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What is the best treatment for syndesmosis fixation? Suture-button or syndesmotic screw ? Bilateral CT-based early postoperative analysis. Foot Ankle Surg 2023; 29:128-135. [PMID: 36535844 DOI: 10.1016/j.fas.2022.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to compare the effectiveness of syndesmotic screw (SS) and suture button (SB) on the reduction and fixation of syndesmosis via early postoperative bilateral computed tomography (CT). METHODS This single-center retrospective study included 76 patients aged ≥ 18 years with a unilateral syndesmosis injury. SS was applied to 40 patients and SB to 36 patients. The differences between the sides stabilized using SB or SS and the intact sides were analyzed using the parameters of tibio-fibular clear space (∆CS) and anterior or posterior sagittal translation (∆ST) depending on the orientation of the fibula. The cases in which the fibula was translocated to the posterior of the tibia after the change of ∆ST and ∆CS> 2 mm were evaluated as malreduction. Axial CT images taken from the level of syndesmosis fixation were divided into 4 zones according to the orientation angle of the implant sent from the fibula to the tibia. RESULTS No significant difference was found in the analyses performed between total patient group with malreduction and fixation groups in terms of ∆CS and ∆ST values (p = 0.708, p = 0.289). It was observed that the fixation material was in zone 3 in 54 patients and in zone 2 in 22 patients. No significant difference was found in the analyses performed between the SS and SB groups according to the implant zone (p = 0.191). In the SS group sent from Zone 2, the malreduction rate according to the ∆ST value of syndesmosis was found to be significantly higher than in the SB group (p = 0.008, p = 0.003). CONCLUSION When the implant is applied with the correct technique, there is no difference between SS and SB in terms of early postoperative reduction. When the SS is advanced at an inappropriate angle, it negatively affects the reduction of the fibula, while SB can better tolerate angle errors up to certain degrees due to its flexible structure. Therefore, it can be presumed that the suture button system is a more convenient method in the reduction and fixation of syndesmosis than the syndesmotic screw. LEVEL OF EVIDENCE Level IV.
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“Flexible nature of fixation” in syndesmotic stabilization of the inferior tibiofibular joint affects the radiological reduction outcome. INTERNATIONAL ORTHOPAEDICS 2022; 46:2649-2657. [PMID: 35982324 PMCID: PMC9556355 DOI: 10.1007/s00264-022-05550-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/11/2022] [Indexed: 11/01/2022]
Abstract
Abstract
Purpose
Fibular mobility after suture button stabilization (SBS) of inferior tibiofibular joint (syndesmosis) injuries has been described. This effect is called the “flexible nature of fixation (FNF).” In this study, we aimed to quantify FNF in syndesmotic stabilization.
Methods
Postoperative bilateral computed tomography (CT) of ankle fractures with syndesmosis stabilization by SBS or syndesmotic screw (SYS) was retrospectively analyzed. The transverse offset (TO) and vertical offset (VO) were defined by evaluating the drill channels. The reduction outcome was evaluated by the side-to-side difference between the clear space and the anterior tibiofibular distance (antTFD). The calculated anterior tibiofibular distance (cal-antTFD) was calculated by subtracting the TO from the validated antTFD. Subsequently, a reevaluation of the reduction outcomes after SYS or SBS stabilization was performed using cal-antTFD.
Results
Sixty patients (44 with SBS and 16 with SYS stabilization) were analyzed. The intra-rater and inter-rater reliabilities for TO and VO were excellent (α > 0.92). SYS stabilization showed lower mean TO (− 0.02 mm; SD 0.14) and VO (0.11 mm; SD, 0.29 mm) than SBS stabilization (TO 1.16 mm, SD 1.4 mm; VO 0.2 mm, SD 0.8 mm; p = 0.001). The rate of malreduction according to cal-antTFD was higher than that of antFTD (p = 0.033).
Conclusion
The presented method, which evaluates the position of the tibial to the fibular drill channel, allowed the quantification of the “FNF.” The often described difference in the dynamic stabilization of SBS compared to the rigid stabilization by SYS could be objectified. Considering cal-antTFD illustrates that FNF potentially reduces the rate of malreduction in SBS stabilization.
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Effect of weightbearing and foot positioning on 3D distal tibiofibular joint parameters. Sci Rep 2022; 12:9357. [PMID: 35672426 PMCID: PMC9174190 DOI: 10.1038/s41598-022-12963-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 05/06/2022] [Indexed: 12/14/2022] Open
Abstract
The aim of this study was to investigate the effect of different loading scenarios and foot positions on the configuration of the distal tibiofibular joint (DTFJ). Fourteen paired human cadaveric lower legs were mounted in a loading frame. Computed tomography scans were obtained in unloaded state (75 N) and single-leg loaded stand (700 N) of each specimen in five foot positions: neutral, 15° external rotation, 15° internal rotation, 20° dorsiflexion, and 20° plantarflexion. An automated three-dimensional measurement protocol was used to assess clear space (diastasis), translational angle (rotation), and vertical offset (fibular shortening) in each foot position and loading condition. Foot positioning had a significant effect on DTFJ configuration. Largest effects were related to clear space increase by 0.46 mm (SD 0.21 mm) in loaded dorsal flexion and translation angle of 2.36° (SD 1.03°) in loaded external rotation, both versus loaded neutral position. Loading had no effect on clear space and vertical offset in any position. Translation angle was significantly influenced under loading by - 0.81° (SD 0.69°) in internal rotation only. Foot positioning noticeably influences the measurements when evaluating DTFJ configuration. Loading seems to have no relevant effect on native ankles in neutral position.
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Hennings R, Spiegl UJ, Fuchs C, Hepp P, Fakler JKM, Ahrberg AB. Does the orientation of syndesmosis fixative device affect the immediate reduction of the distal tibiofibular joint? Arch Orthop Trauma Surg 2022; 142:3213-3220. [PMID: 34363523 PMCID: PMC9522764 DOI: 10.1007/s00402-021-04073-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Incongruent stabilization of the distal tibiofibular joint (syndesmosis) results in poorer long-term outcome in malleolar fractures. The aim was to analyze whether the orientation of the syndesmotic stabilization would affect the immediate reduction imaged in computed tomography (CT). MATERIALS AND METHODS The syndesmotic congruity in 114 ankle fractures with stabilization of the syndesmosis were retrospectively analyzed in the post-operative bilateral CT scans. The incisura device angle (IDA) was defined and correlated with the side-to-side difference of Leporjärvi clear-space (ΔLCS), anterior tibiofibular distance (ΔantTFD) and Nault talar dome angle (ΔNTDA) regardless of the stabilization technique and separately for suture button system and syndesmotic screw. Asymmetric reduction was defined as ΔLCS > 2 mm and |ΔantTFD|> 2 mm. RESULTS Regardless of the stabilization technique, no correlation between the IDA and the ΔLCS (r = 0.069), the ΔantTFD (r = 0.019) nor the ΔNTDA (r = 0.177) could be observed. There were no differences between suture button system and syndesmotic screw. Asymmetrical reduction was detected in 46% of the cases, while sagittal asymmetry was most common. No association was found between the orientation of stabilization device and occurrence of asymmetrical reduction (p > 0.05). The results of suture button system and syndesmotic screw were comparable in this respect (p > 0.05). CONCLUSION Poor correlation between the orientation of the stabilization device and the immediate post-operative congruity of the syndesmosis could be shown. In contrast to current literature, this study did not show difference of suture button system over syndesmotic screw in this regard. Careful adjustment of the fibula in anteroposterior orientation should be given special attention.
