Syndesmosis Stabilisation: Screws Versus Flexible Fixation

Meta-analysis of elastic versus rigid fixation in the treatment of acute tibiofibular syndesmosis injury

OBJECTIVE

The objective of this study was to conduct a meta-analysis by synthesizing multiple literature sources to explore whether there are any differences between elastic fixation and rigid fixation in the treatment of acute tibiofibular syndesmosis injuries. The aim was to provide effective guidance for clinical treatment.

METHODS

We conducted a comprehensive search across seven databases, including both Chinese and English, to include all studies related to the treatment of acute tibiofibular syndesmosis injuries with elastic fixation and rigid fixation published between January 1, 2013, and November 15, 2022. Following the PRISMA guidelines, we rigorously screened, assessed, and extracted data from the included studies. The outcome measures included AOFAS scores at 3, 6, and 12 months postoperatively; tibiofibular clear space (TBCS) and tibiofibular overlap distance (TBOL) at the early postoperative and 12-month follow-up; intraoperative blood loss; operative time; time to full weight-bearing postoperatively; and postoperative complications. Meta-analysis was performed using Review Manager 5.4.

RESULTS

A total of 35 studies were included, comprising 16 randomized controlled trials and 19 retrospective cohort studies. The study population included 2120 cases, with 1044 cases in the elastic fixation group and 1076 cases in the rigid fixation group. The elastic fixation group had higher AOFAS scores at 3, 6, and 12 months postoperatively compared to the rigid fixation group. Although the elastic fixation group had a slightly larger TBCS than the rigid fixation group in the early postoperative period, the difference between the two groups became statistically insignificant at 12 months postoperatively. There was no statistically significant difference in TBOL between the two groups in the early postoperative period, but at 12 months, the elastic fixation group had a greater TBOL than the rigid fixation group. Additionally, the elastic fixation group had lower rates of postoperative local irritation, wound infection, and postoperative internal fixation loosening or rupture compared to the rigid fixation group. The rate of postoperative tibiofibular redislocation did not differ statistically between the two groups. The time to full weight-bearing was shorter in the elastic fixation group than in the rigid fixation group. Although the elastic fixation group had a slightly longer operative time, there was no statistically significant difference in intraoperative blood loss between the two groups.

CONCLUSION

Compared to rigid fixation, elastic fixation in the treatment of acute tibiofibular syndesmosis injuries offers several advantages, including better postoperative ankle joint function recovery, more precise anatomical reduction of the syndesmosis postoperatively, a lower incidence of postoperative complications, and shorter time to full weight-bearing postoperatively. These findings provide robust guidance for clinical treatment.

The Radiological Anatomy of the Distal Tibiofibular Joint: A Retrospective Computed Tomography Study

Introduction Distal tibiofibular joint (DTFJ) injuries are commonly encountered in patients with ankle fractures. Achieving optimal fixation is mandatory, but it requires a thorough understanding of the local anatomical relationships. For this reason, we performed a retrospective CT study in healthy ankles to radiologically describe the normal anatomy of the DTFJ and the anatomical relationship of the fibula within the ankle joint. Materials and methods For this study, we retrospectively examined 60 CT scans of healthy, non-injured ankles in a plantigrade position. Patients with prior ankle surgery or systemic diseases with ankle involvement were excluded because we needed to describe the normal anatomy of the joint. The radiological evaluation included the position of the fibula in the fibular notch and the rotational relationship of the fibula with the talus and the medial malleolus. Results Our study included 60 healthy ankles. Thirty-three were right ankles, and 27 were left. The cohort included 36 females and 24 males with a mean age of 48.3 years old. We found that the fibular notch was retroverted on the transverse plane, with the tibiofibular engagement being 0.11 mm (SD=1.57 mm, SE=0.2 mm), at 1 cm proximally to the tibial plafond. Additionally, we observed that the fibula was internally rotated against the lateral talar facet, while the medial and lateral malleolus facets were externally rotated in between. Moreover, we found a strong positive correlation between the incisura retroversion and fibular engagement at 1 cm above the tibial plafond line (Pearson correlation=0.273, p=0.03). Conclusion Our study highlights the importance of gaining a comprehensive understanding of the inherent anatomy of the DTFJ to achieve reduction goals in ankle fractures. According to our results, in ankle fracture treatment, surgeons should aim for anatomical fracture and syndesmotic fixation, with the fibula in internal rotation against the lateral talar facet. Additionally, as normal tibiofibular engagement is borderline, we do not suggest that over-tightening the syndesmotic screws is essential. This study's findings can aid surgeons in reducing the malreduction rates in patients with ankle fractures.

