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Khurana A, Kumar A, Katekar S, Kapoor D, Vishwakarma G, Shah A, Singh MS. Is routine removal of syndesmotic screw justified? A meta-analysis. Foot (Edinb) 2021; 49:101776. [PMID: 33992455 DOI: 10.1016/j.foot.2021.101776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 01/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Syndesmosis injuries are common with rotational ankle injuries, and placement of a positional syndesmotic screw to maintain its reduction is used as the ligaments heal. There is no clear consensus on routine removal or retention of syndesmotic screw. This study aimed to appraise the current evidence both on removal and retention of syndesmotic screw and to conduct a meta-analysis comparing outcomes and rate of complications of syndesmotic screw removal and retention. METHODS Following PROSPERO registration, a systematic search using was performed using keywords ('Syndesmosis' OR 'Syndesmotic' OR 'Transsyndesmotic' OR 'distal tibiofibular') AND ('Screw') AND ('Removal' OR 'Retention') AND 'Outcome' in various databases. No language restrictions were applied and the meta-analysis incorporated the PRISMA statement. VAS (Visual analogue scale for pain), AOFAS (American Orthopaedic Foot And Ankle Society) scores expressed as mean ± SD, and both groups' complication rates were compared. Comparisons with a random-effects model were performed, and heterogeneity between the studies was calculated using the I2 statistic. T-test for two independent sample means was used to compare pooled mean and Z-test for two proportions to assess the difference in the proportion of complications. RESULTS A total of 7 studies with 522 patients were included in this review for analysis. Pooled analysis showed non-significant difference in AOFAS score (MD = -1.84; 95% CI: -4.33 to 0.66; p = 0.150) as well as for VAS score (MD = -0.48; 95% CI: -1.56 to 0.60; p = 0.390) between the two groups. The value of z and p-value for complication rates was 0.6021 and 0.5485, respectively, which was not significant. CONCLUSION There doesn't appear to be a difference in functional outcome, pain scores, and complication rates between patients who had their syndesmotic screws removed and those where screw was retained. The fear of inferior outcomes with retained screws is thus unfounded, and routine removal adds to morbidity and financial burden. In conclusion, present data does not support the routine removal of the intact syndesmosis screw, and a change in practice is needed to abandon routine syndesmotic screw removal.
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Affiliation(s)
- Ankit Khurana
- Department of Orthopaedics, ESI Hospital, Rohini, Delhi, India
| | - Arun Kumar
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | - Shyam Katekar
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | - Darshan Kapoor
- Department of Orthopaedics, Indian Spinal Injury Centre, Delhi, India
| | | | - Ashish Shah
- Department of Orthopaedics, UAB, Birmingham, Alabama, USA
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Kamin K, Kleber C, Marx C, Schaser KD, Rammelt S. [Minimally invasive fixation of distal fibular fractures with intramedullary nailing]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:104-111. [PMID: 33728477 DOI: 10.1007/s00064-021-00702-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Minimally invasive osteosynthesis of distal fibula fractures serves as a biomechanically stable and soft-tissue-friendly fixation method in the case of an unstable fracture, poor bone quality, and/or critical soft tissue conditions with restoration of the length, axis and rotation of the distal fibula as well as stabilization of the ankle mortise. The goal is to reduce and stabilize the distal fibular fracture in a quick and stable manner that protects the soft tissues in ankle fractures. INDICATIONS Unstable malleolar fractures and fracture dislocations; fibular fractures in combination with distal tibia fractures; critical soft tissue conditions around the ankle. CONTRAINDICATIONS No consent to surgery by the patient. Overall critical (life-threatening) general condition preventing surgery to the extremities. Very narrow medullary canal of the fibula (less than 3 mm, depending on the implant). SURGICAL TECHNIQUE Percutaneous placement of a guidewire into the distal fibular tip, opening the medullary canal and drilling the medullary canal in the distal fragment. Reduction of the axis by introduction of the fibular nail, with additional percutaneous use of reduction clamps for restoration of fibular length and rotation, if necessary. Placement of distal locking screws over the targeting device while maintaining rotation and length, in addition proximal static locking is mandatory to maintain the length of the fibula. In case of residual syndesmotic instability after fracture fixation, syndesmotic screws are inserted through the fibular nail via the aiming device. POSTOPERATIVE MANAGEMENT Following surgery, rest and elevation of the injured leg, and local cooling are indicated. Subsequently, mobilization with partial weight bearing (15-20 kg) in an ankle foot orthosis or plaster/cast for 6 weeks. RESULTS Minimally invasive fibular fixation with an intramedullary nail results in a significantly lower rate of wound healing complications compared with lateral plating. Reported union rates range from 97.4 to 100% with current nail designs. The quality of reduction and functional outcome is comparable to that after plate fixation. A certain learning curve has to be respected.
