Treatment Of Syndesmosis Injury Research Articles

A Classification for Syndesmosis Injuries Based on Soft Tissue and Bony Anatomy

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis injuries result in potential separation to the intimate distal tibial and fibular connection/articulation and can result in meaningful ongoing disability and the development of early post-traumatic arthritis. The injury pattern includes ligament injuries, cartilage damage, and/or fractures. These injury patterns may predicate outcomes. The associated fractures and ligament injuries may also determine the nature of fixation and management required. While classification exists for posterior malleolar, fibular, and ankle fractures, no systematic approach exists for the classification and treatment of syndesmosis injuries. This study aims to describe a comprehensive classification system for syndesmosis injuries and determine its validity. Methods: Descriptive system: The ankle was divided into five zones based on bony and soft tissue anatomic locations: lateral (L), medial (M), posterior (P), anterior (A), and intraarticular (I). In each location no injury is type 0, soft tissue/avulsion injury type 1, and boney injury type 2. (Figure 1). Study group: Patients with operative syndesmosis injuries in a single institution between January 2002 and December 2012 were reviewed. Injury patterns were classified by 3 experts, 2 semi-experts, and 2 musculoskeletal radiologists based on orthogonal anteroposterior and lateral radiographs. Statistical analysis: A 103-patient cohort was deemed to be sufficient based on power analysis Weighted kappa statistics with quadratic weights was used for test retest analysis. For inter-rater reliability, a separate analysis was completed for experts, semi-experts, and radiologists. Intraclass correlation coefficients were obtained. Results: All injuries could be classified according to the proposed classification. The most frequent pattern was the type B221 (13%) and C221 (12%). The interobserver agreement among all observers was excellent for the medial (ICC of 0.847) and lateral aspect (ICC of 0.762), good for the posterior aspect (ICC of 0.615), and poor for the anterior aspect (ICC of 0.233) (Table 1). The classification showed good to excellent intraobserver agreement except for the anterior aspect, which had poor agreement for the semi-expert raters (Table2). Conclusion: The syndesmosis classification is a valid system to represent the complexity of injuries that may occur. Inter- and intraobserver agreement among raters with different levels of expertise in classifying injuries based only on X-ray was good to excellent, with the exception of the anterior aspect which may require additional imaging techniques for proper classification. The categorization of different injuries by their location allows for a better understanding of how injurie presents. It should lead to improved research outcomes and communication between professionals regarding injury patterns and potential treatments in the future, as not all syndesmosis injuries are the same.

Suture button fixation method used in the treatment of syndesmosis injury: A biomechanical analysis of the effect of the placement of the button on the distal tibiofibular joint in the mid-stance phase with finite elements method

The purpose of this study is to research the effect of suture button (SB) fixation, a method used at the treatment of ankle syndesmosis injury, which was applied in various angles, pretension force, and levels, on the distal tibiofibular joint (DTFJ) in the mid-stance phase, with the help of three-dimensional finite elements method (FEM) METHOD: The ankle of a healthy individual was digitally analyzed by a finite element method-based package computer program. Then, anterior inferior tibiofibular ligament (AITFL), interosseous ligament, posterior inferior tibiofibular ligament (PITFL) and deltoid ligament (DL) were cut and force and rotation has been applied to the proximal tibia, resulting in syndesmosis injury. Then, various suture button applications on the injured model have been analyzed. Three parameters have been changed; which were divergence in the axial plane (20°, 30°, 40°), distance from the ankle (2, 3, 4cm), and pretension force (200, 300, 600N) RESULTS: As the result of this study, the rotation, change in the gap between the distal tibia and distal fibula, and the displacements of the fibula in the x and y axes have been obtained, and numerical results were evaluated. As the force increased, rotation, change in the gap between the distal tibia and distal fibula, and the displacements of the fibula decreased. As suture button application rotation increased, change in the gap between the distal tibia and distal fibula, and displacements of the fibula increased. As the distance from the ankle increases and reaches a certain level, the results converge to those of the healthy model; in the proximal, it diverges from healthy results. In the study, it has been shown that abnormal tibiofibular joint movements can be prevented with suture button application, and optimum application parameters (divergence in the axial plane, distance from the ankle, and pretension force) are given for proper reduction.

The Impact of Suture Button Removal in Syndesmosis Fixation.