Clinical and Biomechanical Outcomes of Suture Button Fixation for Ligamentous Lisfranc Injury: A Systematic Review and Meta-analysis

Background

Flexible ligamentous fixation has increased in popularity for the treatment of ligamentous Lisfranc injury, but the optimal fixation strategy is unclear.

Purpose

To review the biomechanical, clinical, and radiographic results of ligamentous Lisfranc injuries treated with flexible fixation.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic literature review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed/Medline and Google Scholar literature databases were queried for clinical and biomechanical (cadaveric) studies relating to flexible fixation of ligamentous Lisfranc injury. Outcomes of interest included patient-reported outcome scores, clinical/biomechanical results, radiographic alignment, and return to activity. Where appropriate, meta-analysis of the postoperative outcomes was performed.

Results

Of the 34 initial studies, 14 articles (243 feet) were included in the analysis. In the 11 clinical studies (216 patients), the mean postoperative American Orthopaedic Foot & Ankle Society score was 90.1 (n = 150; 6 studies) and the mean visual analog scale score was 1.5 (n = 137; 5 studies). The rate of return to activity was 100% (n = 35; 5 studies), and 100% of patients maintained radiographic alignment postoperatively (n = 62; 6 studies). No complications or subsequent hardware removals were reported. Of the 3 biomechanical studies (27 feet), 1 study found significantly greater change in diastasis under axial load between intact and postfixation ligaments with suture button versus screw fixation (+1.1 vs -0.1 mm; P < .05), another found no difference in the decrease in diastasis under axial load between the injured state and screw or suture button fixation (1.2 vs 1.0 mm; P = .5), and the third found no difference in displacement between intact and either screw or suture button fixation under either axial (intact vs screw: 1.0 vs 2.0 mm, P = .1; intact vs suture button: 0.6 vs 1.8 mm, P = .1) or abduction (intact vs screw: 1.5 vs 1.1 mm, P = .5; intact vs suture button: 1.3 vs 2.1 mm, P = .1) load.

Conclusion

Flexible fixation use in the treatment of ligamentous Lisfranc injury was found to have significant potential as a fixation option, as demonstrated by excellent clinical results. Biomechanical evidence was inconclusive but suggested a trend toward decreased diastasis in specimens fixed with screws compared with suture buttons.

High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment?

Probably one of the most controversial subjects in the orthopedic field is the distal tibiofibular articulation. Even though its most primary knowledge can be a matter of enormous debate, it is in the diagnosis and treatment most of the disagreements reign. Distinguishing between injury and instability remains challenging as well as an optimal clinical decision regarding surgical intervention. The last years presented technology and that was able to bring body to an already well-developed scientifical rationale. In this review article, we aim to demonstrate the current data behind syndesmotic instability in the ligament scenario, whereas using few fracture concepts.

Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study

Background: Syndesmotic injuries are common lesions associated with ankle fractures. Static and dynamic fixation are frequently used in syndesmotic injury-associated ankle fractures. The purpose of this study is to compare short- and mid-term quality of life, clinical outcomes, and gait after static stabilization with a trans-syndesmotic screw or dynamic stabilization with a suture button device. Methods: Here, 230 patients were enrolled in a retrospective observational study. They were divided in two groups according to the fixation procedure (Arthrex TightRope®, Munich, Germany) synthesis vs. osteosynthesis with a 3.5 mm trans-syndesmotic tricortical screw). They then underwent clinical assessment using the American Foot and Ankle Score (AOFAS) at 1, 2, 6, 12, and 24 months after surgery. Quality of life was assessed according to the EuroQol-5 Dimension (EQ-5D) at 2 and 24 months after surgery in the follow-up; gait analysis was performed 2 and 24 months postoperatively. Results: Significant differences were found at a two-month follow-up according to the AOFAS (p = 0.0001) and EQ-5D (p = 0.0208) scores. No differences were noted in the other follow-ups (p > 0.05) or gait analysis. Conclusion: The dynamic and static fixation of syndesmotic injuries in ankle fracture are both efficacious and valid procedures for avoiding ankle instability. The suture button device was comparable to the screw fixation according to functional outcomes and gait analysis.

Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study

BACKGROUND

Syndesmotic injuries are common lesions associated with ankle fractures. Static and dynamic fixation are frequently used in syndesmotic injury-associated ankle fractures. The purpose of this study is to compare short- and mid-term quality of life, clinical outcomes, and gait after static stabilization with a trans-syndesmotic screw or dynamic stabilization with a suture button device.

