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Yodrabum N, Chaikangwan I, Tianrungroj J, Suksantilap S, Chalalaisathaphorn S, Siriwanarangsun P. Radiological landmark of syndesmotic ligament complex by magnetic resonance imaging correlate with fibula free flap harvesting procedure. Sci Rep 2023; 13:20844. [PMID: 38012256 PMCID: PMC10682006 DOI: 10.1038/s41598-023-47619-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023] Open
Abstract
Preservation of syndesmotic ligaments is crucial for preventing adverse sequelae at the donor site following free fibula osteocutaneous flap harvesting. This study sought to determine the relationship between distal tibiofibular ligaments and the fibular segment to identify radiological landmarks that facilitate safe and precise flap. The distances between the distal tibiofibular ligaments (anterior inferior tibiofibular ligament [AITFL], posterior inferior tibiofibular ligament [PITFL]) and the fibular segment, as well as the lower border of the interosseous membrane, were measured on magnetic resonance imaging (MRI) scans of 296 patients without any perceivable ankle abnormalities. The mean distances (± SD) between the distal end of the fibula and the AITFL, PITFL, and lower interosseous membrane border were 3.0 ± 0.4 cm, 2.6 ± 0.4 cm, and 3.9 ± 0.6 cm, respectively. The distance between the talar dome and the PITFL exhibited a range of 0.0-0.5 cm. Our findings support preserving a distal fibular remnant of at least 4 cm to avoid injury to the syndesmotic ligament throughout fibula osteocutaneous flap harvesting. The talar dome could serve as a useful radiological landmark for identifying the upper border of PITFL during preoperative evaluation, and thus facilitating precise and safe flap procurement.
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Affiliation(s)
- Nutcha Yodrabum
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Irin Chaikangwan
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Jirapat Tianrungroj
- Division of Plastic Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Songsak Suksantilap
- Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Palanan Siriwanarangsun
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Gomes TM, Oliva XM, Viridiana Sanchez E, Soares S, Diaz T. Anatomy of the Ankle and Subtalar Joint Ligaments: What We Do Not Know About It? Foot Ankle Clin 2023; 28:201-216. [PMID: 37137619 DOI: 10.1016/j.fcl.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Understanding of the ankle and subtalar joint ligaments is essential to recognize and manage foot and ankle disorders. The stability of both joints relies on the integrity of its ligaments. The ankle joint is stabilized by the lateral and medial ligamentous complexes while the subtalar joint is stabilized by its extrinsic and intrinsic ligaments. Most injuries to these ligaments are linked with ankle sprains. Inversion or eversion mechanics affect the ligamentous complexes. A profound knowledge of the ligament's anatomy allows orthopedic surgeons to further understand anatomic or nonanatomic reconstructions.
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Affiliation(s)
- Tiago Mota Gomes
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Xavier Martin Oliva
- Department of Orthopedics, Clinica Del Remei, Barcelona, Spain; Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain.
| | - Elsa Viridiana Sanchez
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Sérgio Soares
- Foot and Ankle Unit, Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain; Department of Orthopaedics, Hôpital Fribourgeois, Villars-sur-Glâne, Switzerland
| | - Tania Diaz
- Department of Anatomy and Human Embryology, Faculty of Medicine, University of Barcelona, Barcelona, Spain
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Liao J, Zhang J, Ni W, Luo G. A retrospective study of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Front Surg 2022; 9:912024. [PMID: 36386501 PMCID: PMC9645235 DOI: 10.3389/fsurg.2022.912024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 09/27/2022] [Indexed: 11/22/2022] Open
Abstract
Background To compare clinical outcomes of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Methods Patients diagnosed with lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption who received open reduction and internal fixation (ORIF) were retrospectively reviewed. Seventy-eight patients were enrolled into the study, including 40 patients treated with lateral malleolus fracture ORIF and trans-syndesmotic fixation, and 38 patients treated with lateral malleolus fracture ORIF and deltoid ligament repair. Basic information and pre- and postoperative radiological materials were reviewed. Visual analog pain scale (VAS) score, Olerud-Molander score, and the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale were used for evaluating pain control and functional recovery postoperatively at different time points. Results No complication was reported in both groups. In the trans-syndesmotic fixation group, all patients received syndesmotic screw removal 6-8 weeks postoperatively. The Olerud-Molander score and AOFAS Ankle-Hindfoot Scale in the deltoid ligament repair group were higher than the trans-syndesmotic fixation group 3 months after operation. No statistical difference was found between the two groups in VAS score from 1 to 12 months postoperatively. Conclusions Lateral malleolus fracture ORIF and deltoid ligament repair is an effective method for lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption. Compared with trans-syndesmotic fixation, deltoid ligament repair holds the advantage of not needing surgical removal of inferior tibiofibular screws postoperatively.