The suture button (SB) device was introduced to negate the need for routine hardware removal in the treatment of syndesmosis injuries. However, a considerable SB removal rate has been reported, and the impact of removal is unknown. This study aimed to evaluate the radiographic and clinical outcomes after removal of SB for syndesmosis fixation. A total of 36 patients who underwent removal surgery after syndesmosis fixation using SB were identified. The mean postoperative time to removal was 12.2 months. On a plain radiograph, tibiofibular clear space (TFCS) was measured and compared at three follow-up time points. In patients with computed tomography (CT) imaging (n = 18), the anterior-to-posterior (A/P) ratio was measured to evaluate changes in quality of reduction. Additionally, clinical outcomes were assessed. There were no significant differences in TFCS between the three follow-up periods. None of the patients exhibited recurrent diastasis after SB removal. Although CT analysis demonstrated malreduction in six patients (33.3%), five of six patients had a subsequent spontaneous reduction of the syndesmosis. Clinically, all patients described the resolution of symptoms related to painful hardware at the final follow-up. Our results demonstrate that SB removal at one year following syndesmosis fixation leads to improved clinical symptoms without negatively impacting the quality of syndesmosis reduction.

Suture button versus syndesmosis screw fixation in pronation-external rotation ankle fractures: A minimum 6-year follow-up of a randomised controlled trial

Randomised controlled trials (RCT) with short-term follow-ups have shown that, in treatment of syndesmosis injuries, a suture button device (SB) resulted in better radiographic and functional outcome compared to syndesmosis screw fixation (SS). However, only one RCT has reported long-term results; thus, the syndesmosis malreduction rates for both implants might increase during longer follow-up. The primary objective of this RCT was to evaluate the maintenance of syndesmosis reduction with the SS compared to the SB fixation in patients during a minimum follow-up of 6-years. The secondary objectives were to assess the post-traumatic osteoarthritis (OA) grade and the functional outcome. At Oulu University Hospital, between January 2010 and December 2011, we enrolled 43 patients with Lauge-Hansen pronation-external rotation type 4/Weber C, ankle fractures with unstable syndesmosis. Patients were randomised to treatment with either a single 3.5-mm tricortical SS (22 patients) or an SB (21 patients). The mean follow-up was 7.1 years (range, 6.2-7.9). Syndesmosis reduction and OA grade was assessed with standing cone-beam computed tomography (CBCT) of both ankles. Malreduction was defined as >2mm side-to-side difference in the mean width of the syndesmosis. OA was graded according to the Morrey & Wiedeman classification. The Olerud-Molander Ankle Outcome Score (OMAS) and a quality of life questionnaire (RAND 36-Item Health Survey) were used to evaluate functional outcome. Two syndesmoses in the SS group and one in the SB group were malreduced (P=0.58). Moderate OA after a mean of 7 years post-injury was common. In the SS and SB groups, 9 of 16 and 11 of 13 patients, respectively, had one or more grades serious OA in the injured ankle than in the uninjured ankle (P=0.11). The mean OMAS was 88 in the SS group and 78 in the SB group (difference between means 7.1, 95% CI: -7.0-21.1, P=0.32). The RAND-36 results did not differ between groups. The SS and SB maintained syndesmosis reduction equally well during follow-up. Our study findings also suggest that both methods result in moderate OA rates and the functional outcome is comparable between these two syndesmosis fixation methods.

Methods of Tibiofibular Syndesmosis Fixation.

The tibiofibular syndesmosis is a ligamentous structure connecting the distal ends of the tibia and fibula. This article presents and compares the available methods of treatment of syndesmosis injuries. Current publications from the online database PubMed and relevant available books are analysed and compared with AO Surgery guidelines. Metal and bioabsorbable syndesmotic screws and the suture button technique, including all possible modifications of these approaches, are compared. The focus is on the technical aspects of the procedures, functional outcomes and complications of these procedures. According to the literature, the best long-term functional outcomes are obtained with the dynamic fixation method involving the suture button. This fixation technique is closest to a physiological connection, there is no need to subsequently remove the implant and return to work is faster. Given all this, the popularity of this fixation technique can be expected to increase dynamically.

Syndesmosis fixation in supination-external rotation ankle fractures. Long-Term results of a prospective randomised study

The clinical relevance and treatment of syndesmosis injury in supination-external rotation (SER) ankle fractures are controversial. After malleolar fixation 24 SER 4 ankle fracture patients with unstable syndesmosis in external rotation stress test were randomised to syndesmosis transfixation with a screw (13 patients) or no fixation (11 patients). Mean follow-up time was 9.7 years (range, 8.9-11.0). The primary outcome measure was the Olerud-Molander Ankle Outcome Score (OMAS). Secondary outcome measures included ankle mortise congruity and degenerative osteoarthritis, 100-mm visual analogue scale for function and pain, RAND 36-Item Health Survey, and range of motion. Mean OMAS in the syndesmosis transfixation group was 87.3 (SD 15.5) and in the no-syndesmosis-fixation group 89.0 (SD 16.0) (difference between means 1.8, 95% CI -10.4-14.0, P = 0.76). There were no differences between the two groups in secondary outcome measures. With the numbers available, SER 4 ankle fractures with unstable syndesmosis can be treated with malleolar fixation only, with good to excellent long-term functional outcome.