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Affiliation(s)
- Konrad Kamin
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland.
| | - Christian Kleber
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Christine Marx
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Klaus-Dieter Schaser
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
| | - Stefan Rammelt
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland
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Swords MP, Shank JR. Indications and Surgical Treatment of Acute and Chronic Tibiofibular Syndesmotic Injuries with and Without Associated Fractures. Foot Ankle Clin 2021; 26:103-119. [PMID: 33487234 DOI: 10.1016/j.fcl.2020.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.
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Affiliation(s)
- Michael P Swords
- Michigan Orthopedic Center, 2815 Pennsylvania Avenue, Suite 204, Lansing, MI 48823, USA.
| | - John R Shank
- Department of Orthopedic Surgery, Colorado Center of Orthopaedic Excellence, 2446 Research Parkway, Suite 200, Colorado Springs, CO 80920, USA
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van den Heuvel SB, Dingemans SA, Gardenbroek TJ, Schepers T. Assessing Quality of Syndesmotic Reduction in Surgically Treated Acute Syndesmotic Injuries: A Systematic Review. J Foot Ankle Surg 2019; 58:144-150. [PMID: 30583776 DOI: 10.1053/j.jfas.2018.08.038] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Indexed: 02/03/2023]
Abstract
There is no universal method with cutoff values for the assessment of distal tibiofibular joint reduction in acute syndesmotic injuries. It is important to detect malreductions because they may lead to impaired functional outcome and may demand reoperations. The aim of this study was to systematically review the literature to evaluate the appropriateness of different image techniques in determining syndesmotic malalignment. A literature search was conducted in Medline, Embase, and the Cochrane Library to search for articles assessing syndesmotic reduction. Excluded were articles where no criteria and/or measurements for syndesmotic reduction were provided, only normative values were provided and reviews. In total, 2157 articles were found, of which 1421 studies were screened for title and abstract after exclusion of duplicates. One hundred ten studies were eligible for full-text analysis. Of these, 61 were excluded. Three studies where added after screening the included references. Fifty-two studies were included, of which 32 were original publications and 20 were publications referring to the original publications. From the original publications, 14 used plains radiographs, 19 computed tomographic (CT) scans, and 5 used 3-dimensional CT scans (some authors used >1 modality in their study). For each modality, a large number of parameters and different cutoff values were reported. CT scanning is superior to plain radiography in the assessment of the quality of joint reduction. Parameters used the most were fibular position in the incisura and fibular rotation. The criteria for adequate reduction should at least include the position of the fibula in the incisura and rotation of the fibula, while ensuring adequate fibular length, all equaling or at least approaching the values of the uninjured contralateral side.
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Affiliation(s)
| | - Siem A Dingemans
- Surgical Resident, Trauma Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Tjibbe J Gardenbroek
- Surgical Resident, Trauma Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Tim Schepers
- Trauma Surgeon, Trauma Unit, Academic Medical Center, Amsterdam, the Netherlands.
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Abstract
Ankle injuries are a common traumatic injury. Rupture to the syndesmosis may occur as a result of these injuries. Strategies for the treatment of both acute and chronic syndesmotic repair are reviewed in detail. Significance of Chaput, Wagstaffe, and posterior malleolus fractures on syndesmotic stability are reviewed. Treatment considerations for total ankle arthroplasty are discussed, and correction of coronal plane deformity as a result of late syndesmotic injury at the time of ankle arthroplasty is outlined.
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Affiliation(s)
- Michael Swords
- Orthopedic Surgery, Sparrow Hospital, Michigan Orthopedic Center, 2815 South Pennsylvania Avenue, Suite 204, Lansing, MI 48910, USA.
| | - Jean Brilhault
- Service de Chirurgie Orthopédique, C.H.R.U. Tours, 1, Tours F-37000, France; Service de Chirurgie Orthopédique, C.H.R.U. Tours, Université François-Rabelais de Tours, 37044 Tours Cedex 9, France
| | - Andrew Sands
- Foot and Ankle Surgery, Weill Cornell Medical College, Downtown Orthopedic Associates, AO Foot and Ankle Expert Group, 170 William Street, New York, NY 10038, USA
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Dingemans SA, Birnie MFN, Sanders FRK, van den Bekerom MPJ, Backes M, van Beeck E, Bloemers FW, van Dijkman B, Flikweert E, Haverkamp D, Holtslag HR, Hoogendoorn JM, Joosse P, Parkkinen M, Roukema G, Sosef N, Twigt BA, van Veen RN, van der Veen AH, Vermeulen J, Winkelhagen J, van der Zwaard BC, van Dieren S, Goslings JC, Schepers T. Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial). BMC Musculoskelet Disord 2018; 19:35. [PMID: 29386053 PMCID: PMC5793393 DOI: 10.1186/s12891-018-1946-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/16/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. DESIGN This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. DISCUSSION If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. TRIAL REGISTRATION This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.