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Kohler FC, Schenk P, Koehler P, Hofmann GO, Biedermann U, Wildemann B, Graul I, Hallbauer J. The role of the posterior malleolus in the treatment of unstable upper ankle joint injuries - A biomechanical study. Foot Ankle Surg 2022; 28:979-985. [PMID: 35177329 DOI: 10.1016/j.fas.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/28/2022] [Accepted: 02/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This biomechanical study aimed to test if the fixation of the posterior malleolus (PM) only with screws inserted from posterior to anterior (PA) restores stability comparable with the natural condition. The extent of stability was also compared with that of anterior to posterior (AP) screw osteosynthesis (OS) with an additional syndesmotic screw (SS). METHODS First, the stability of the upper ankle joint in seven pairs of intact lower legs were examined. Subsequently, half of the lower legs were treated with PA screw fixation of a PM fracture without SS and the other half with AP screw fixation with additional tricortical SS. RESULTS PA OS without SS showed significantly more diastasis (p = 0.027). The AP OS with an SS revealed a diastasis that was comparable with the intact condition (p = 0.797). The use of SS led to significantly higher stability compared to OS without SS (p = 0.019). CONCLUSIONS The Fixation of the PM alone without an additional syndesmotic screw cannot achieve intact upper ankle stability. Fixation of a PM fracture with an SS helps in nearly achieving the natural condition.
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Affiliation(s)
- F C Kohler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany.
| | - P Schenk
- Reseaserch Executive Department, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - P Koehler
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - G O Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany; Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost, 06112 Halle, Germany
| | - U Biedermann
- Institute of Anatomy I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - B Wildemann
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - I Graul
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
| | - J Hallbauer
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07747 Jena, Germany
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAnkle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations.MethodsThe available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores.ResultsA total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%).ConclusionsCollectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Correspondence: Yun-Feng Rui
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Rozis M, Vlachos C, Vasiliadis E, Pneumaticos SG. Elastic Reconstruction of Chronic Instability of the Distal Tibiofibular Joint in an Obese Patient: A Case Report. Cureus 2022; 14:e25469. [PMID: 35783891 PMCID: PMC9249369 DOI: 10.7759/cureus.25469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 12/05/2022] Open
Abstract
An active, obese young patient was admitted to our clinic complaining of chronic ankle pain after fixation of his lateral malleolus fracture. His symptoms consisted of intermittent pain after prolonged walking, swelling, and feeling of instability. His clinical and radiological evaluations indicated chronic mechanical instability of his distal tibiofibular syndesmosis that remained unresponsive to conservative treatment. Considering his age and activity level, we proceeded to a global syndesmotic reconstruction of the three major syndesmotic ligaments with split-thickness peroneus longus graft. According to this technique, the graft was passed through specific tibiofibular tunnels restoring the native stability and elasticity of the region. The patient had an optimal postoperative function, with diminished symptoms and increased clinical scores. His late radiological evaluation revealed an anatomic ankle reduction with restoring his normal syndesmotic anatomy compared to his contralateral limb. Regardless of his high BMI, we noticed no further subluxation of his talus, while his general symptomatology was unremarkable at the 12-month follow-up. In conclusion, elastic reconstruction of the distal tibiofibular joint with split-thickness peroneus longus graft provides excellent results at 12 months regardless of the patient’s BMI. To our knowledge, this is the only technique that restores the three main regional ligaments, simultaneously allowing for close-to-normal biomechanics and providing excellent short-term clinical outcomes.
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Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med 2022; 11:jcm11020331. [PMID: 35054025 PMCID: PMC8780481 DOI: 10.3390/jcm11020331] [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] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/26/2021] [Accepted: 01/05/2022] [Indexed: 02/01/2023] Open
Abstract
Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.
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Surgical Anatomy for Fibular Free Flap Focusing on the Inferior Tibiofibular Syndesmotic System: A Cadaveric Study and Case Series of 3-Dimensional Prefabricate Cutting Guided Fibular Free Flap. J Craniofac Surg 2021; 33:951-955. [DOI: 10.1097/scs.0000000000008323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Kaiser PB, Bejarano-Pineda L, Kwon JY, DiGiovanni CW, Guss D. The Syndesmosis, Part II: Surgical Treatment Strategies. Orthop Clin North Am 2021; 52:417-432. [PMID: 34538352 DOI: 10.1016/j.ocl.2021.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Syndesmotic injuries in the setting of ankle fracture are critically important to diagnosis and treat to restore an anatomic tibiotalar relationship. Physical examination and clinical suspicion remain critically important for diagnosis. Ultrasound examination and weight-bearing computed tomography scans are evolving to help diagnosis more subtle injuries. Although flexible syndesmotic fixation may decrease malreduction rates, the benefits over rigid fixation is the subject of ongoing study. Anatomic reduction remains critical regardless of fixation choice. Routine removal of rigid syndesmotic hardware does not seem to offer substantial clinical improvement in pain or range of motion; however, broken hardware may cause irritation.
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Affiliation(s)
- Philip B Kaiser
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA.
| | - Lorena Bejarano-Pineda
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - John Y Kwon
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Christopher W DiGiovanni
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
| | - Daniel Guss
- Department of Orthopaedic Surgery, Foot and Ankle Service, Harvard Medical School, Massachusetts General Hospital and Newton-Wellesley Hospital, Boston, MA, USA; Foot & Ankle Research and Innovation Laboratory - Harvard Medical School, Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital - Newton-Wellesley Hospital, Boston, MA, USA
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