METHODS

Here, 230 patients were enrolled in a retrospective observational study. They were divided in two groups according to the fixation procedure (Arthrex TightRope^®, Munich, Germany) synthesis vs. osteosynthesis with a 3.5 mm trans-syndesmotic tricortical screw). They then underwent clinical assessment using the American Foot and Ankle Score (AOFAS) at 1, 2, 6, 12, and 24 months after surgery. Quality of life was assessed according to the EuroQol-5 Dimension (EQ-5D) at 2 and 24 months after surgery in the follow-up; gait analysis was performed 2 and 24 months postoperatively.

RESULTS

Significant differences were found at a two-month follow-up according to the AOFAS (p = 0.0001) and EQ-5D (p = 0.0208) scores. No differences were noted in the other follow-ups (p > 0.05) or gait analysis.

CONCLUSION

The dynamic and static fixation of syndesmotic injuries in ankle fracture are both efficacious and valid procedures for avoiding ankle instability. The suture button device was comparable to the screw fixation according to functional outcomes and gait analysis.

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

BACKGROUND

Aims 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.

METHODS

Both 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.

RESULTS

The 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.

CONCLUSION

The 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.

The Effectiveness of Rehabilitation Program After Hybrid Osteosynthesis in Ankle Joint Unstable Injuries

Aim: To develop a rehabilitation protocol for patients with the unstable ankle joint injuries by doing comparative analysis between HSEF functional results and the traditional method. Materials and Methods: The study was performed on 61 patients with the unstable ankle trans- or supra-syndesmotic fractures. Patients were divided into two equal groups where I = main and II = control due to the age, distribution and disorders. 10 patients from the group I were operated using HSEF, the other 51 were selected for the traditional osteosynthesis (plate and positioning screw). For the monitoring of osteosynthesis quality was used The Foot and Ankle Disability Index (FADI) scale. Nonparametric statistical analysis was completed using Statistica 13.0 computer software. Results: After application of HSEF method authors of this paper created original rehabilitation protocol. Limitations in the rehabilitation process (e.g., not weightbearing) on 42}3 day in the control group II caused a significant gap in the results of ankle joint functional recovery. On day56}3, the main group I overreached the control group II by 1.5 (p3<0.001). With each FU 1-3 of the main group I, the total sum of points according to FADI (subscale of sports activity) steadily increased by 5, and with FU 3 on the 56}3 day, reached 16 points. Positive quantitative dynamics in scores were the characteristic of patients from both groups (advantage of the group I was insignificant (by 2 points) (p4<0.001)), although none of them reached the normal (32 points) at the final term (FU 4). Conclusion:Provided results proved the effectiveness of the developed rehabilitation protocol. It enhanced patients recovery up to 1-2 weeks.

Radiographic Assessment of Tibiofibular Syndesmosis Injury with Different Durations and Types of Fixation

Introduction: There is no consensus among orthopedic surgeons on the number of cortical layers (tricortical or quadricortical fixation) involved or the duration of syndesmotic fixation after a tibiofibular syndesmosis (TFSD)-injury treatment. The purpose of this study was to assess radiographic parameters following the treatment of TFSD injuries, with various time-windows of syndesmotic screw removal and numbers of cortical layers involved. Materials and Methods: Fifty-five patients, aged from 25 to 75 years, were included in the study. The follow-up period ranged from 2 years to 4 years and 2 months. The patients were subdivided into groups based on the duration of the syndesmotic fixation (8–15 weeks—19 patients or 16–22 weeks—36 patients) and the number of cortices involved (tricortical—17 patients or quadricortical fixation—38 patients). Results: The quadricortical fixation group showed a significant development of ankle joint arthritis and subtalar joint arthritis at the final follow-up. The mean medial clear space was 2.84 mm in the tricortical fixation group and 3.5 mm in the quadricortical fixation group (p = 0.005). Both groups, with different screw removal times showed significant development of posttraumatic arthritis. A comparison of the two groups (with different time-windows of the screw removal) revealed a significant difference only in terms of the postoperative tibiofibular (TF) overlap and the observed rates of talonavicular arthritis at the final follow-up. Discussion: We found that the duration of the screw fixation had no effect on most of the evaluated radiographic parameters. Only the postoperative TF overlap was lower in the 8–15-week fixation group, and the proportion of patients with talonavicular joint arthritis at the final follow-up was higher in the 16–22-week fixation group. In addition, the number of cortices involved in the screw fixation had no effect on the radiographic outcomes in our patients, apart from the differences in one parameter—the medial clear space—at the final follow-up. Conclusion: We achieved similar radiographic results irrespective of the duration of the screw fixation and the number of cortices involved. All study subgroups showed the development of adjacent-joint arthritis following treatment. Considering the results of our study, the economic and medical aspects of treatment, and the possibility of a faster recovery, the most optimal solution seems to be the use of a tricortical fixation, with the screws being removed after 8–15 weeks.

Joint Preservation for Posttraumatic Ankle Arthritis After Tibial Plafond Fracture

Management of posttraumatic ankle arthritis due to tibial plafond fracture is technically demanding. The distal tibial plafond-plasty could be an alternative to preserve the ankle joint for young patients with limited ankle arthritis. The surgical principles are to realign the mechanical axis, reconstruct the articular surface of the distal tibial plafond, and achieve a congruent and stable ankle joint. In addition to the anteroposterior view of the ankle joint, the lateral view was also paramount for surgeons to fully evaluate the reduction quality. The revision procedures are as follows: osteotomy for exposure, articular surface reconstruction, bone grafting, and osteotomy fixation.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

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.

Syndesmotic Stabilization: Syndesmotic Screw Versus Flexible Fixation: A Systematic Review

Syndesmotic injuries are common injuries that occur in isolation or associated with ankle fractures. The suture button device fixation (SBDF) has become increasingly attractive to orthopedic surgeons as an alternative to metallic screw fixation (MSF) for syndesmotic fixation. This review involved the highest-quality clinical biomechanical and cost analysis studies to provide a comprehensive review. A literature search in the electronic databases was conducted to identify clinical, biomechanical as well as cost analysis studies in which the MSF was compared to SBDF from 1990 to 2018. Only comparative clinical studies with a level of evidence I or II were included besides any comparative biomechanical or cost analysis study. The (PRISMA) guidelines were followed. Eight clinical, 11 biomechanical, and 3 cost analysis studies were included. The clinical studies consisted of 5 randomized controlled trials (RCTs) and 3 cohort studies. The average American Orthopaedic Foot and Ankle Society score for the SBDF group was (92.4) compared to (86.6) for the MSF group at 1 year follow-up. SBDF group showed a lower rate of malreduction, implant removal, implant failure, and complications. The biomechanical studies showed better reduction accuracy in the SBDF group. The reduction maintenance was comparable in the coronal plane but not in the sagittal plane. The cost-effectiveness of the SBDF was highly dependent on the difference in implant removal rate. In conclusion, the SBDF showed comparable to better outcomes compared to the MSF. It may be a better option for syndesmotic fixation.

Checkrein Deformity of the Hallux Caused by Misplaced Suture-Button Syndesmosis Fixation: A Case Report

Ankle fractures are common injuries. If an ankle fracture is combined with tibiofibular syndesmosis separation, then tibiofibular transfixation should be used to stabilize the syndesmosis; in such cases, flexible (suture-button) fixation is an option. We surgically treated a male patient's unstable ankle fracture with internal fixation devices, including a suture-button fixator, and observed the development of a flexor hallucis longus checkrein deformity in the postoperative period. The aim of this report is to describe this rare postoperative complication associated with the use of suture-button transfixation of the tibiofibular syndesmosis.

Hybrid Fixation for Danis-Weber Type C Fractures With Syndesmosis Injury

BACKGROUND

This study aimed to assess the clinical and radiological outcomes of hybrid fixation for Danis-Weber type C ankle fractures with a syndesmotic injury.

METHODS

From January 2016 to April 2018, we retrospectively reviewed consecutive patients who underwent hybrid fixation for Danis-Weber type C ankle fractures with syndesmotic injury with a minimum follow-up of 12 months. We excluded patients who achieved syndesmosis stability after fracture fixation. In all patients, we allowed partial weightbearing at 4 weeks postoperatively. We evaluated the visual analog scale for ankle pain, the Olerud-Molander ankle score, and the American Orthopaedic Foot & Ankle Society score. Malreduction of the syndesmosis was defined based on 2 previously reported methods. Fourteen patients (11 men and 3 women) were included in this study. There were 11 patients with pronation external rotation-type fractures and 3 patients with Maisonneuve fractures. The average age at operation was 37.2 years (range, 18-70 years).

RESULTS

Clinical scores were significantly improved at the last follow-up. Postoperative malreduction was observed only in 1 patient (7.1%).

CONCLUSION

Hybrid fixation using a suture-button device combined with a syndesmotic screw in Danis-Weber type C fractures with syndesmosis injury showed a high accuracy of reduction, a low rate of diastasis, and favorable clinical outcomes. This combined method could be a good alternative treatment option for Danis-Weber type C ankle fractures with a syndesmosis injury.

LEVEL OF EVIDENCE

Level IV, case series.

Cortical Button Fixation for Proximal Tibiofibular Instability: A Technical Report

Instability of the proximal tibiofibular joint (PTFJ) is a rare injury pattern than can affect high-demand athletes involved in twisting or pivoting movements on a flexed knee. Instability may produce painful subluxations during provocative activity and occasional neuritic symptoms from tethering of the common peroneal nerve at the fibular neck. There are several reports of reconstruction for symptomatic PTFJ instability; however, no optimal treatment has been elucidated in the literature. Use of a cortical button suspensory device for fixation of the PTFJ offers the advantage of stabilizing the joint without need for free graft harvest or rigid screw fixation. The present technical report illustrates the operative technique and the advantages, disadvantages, pearls, and pitfalls associated with this operation.

Implications of Classification of Os Trigonum: A Study Based on Computed Tomography Three-Dimensional Imaging

BACKGROUND The os trigonum is an accessory bone that is not fully fused with the talus during secondary ossification, and is one of the risk factors of posterior malleolus impact syndrome. The purpose of this study was to classify the os trigonum and to guide the diagnosis and treatment of related clinical diseases. MATERIAL AND METHODS Ankle computed tomography (CT) scans of 586 Chinese patients between October 2014 and October 2018 were reviewed. CT images of 1011 ankle joints were reconstructed to evaluate the classification of the os trigonum and the measurement of anatomical parameters. RESULTS The incidences of os trigonum in 3 groups were determined as type I (1.9%), type II (10.5%), and type III (14.7%). The macro-axis of type II (0.89±0.31) cm was significantly larger than with type I (0.65±0.24 cm) and type III (0.74±0.23 cm) (p<0.05).The minor axis of similar of type I (0.41±0.23 cm) was significantly shorter than that of type II (0.58±0.32 cm) and type III (0.55±0.16 cm) (p<0.05).The distance from os trigonum to calcaneal tubercle was significantly different than that of type I (1.33±0.52 cm), type II (1.67±0.55 cm), and type III (1.84±0.45 cm) (p<0.05). CONCLUSIONS This study showed that os trigonum has a high incidence. Type I was the least common, the volume of type II was larger, and type III was more common. The anatomical parameters of each type may improve treatment of related diseases and the further development of ankle arthroscopic surgery.

[Effectiveness comparison of flexible fixation and rigid fixation in treatment of ankle pronation-external rotation fractures with distal tibiofibular syndesmosis]

Objective

To compare the effectiveness of flexible fixation and rigid fixation in the treatment of ankle pronation-external rotation fractures with distal tibiofibular syndesmosis.

Methods

A retrospective analysis was made on the clinical data of 50 patients with ankle pronation-external rotation fractures and distal tibiofibular syndesmosis treated between January 2013 and December 2015. Suture-button fixation was used in 23 patients (flexible fixation group) and cortical screw fixation in 27 patients (rigid fixation group). There was no significant difference in age, gender, weight, side, fracture type, and time from trauma to surgery between 2 groups ( P>0.05). The operation time, medial clear space (MCS), tibiofibular clear space (TFCS), tibiofibular overlap (TFO), American Orthopaedic Foot and Ankle Society (AOFAS) score, and Foot and Ankle Disability Index (FADI) score were compared between 2 groups.

Results

The operation time was (83.0±9.1) minutes in the flexible fixation group and was (79.6±13.1) minutes in the rigid fixation group, showing no significant difference ( t=1.052, P=0.265). All patients achieved healing of incision by first intention. The patients were followed up 12-20 months (mean, 14 months). The X-ray films showed good healing of fracture in 2 groups. There was no screw fracture, delayed union or nounion. The fracture healing time was (12.1±2.5) months in the flexible fixation group and was (11.3±3.2) months in the rigid fixation group, showing no significant difference between 2 groups ( t=1.024, P=0.192). Reduction loss occurred after removal of screw in 2 cases of the rigid fixation group. At last follow-up, there was no significant difference in MCS, TFCS, TFO, AOFAS score and FADI score between 2 groups ( P>0.05).

Conclusion

Suture-button fixation has similar effectiveness to screw fixation in ankle function and imaging findings, and flexible fixation has lower risk of reduction loss of distal tibiofibular syndesmosis than rigid fixation.

Stability in ankle fractures: Diagnosis and treatment

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057.