Chronic Injury of Distal Tibiofibular Syndesmosis with Ankle Fracture Dislocation: A Case Report

Background: Syndesmotic injury is one of the major causes of ankle pain and arthritis in athletes. Syndesmotic instability may remain undetectable when occurring with ankle fractures.Case Report: A 59-year-old man presented to the orthopedic clinic with a history of surgery for fracture-dislocation of ankle two months before his visit. During revision surgery, we performed an open reduction, tension band wiring (TBW), and syndesmotic screw fixation. The results were satisfactory, with an almost full ankle range of motion (ROM) and good skin condition. Conclusion: Early diagnosis and treatment of syndesmosis injury can prevent the complications such as chronic pain, osteoarthritis (OA), and stiffness. There is no consensus on the treatment of syndesmosis injury, but the main factors in determining the treatment plan are tibiofibular joint stability or instability and the amount of time that the injury has occurred. Magnetic resonance imaging (MRI) and computed tomography (CT) can also be used in addition to X-rays in cases of suspected syndesmosis injury

The evaluation of radiological measurements used in diagnosis and treatment of syndesmosis injury: A regional study in Turkey.

Objectives This study aims to improve the diagnostic reliability of syndesmosis injuries through evaluation of radiological measurements in the Turkish population and to provide mean reference values to prevent malreduction and overcompression during the treatment.Patients and methods This retrospective study was performed between January 2018 and May 2018. The bilateral anteroposterior (AP) and lateral radiographs of 100 patients (60 males, 40 females; mean age 42.9 years; range, 23 to 72 years) who presented at our polyclinic were analyzed. Tibiofibular overlap (TFO), tibiofibular clear space (TFCS) and medial clear space (MCS) measurements were performed on the AP radiographs. The lateral radiographs were evaluated in respect of the anterior tibiofibular interval (ATFI), posterior tibiofibular interval (PTFI), and anterior tibiofibular ratio (ATFR) for syndesmosis reduction assessment. The lower and upper limits, mean and median values of the measurements were recorded.Results The measurements on the AP radiographs were determined to be as TFO: 7.9±2.4 mm (4-13), TFCS: 3.8±0.9 mm (2.2-6), MCS: 3.3±0.4 mm (2.7-4.5), and superior clear space: 3.3±0.3 mm (2.7-3.8). According to the measurements on the AP radiographs, the TFCS did not show any difference in terms of the variables of age, gender and side (p=0.070, p=0.219 and p=1.0, respectively). These measurements on the AP radiographs showed a high statistical consistency in terms of side (p=0.72, p=1.0, p=0.900 and p=0.920, respectively). The measurements on the lateral radiographs were as ATFI: 12.8±2.4 mm (8-18), PTFI: 6.1±2.9 mm (3-15) and ATFR: 0.4±0.1 (0.28-0.5). According to the measurements on the lateral radiographs, the ATFR did not show any difference in terms of the variables of age, gender and side (p=0.750, p=0.570 and p=0.848, respectively). The lateral measurements indicated statistical consistency in terms of side (p=0.400, p=0.260 and p=0.848, respectively).ConclusionOn the AP radiographs, TFCS was found to be reliable and the intraoperative evaluation of its high consistency with the opposite extremity is appropriate to avoid overcompression. The evaluation of ATFR on lateral radiographs was found to be reliable and evaluation is recommended to avoid intraoperative malreduction.

Syndesmosis injuries at the ankle

Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options. The aim of this review is to summarize the current knowledge on syndesmotic instability and to present some recommendations for the clinical practice for acute an chronic injuries. Analysis of the current literature concerning the anatomy, etiology, diagnostics and treatment of syndesmosis injuries. Purely ligamentous injuries (high ankle sprains) are not associated with alatent or frank tibiofibular diastasis and can be treated with an extended protocol of physiotherapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments and requires surgical stabilization. Syndesmotic disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. The proposed means of fixation are one or more tibiofibular screws or suture button implants. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. The most frequent complication is syndesmotic malreduction and can be minimized with direct visualization and intraoperative 3D scanning. Other complications include hardware failure, adhesions, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis. The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.

Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures

17 patients with ankle syndesmosic injury were treated with a 4.5mm single cortical screw fixation (passage of screw 4 cortices) and 15 patients were treated with single-level elastic fixation material. All patients were evaluated according to the AOFAS ankle and posterior foot scale at the third, sixth and twelfth months after the fixation. The ankle range of movement was recorded together with the healthy side. The Student's t test was used for statistical comparisons. No statistical significant difference was observed between the AOFAS scores (p>0.05). The range of dorsiflexion and plantar flexion motion of the elastic fixation group at the 6th and 12th months were significantly better compared to the screw fixation group (p<0.01). Elastic fixation is as functional as screw fixation in the treatment of ankle syndesmosis injuries. The unnecessary need of a second surgical intervention for removal of the fixation material is another advantageous aspect of this method of fixation.

Su1.6 Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures

Su1.6 Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures