fractures and sprains of the ankle joint, and the least common are peritalar dislocations. Study aim: The aim of the study was to answer the following research questions: 1. What are the most common causes of traumatic injuries to the ankle and subtalar joints, and what are the most common causes of these injures?; 2. What diagnostic methods of traumatic injuries to the ankle and subtalar joints in the analysed period of clinical observation dominated in their imaging?; 3. What are the recommended treatments for traumatic injures of the ankle and subtalar joints? Materials and methods: The aim of the study was carried out on the basis of analysing publications and conference presentations regarding traumatic injuries by employees of the Department of Trauma Surgery and Orthopaedics, the 5th Military Clinic Hospital with Polyclinic, Independent Public Healthcare Centre in Kraków, covering the years from 1992 to 2017. The research methodology, on the other hand, was based on analysis of the content concerning thematically compatible publications and scientific studies with the adopted objectives of the work and established research questions. In the study, 2 thematic monographs (books) were also included, which were published by Państwowy Zakład Wydawnictw Lekarskich (PZWL) [Eng. National Institute of Medical Publishing] in 2020 and 2021 by a retired clinic employee. They are partly based on its clinical material from 1992 to 2017. Results: In the analysed period, 58 of the identified scientific studies were thematically consistent with the adopted research objectives and established research questions. Those were 20 original creative papers (34.5%), 3 review papers (5.2%), 4 case studies (6.9%), 1 postdoctoral dissertation (1.7%), 4 doctoral dissertations (6.9%) and 1 (1.7%) thematic monograph (book), 11 (18.9%) chapters in thematic monographs (book) and 14 (24.2%) conference and convention presentations. Conclusions: 1. The most common causes of traumatic injuries to the ankle and subtalar joints are so-called sports-related injuries or those caused by traffic accidents as well as falls on a hard surface at the same level, especially in people with bone tissue demineralisation disorders. Most often, they are in the form of ankle fractures, and the least common are peritalar dislocations. 2. Clinical diagnosis of traumatic injuries to the ankle and subtalar joints requires manual tests regarding their stability, and imaging examinations are based primarily on ultrasound, MRA and MRI. With regard to post-traumatic instability of the ankle joint, these diagnostics require radiological examination in forced positions. 3. Fractures of the ankle-shin joint require surgical treatment based on the open reposition of bone fragments and their effective stabilisation, as well as on the fixation of tibiofibular syndesmosis. On the other hand, peritalar dislocations can be treated non-operatively, while selected types of damage can be treated surgically. A necessary supplement to the treatment of the traumatic injuries in question is a consistently implemented and individualised programme of physiotherapy.

Determining the Tightrope Tightening Force for Effective Fixation of the Tibiofibular Syndesmosis during Osteomeatal Synthesis of Fibula Injuries

The issue of choosing the method for optimal surgical treatment of a broken fibula has been debatable for many years. At the same time, concomitant repair of tibiofibular syndesmosis injuries does not have a unified approach. It has been determined that osteosynthesis of broken shin bones with syndesmosis injury should combine stable fixation of the broken bone and should not limit the elastic properties of the syndesmosis. In case of a broken fibula, it is recommended to use a stable extracortical fixator and an elastic connection of the syndesmosis injury using a tightrope. An analytical model of the broken fibula, which is blocked with an extracortical fixator metal plate and elastically fixed with a tightrope, has been developed. The research object is the stress–strain state of the “broken fibula–extracortical titanium plate” composition under the action of tightrope tightening fixation. The main research result is an analytical dependence, which makes it possible to determine the permissible value of the tightrope tightening force for elastic fixation of the tibiofibular syndesmosis. The research results have been tested numerically, and the influence of the parameters of plate, bone and damage localization on the permissible value of the tightrope tightening force has been analyzed. By using the rational tightrope tightening force with stable–elastic fixation of the broken shin, it is possible to reduce the time before the start of loading on the injured extremity and accelerate the functional recovery of the patient.

Which test is the best? An updated literature review of imaging modalities for acute ankle diastasis injuries.

Ankle diastasis injuries, or ankle syndesmotic injuries, are common among athletes who usually experience a traumatic injury to the ankle. Long‐term complications are avoidable when these injuries are diagnosed promptly and accurately treated. Whilst ankle arthroscopy remains the gold standard diagnostic modality for ankle diastasis injuries, imaging modalities are still widely utilised due to the treatment having greater accessibility, being less invasive and the most cost effective. There are various imaging modalities used to diagnose diastasis injuries, varying in levels of specificity and sensitivity. These observation methods include; X‐ray, computed tomography (CT), magnetic resonance imaging (MRI) and ankle arthroscopy. This article uncovers common criteria and parameters to diagnose diastasis injuries through the implementation of different imaging modalities. The conclusions addressed within this article are deduced from a total of 338 articles being screened with only 43 articles being selected for the purposes of this examination. Across most articles, it was concluded that that plain X‐ray should be used in the first instance due to its wide availability, quick processing time, and low cost. CT is the next recommended investigation due to its increased sensitivity and specificity, ability to show the positional relationship of the distal tibiofibular syndesmosis, and reliability in detecting minor diastasis injuries. MRI is recommended when ankle diastasis injuries are suspected, but not diagnosed on previous imaging modalities. It has the highest sensitivity and specificity compared to X‐ray and CT.

The concept of ring of injuries: evaluation in ankle trauma.

Radiographs are first-line imaging in ankle trauma but lack sensitivity to detect ligamentous injuries and undisplaced fractures. Our hypothesis was that ankle injuries occur in predefined sequences along two osteoligamentous rings, so that occult injuries non-visible on initial radiographs can be predicted. We, therefore, aimed to validate a ring model of progressive damages in the interpretation of ankle trauma radiographs. This study retrospectively enrolled 277 adult patients that presented an acute fibular fracture on ankle radiographs between May and November 2019. Four different types of fibula fracture were differentiated, each being considered to correspond to a different mechanism of injury. Patients were classified into four groups, upon the appearance of their fibular fracture. Then, injuries to the distal tibiofibular syndesmosis, medial malleolus, and deltoid ligament (medial clear space) were assessed in each patient radiographs. Traumatic injuries were independently evaluated by a resident and an experienced MSK radiologist. For each patient, observed features were compared to those predicted by the ring concept. Inter- and intraobserver agreements were calculated. Injuries were observed according to the predictable sequence in 266 of the 277 patients (96%). In the 11 remaining patients, discordances were presumably due to undisplaced injuries to the syndesmosis or deltoid ligament. Agreements were considered very good for each evaluated item. The Lauge-Hansen ring concept was found to be highly accurate and reproducible for radiographic assessment of ankle injuries. Discordances to the predicted sequence might reflect occult injuries, especially of the syndesmosis or deltoid ligament.

Kinematic Tibiofibular Syndesmotic Measurements as Indicators of Tibiotalar Osteoarthritis: Exploratory Analysis Using 4-Dimensional Computed Tomography.

The aim of this study was to evaluate the association between 4-dimensional computed tomography (4DCT)-derived measurements of tibiofibular syndesmosis during active dorsiflexion-plantarflexion motion and the presence of tibiotalar osteoarthritis (OA). Sixteen ankle joints underwent 4DCT imaging during active dorsiflexion-plantarflexion. Syndesmotic anterior distance (SAD) and syndesmotic translation (ST) were obtained by a foot-and-ankle surgeon. We used Kellgren-Lawrence (KL) grading to determine tibiotalar OA. Of 16 scanned ankles, 12 ankles had KL ≥2 at the tibiotalar joint. In these ankles, SAD (-0.4, P = 0.02) and ST (-0.9, P = 0.006) measurements significantly changed during the dorsiflexion-plantarflexion motion. Changes in SAD measurements were significantly correlated with the KL grades (correlation coefficient: -0.688, P = 0.003); however, the changes in ST measurements were not significantly correlated with the KL grade. Our exploratory cross-sectional analysis shows that SAD measurement changes during motion using 4DCT are correlated with the tibiotalar OA grading. This measurement may be used but requires confirmation in larger studies including patients with actual syndesmotic injuries.

Comparison of Two Surgical Approaches to Supination-External Rotation-Type Ankle Fractures.

Objective To compare the clinical outcome and postoperative complications of the treatment of supination-external rotation-type ankle fractures using the posterolateral approach in the prone position and the lateral approach in the supine position. Methods A retrospective cohort study was conducted in our hospital, including a total of 66 patients ranging from January 2013 to February 2016, regardless of age or sex. All the patients were classified as Lauge-Hansen supination-external rotation (SER)-type ankle fractures and were assigned to receive an open reduction and internal fixation (ORIF) through a posterolateral approach performed in the prone position (the “posterolateral approach group,” 32 patients), or a lateral approach performed in the supine position (the “Lateral Approach Group,” 34 patients). In the posterolateral approach group, 5 patients had Grade II fractures, 8 had Grade III fractures, and 19 had Grade IV fractures; among whom, 12 underwent fixation of the posterior malleolus with hollow screws and 6 with plates, and none of them had fixation of the distal tibiofibular syndesmosis; in the lateral approach group, 4 patients had Grade II fractures, 12 had Grade III fractures, and 18 had Grade IV fractures; among whom, 21 received fixation of the posterior malleolus, and 5 received fixation of the distal tibiofibular syndesmosis. The postoperative complications and ankle scores were recorded. Results After 1 year of follow-up, in the posterolateral approach group, the incision healed by primary intention and sutures were removed 2 weeks after the operation in all patients; 1 patient had pain in the region posterior to the fibula, presumably peroneal tendon irritation induced by internal fixation, which disappeared after fracture union and fixation device removal; no loosening or breakage of the internal fixation device was reported; the rate of good to excellent results was 96.8% at 12 months. In the lateral approach group: 1 case of wound infection, 1 case of necrosis of lateral skin flap, and 3 cases of lateral skin irritation were reported; the rate of good to excellent results was 94.6% at 12 months. Conclusion Compared with the traditional lateral approach, the posterolateral approach for the reduction and internal fixation of supination-external rotation-type ankle fractures performed in the prone position has more satisfactory clinical outcomes, with better reduction, more secure fixation, and smaller wound.

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

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

Can Weightbearing Cone-beam CT Reliably Differentiate Between Stable and Unstable Syndesmotic Ankle Injuries? A Systematic Review and Meta-analysis.

Ankle injuries are common presentations to the emergency department and may lead to syndesmotic instability. These have a high socioeconomic burden due to prolonged rehabilitation, chronic pain, and posttraumatic arthritis. Early diagnosis is essential to minimize these complications, and the assessment of instability in the clinical setting is often limited by pain and clinician experience. Cross-sectional imaging of the distal syndesmosis accurately evaluates the syndesmosis through abnormal bony relationships, which in the presence of instability, worsens during physiological loading. Cone-beam CT (CBCT) has gained popularity in the diagnosis of these injuries because it enables syndesmotic assessment under weightbearing conditions, it mitigates the high radiation dose, and it is time-efficient. The purposes of this systematic review were: (1) to establish normal values for weightbearing CBCT of the syndesmosis in uninjured ankles and ascertain interobserver reliability and (2) to identify the impact of weightbearing on the syndesmosis in patients with occult ankle injuries and assess the effect of patient demographics on these metrics. This systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in PROSPERO (ID CRD42021248623). MEDLINE, PubMed, Embase, and Emcare databases were searched for studies assessing for syndesmotic instability, of which 307 studies were screened and 11 studies with 559 ankles in 408 uninjured patients and 151 patients with syndesmotic instability were included. All patients 18 years of age or older presenting with unilateral ankle injuries who underwent weightbearing CBCT for the diagnosis of an occult fracture or syndesmotic instability compared with the uninjured contralateral side were included. A control group of uninjured ankles was identified during weightbearing CBCT performed for other indications such as forefoot or midfoot injuries. Methodological assessment of the studies was performed using the Risk of Bias In Non-randomized Studies (ROBINS-1) tool and most included studies had a low risk of bias. Thus, a random-effects restricted maximum likelihood ratio model was used. In the uninjured ankle, the mean area of the tibiofibular syndesmosis was 112.5 ± 7.1 mm 2 , which increased to 157.5 ± 9.6 mm 2 after injury when compared with uninjured ankles with a standardized mean difference of 29.5 (95% confidence interval 19.5 to 39.5; p < 0.01), and an excellent interobserver agreement (κ = 1.0 [95% CI 0.9 to 1.0]). However, syndesmosis volume decreased with age (β = -0.76; p = 0.04), and therefore, has a negative association with increasing age. Our study has shown that the syndesmotic area is the most reliable parameter in the assessment of syndesmotic injuries because it increases in the presence of instability during weightbearing status. It is a composite measurement that could potentially allow clinicians to use weightbearing CBCT as an adjunct when there is a clinical suspicion of syndesmotic instability. Thus, weightbearing CBCT has the potential of being diagnostic of syndesmotic instability and should be evaluated against current radiological modalities to evaluate its accuracy. Level IV, prognostic study.

A Novel Adjustable EndoButton Fixation Assisted by 3D Printing Technology for Tibiofibular Syndesmosis Injury: A Biomechanical Study.

Purpose: The recommendations for surgical fixation of tibiofibular syndesmosis injuries are increasingly challenging for many clinical orthopedists, as international consensus has not been published for the optimal treatment of the injury. Thus, we have created a 3D-printed navigation template for a precise bone tunnel and a novel adjustable EndoButton fixation (NAE) for the ideal treatment. The purpose of this research was to evaluate the accuracy of the 3D-printed navigation template and explore the biomechanical performance of the NAE technique by comparing it with the intact syndesmosis, screw technique, and TightRope (TR) technique. Methods: Twenty-four human cadaveric legs were randomly allocated to four groups: the NAE group (n = 6), TR group (n = 6), screw group (n = 6), and intact group (n = 6). A personalized navigation template based on computed tomography scans was designed, and 3D printing models were generated for the distal tibiofibular syndesmosis. The NAE, TR, and screw group were performed via 3D-printed navigation template, respectively. All groups were tested under increasing loading forces including axial loading (from 100 N to 700 N) and torsional loading (from 1 N to 5 N), which were performed in different ankle positions. The displacements of the tibiofibular syndesmosis were analyzed using the Bose Electroforce 3510-AT biomechanical testing equipment. Results: Surgical fixations were conducted successfully through a 3D-printed navigation template. Both in axial or torsional loading experiments, no statistically significant difference was observed in the displacements among the NAE, TR, and intact groups in most situations (p > 0.05), whereas the screw group demonstrated obviously smaller displacements than the abovementioned three groups (p < 0.05). Conclusion: The 3D printing technology application may become beneficial and favorable for locating and making the bone tunnel. Also, the NAE fixation provides the performance of complete ligaments; it also restores physiologic micromotion and avoids insufficient or excessive reduction when compared to the TR and screw technique. This may offer a new fixation for the treatment of tibiofibular syndesmosis injuries that is desirable for clinical promotion.

Повреждение дистального межберцового синдесмоза, пути улучшения результатов лечения (обзор литературы)

Introduction Treatment of patients with distal tibiofibular syndesmosis (DTFS) ruptures remains controversial. Ankle fractures accompanied by syndesmosis rupture are associated with worse outcomes. There is no diagnosis and treatment algorithm for such injuries to date. The objective was to summarize the data on diagnosis and treatment of syndesmotic injury alone and in combination with ankle fractures through world literature review. Material and methods A systematic literature search was undertaken using elibrary, PubMed, ResearchGate databases with articles dated 1990 and later. The search depth was 30 years. With preliminary information collected low-relevant articles were excluded. Meta-analysis studies, randomized controlled trials, systematic reviews, cadaveric biomechanical studies were reviewed. Results Screws and suture buttons can be used to fix DTFS, and Volkmann, Shaput and Wagstaff fractures being transosseous injuries to DTFS can be repaired with osteosynthesis. Imaging evaluation of reduction can be produced with radiography, MSCT, MRI and arthroscopy. Partial injuries to the DTFS, if timely detected, can be treated conservatively with transition to surgical stabilization if signs of instability persist. Discussion Conventional radiography has very low diagnostic value for DTFS injury. Bilateral MSCT is recommended for assessment of a syndesmotic injury and MRI of the ankle joint is practical for partial isolated injuries. Concomitant injuries of the fibular notch of the tibia are recommended to address first prior to transsyndesmotic fixation. Open reduction of displaced DTFS is accompanied by a lower risk of fibular malposition and malreduction. Suture buttons are practical for transsyndesmotic fixation. Removal of positional screws does not affect the functional result of treatment. More stable osteosynthesis would be needed for DTFS injury in neuropathy.

Progress in diagnosis and treatment of fibular fracture in ankle fracture

To summarize the diagnosis and treatment of fibular fracture in ankle fracture. Relevant literature at home and abroad in recent years was widely consulted, and various types of fractures were discussed and summarized according to Danis-Weber classification. Conservative treatment is not an ideal treatment for type A avulsion fracture. The operation method should be determined according to the position and size of bone mass. For simple type B fracture, both conservative treatment and surgical treatment can achieve good results. When the position of type C fracture is high and does not affect the stability of ankle joint, it can be treated conservatively, while when the position is low and affects the stability of ankle joint, it needs surgical treatment. First of all, whether the fibular fracture in the ankle fracture is stable or not should be determined. Whether it is treated surgically or not, the purpose is to restore the tibiofibular syndesmosis and restore the motor function of the ankle.

Modern approaches to the methods and treatment strategy in fractures of the ankle joint with tibiofibular syndesmosis rupture (literature review)

A review of the literature has shown that the problem of treatment for fractures of the ankle joint with rupture of the tibiofibular syndesmosis is still far from being solved, as evidenced by the frequency of unsatisfactory results during surgeries — 4.8–36.8 %. In the future, the issue and the need to develop a dynamic fixation device, which is able to duplicate the function lost due to damage to the tibiofibular syndesmosis, remain relevant.

Retrospective Chart Review: Weight Bearing CT Scans and the Measurement of the Tibiofibular Syndesmosis

Category:AnkleIntroduction/Purpose:Tibiofibular Syndesmosis injuries are commonly misdiagnosed due to their unreliable projection on plain films. Many studies have striven to establish baseline measurements of the distal tibial and fibular articulation. While cadaver, MRI, ultrasound, and non-weight bearing computer tomography (CT) have been utilized, weight bearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish reproducible and widely-referenced baseline anatomic positions. The hypotheses of this study are: 1. Standing, weight bearing CT scan will allow for evaluation and measurement of the tibio-fibular syndesmosis. 2. There will be no side to side variation or sex-based differences in syndesmosis measurements.Methods:A retrospective chart review was conducted using the electronic medical record. Inclusion criteria was applied as follows: Patients who have undergone weight bearing CT of the bilateral lower extremities from 2018 to 2020. One hundred twenty ankle CT scans were acquired for measurements. Measurements were collected by two independent reviewers twice in order to achieve inter- and intra-reliability. The measurements were then analyzed in order to establish a baseline for normal anatomy, compare injured to non-injured side, and observe any sex-based differences.Results:Measurements of uninjured legs were utilized to define normal parameters for tibiofibular syndesmosis on weight bearing CT. Averages were found for measurements of anterior incisura 3.2mm (SD=1.1mm), middle incisura 3.9mm (SD=1.1mm), posterior incisura 5.6mm (SD=1.7mm), alpha angle 16.3° (SD=6.3°), medial clear space 2.2mm (SD=0.6mm).Patients with syndesmotic injuries had significantly larger measurements for anterior (p<0.0001), middle (p=0.0007), and posterior incisura (p=0.002) when compared to uninjured ankles. Males had significantly higher medial clear space widening (p=0.0012) compared to female patients. Anterior incisura (p <0.0001), posterior incisura (p=0.0005) were found to significantly decrease as age increased.Conclusion:This study aims to assist in defining baseline anatomic measurements for syndesmotic parameters. The values and comparisons obtained were able to reinforce that weight bearing CT is valuable in identifying subtle injuries to the TFS while also demonstrating that there is male-to-female and age-related differences that should be kept in mind when radiographically evaluating imaging studies of injured patients.

Static vs Dynamic Fixation of Distal Tibiofibular Syndesmosis: A Review of Overlapping Meta-Analyses

Category:Ankle; SportsIntroduction/Purpose:Multiple Level I meta-analyses have been led comparing traditional static vs. more recently-introduced dynamic strategies of fixation for injuries of the distal tibiofibular syndesmosis (TFS). The aim of this review was to assess their robustness and methodological quality, providing support in the choice of a treatment strategy in case of TFS injury using the highest level of evidence.Methods:In this systematic review, conducted in accordance with the PRISMA guidelines, we identified meta-analyses/systematic reviews comparing static and dynamic fixation methods after acute TFS injury. Robustness of studies was evaluated using the Fragility Index (FI) for meta-analysis and the Fragility Quotient (FQ). The risk of bias was evaluated using the Assessment of Multiple Systematic Reviews(AMSTAR) instrument. Finally, the Jadad Decision Algorithm was applied to select the study which provided the highest quality of evidence to develop recommendations for the fixation strategy of these lesions.Results:Out of 1302 records, 4 Level I meta-analyses were included in this study. Analyzing the statistically significant dichotomous outcomes, the median FI was 3.5 (IQR, 2 to 5.5; range, 1 to 9) while the median FQ was 1.9% (IQR, 1 to 3.5; range 0.35 to 4.4). In total, 37% had a FI of 2 or less and 75% of outcomes had a FI of 4 or less. According to the AMSTAR score and Jadad algorithm, the largest meta-analysis was selected as the highest evidence provided so far.Conclusion:We selected the meta-analysis by Grassi et al. as the highest quality provided so far, which found that dynamic fixation reduced complication rates and improved clinical outcomes compared to static methods of fixation. We demonstrated that meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than 4 patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant. Based on these findings, we recommend caution when interpreting the results of these studies.