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Affiliation(s)
- Robert Hennings
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Ulrich J. Spiegl
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Carolin Fuchs
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Pierre Hepp
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Johannes K. M. Fakler
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
| | - Annette B. Ahrberg
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103 Leipzig, Saxony Germany
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Hennings R, Souleiman F, Heilemann M, Hennings M, Klengel A, Osterhoff G, Hepp P, Ahrberg AB. Suture button versus syndesmotic screw in ankle fractures - evaluation with 3D imaging-based measurements. BMC Musculoskelet Disord 2021; 22:970. [PMID: 34809628 PMCID: PMC8609744 DOI: 10.1186/s12891-021-04834-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/02/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Inadequate reduction of syndesmotic injuries can result in disabling clinical outcomes. The aim of the study was to compare syndesmosis congruity after fixation by syndesmotic screws (SYS) or a suture button system (SBS) using three-dimensional (3D) computed imaging techniques. METHODS In a retrospective single-center study, patients with unilateral stabilization of an ankle fracture with a syndesmotic injury and post-operative bilateral CT scans were analyzed using a recently established 3D method. The side-to-side differences were compared for tibio-fibular clear space (∆CS), translation angle (∆α), and vertical offset (∆z) among patients stabilized with syndesmotic screws or suture button system. Syndesmotic malreduction was defined for ∆CS > 2 mm and for |∆α| > 5°. ∆CS and ∆α were correlated with two-dimensional (2D) measurements. RESULTS Eighteen patients stabilized with a syndesmosis screw and 29 stabilized with a suture button system were analyzed. After stabilization, both groups revealed mild diastasis (SYS: mean ∆CS 0.3 mm, SD 1.1 mm vs SBS: mean ∆CS 0.2 mm, SD 1.2 mm, p = 0.710). In addition, both stabilization methods showed slight dorsalization of the fibula (SYS: mean ∆α 0.5°, SD 4.6° vs SBS: mean ∆α 2.1°, SD 3.7°, p = 0.192). Also, restoration of the fibula-to-tibia length ratio also did not differ between the two groups (SYS: mean Δz of 0.5 mm, SD 2.4 mm vs SBS: mean Δz of 0 mm, SD 1.2 mm; p = 0.477). Malreduction according to high ∆α was most common (26% of cases), with equal distribution between the groups (p = 0.234). ∆CS and ∆α showed good correlation with 2D measurements (ρ = 0.567; ρ = 0.671). CONCLUSION This in vivo analysis of post-operative 3D models showed no differences in immediate post-operative alignment after syndesmotic screws or suture button system. Special attention should be paid to syndesmotic malreduction in the sagittal orientation of the fibula in relation to the tibia in radiological control of the syndesmotic congruity as well as intra-operatively.
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Affiliation(s)
- Robert Hennings
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany.
| | - Firas Souleiman
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
| | - Martin Heilemann
- ZESBO - Centre for Research on Musculoskeletal Systems, University of Leipzig, Semmelweisstraße 14, 04103, Leipzig, Saxony, Germany
| | - Mareike Hennings
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
| | - Alexis Klengel
- Department of Radiology, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
| | - Pierre Hepp
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
| | - Annette B Ahrberg
- Department of Orthopaedics, Traumatology and Plastic Surgery, University of Leipzig, Liebigstr. 20, 04103, Leipzig, Saxony, Germany
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Souleiman F, Heilemann M, Hennings R, Hennings M, Klengel A, Hepp P, Osterhoff G, Ahrberg AB. A standardized approach for exact CT-based three-dimensional position analysis in the distal tibiofibular joint. BMC Med Imaging 2021; 21:41. [PMID: 33676399 PMCID: PMC7937306 DOI: 10.1186/s12880-021-00570-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/18/2021] [Indexed: 02/07/2023] Open
Abstract
Background Assessment of tibiofibular reduction presents an intra- and postoperative challenge. Numerous two-dimensional measurement methods have been described, most of them highly dependent on leg orientation and rater. Aim of the present work was to develop a standardized and orientation-independent 3D based method for the assessment of syndesmotic joint position. Methods In a retrospective single center study, 3D models of bilateral ankle joints, either after unilateral syndesmosis stabilization (operative group) or with no injury (native group) were superimposed (best fit matching) and aligned uniformly. Based on center of gravity calculations three orientation- and rater-independent parameters were determined: tibiofibular clears space (CS), vertical offset between both fibulae, and translation angle of the fibulae about tibia axis. Results Bilateral CT datasets of 57 native and 47 postoperative patients were analyzed. In the native group mean CS was 2.7 (SD, 0.8; range, 0.7–4.9) mm, mean CS side difference was 0.62 (SD, 0.45) mm and mean translation angle was 1.6 (SD, 1.4) degrees regarding absolute values. The operative group was found to show a significantly higher CS side difference of 0.88 (SD, 0.75) mm compared to native group (P = .046). Compared to the healthy contralateral side, operated fibulae showed mean proximal displacement of 0.56 (SD, 1.67) mm (P = .025), dorsal displacement of 1.5 (SD 4.1) degrees (P = .017). Conclusion By using 3D best fit matching, orientation- and rater-dependent errors can be minimized. Large interindividual and small intraindividual differences of uninjured couples support previous recommendations for bilateral imaging. Trial registration: AZ 131/18-ek; AZ 361/19-ek Level of evidence Level III.
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Affiliation(s)
- Firas Souleiman
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Martin Heilemann
- ZESBO - Centre for Research On Musculoskeletal Systems, University of Leipzig, Leipzig, Germany
| | - Robert Hennings
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Mareike Hennings
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Alexis Klengel
- Department of Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Pierre Hepp
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Annette B Ahrberg
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
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