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Affiliation(s)
- S. A. Dingemans
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - M. F. N. Birnie
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - F. R. K. Sanders
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | | | - M. Backes
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - E. van Beeck
- Department of Public Health, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - F. W. Bloemers
- Department of Surgery, Trauma Unit, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - B. van Dijkman
- Department of Surgery, Flevo Hospital, P.O. Box 3005, 1300 EG Almere, The Netherlands
| | - E. Flikweert
- Department of Surgery, Deventer Hospital, P.O. Box 5001, 7400 GC Deventer, The Netherlands
| | - D. Haverkamp
- Department of Surgery, Slotervaart Hospital, P.O. Box 90440, 1006BK Amsterdam, The Netherlands
| | - H. R. Holtslag
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - J. M. Hoogendoorn
- Department of Surgery, Haaglanden MC, P.O. Box 432, 2501 CK The Hague, The Netherlands
| | - P. Joosse
- Department of Surgery, Noordwest Hospital Group, P.O. Box 501, 1815 JD Alkmaar, The Netherlands
| | - M. Parkkinen
- Department of Orthopaedics and Traumatology, Helsinki University Hospital, Topeliuksenkatu 5, 00260 Helsinki, Finland
| | - G. Roukema
- Department of Surgery, Maasstad Hospital, P.O. Box 9100, 3007 AC Rotterdam, The Netherlands
| | - N. Sosef
- Department of Surgery, Spaarne Hospital, P.O. Box 770, 2130 AT Hoofddorp, The Netherlands
| | - B. A. Twigt
- Department of Surgery, BovenIJ Hospital, P.O. Box 37610, 1030 BD Amsterdam, The Netherlands
| | - R. N. van Veen
- Department of Surgery, OLVG, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands
| | - A. H. van der Veen
- Department of Surgery, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - J. Vermeulen
- Department of Surgery, Spaarne Hospital, P.O. Box 770, 2130 AT Hoofddorp, The Netherlands
| | - J. Winkelhagen
- Department of Surgery, Westfries Hospital, P.O. Box 600, 1620 AR Hoorn, The Netherlands
| | - B. C. van der Zwaard
- Department of Orthopaedics, Jeroen Bosch Hospital, P.O. Box 90153, 5200 ME ‘s-Hertogenbosch, The Netherlands
| | - S. van Dieren
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
| | - J. C. Goslings
- Department of Orthopedic Surgery, OLVG, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands
| | - T. Schepers
- Department of Surgery, Trauma Unit, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, 1100 DD Amsterdam, The Netherlands
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Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W. Randomized Trial Comparing Suture Button with Single Syndesmotic Screw for Syndesmosis Injury. J Bone Joint Surg Am 2018; 100:2-12. [PMID: 29298255 DOI: 10.2106/jbjs.16.01011] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared clinical and radiographic results between patients who underwent stabilization of an acutely injured syndesmosis with a suture button (SB) and those treated with 1 quadricortical syndesmotic screw (SS). METHODS Ninety-seven patients, 18 to 70 years old, with an ankle injury that included the syndesmosis were randomized to 2 groups: SB (48 patients) and SS (49). The main outcome measure was the score on the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The secondary outcome measures were the Olerud-Molander Ankle (OMA) score, visual analog scale (VAS), and EuroQol-5D (EQ-5D) Index and VAS. Computed tomography (CT) scans of both ankles were obtained at 2 weeks and 1 and 2 years after surgery. Both groups were allowed partial weight-bearing at 2 weeks and full weight-bearing at 6 weeks. The mean time for SS removal was 85.9 days (range, 39 to 132 days) after surgery. The patients were followed at 6 weeks, 6 months, and 1 and 2 years. Two years of follow-up were completed for 87 (90%) of the patients (46 in the SB group and 41 in the SS group). RESULTS The SS group had more injuries to the posterior malleolus than the SB group. At 2 years, the median AOFAS score was higher in the SB group than in the SS group (96 [interquartile range, or IQR, 90 to 100] versus 86 [IQR, 80 to 96]; p = 0.001), as was the median OMA score (100 [IQR, 95 to 100] versus 90 [IQR, 75 to 100]; p < 0.001). The SB group reported less pain during walking at 2 years than the SS group (median VAS score, 0 [IQR, 0 to 1] versus 1 [IQR, 0 to 2]; p = 0.008) and less pain during rest (median VAS score, 0 [IQR, 0 to 0] versus 0 [IQR, 0 to 1]; p = 0.04). There was no difference between treatments groups with regard to pain at night or during daily activities at 2 years. The SB group had a higher median EQ-5D Index score at 2 years (1.0 [IQR, 1 to 1] versus 0.88 [IQR, 0.8 to 1.0]; p = 0.005). Twenty of 40 patients in the SS group had a difference in the tibiofibular distance of ≥2 mm between the injured and uninjured ankles at 2 years, compared with 8 of 40 in the SB group (p = 0.009). Seven patients in the SS group had symptomatic recurrent syndesmotic diastasis during the treatment period compared with none in the SB group (p = 0.005). CONCLUSIONS The patients treated with an SB had higher AOFAS scores, OMA scores, and EQ-5D Index scores as well as lower (better) VAS scores for pain during walking and pain during rest. Also, the SB group had less widening seen radiographically at 2 years than did the patients in the SS group. No differences in the scores for pain at night or during daily activities were identified. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Mette Renate Andersen
- Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Health Trust (M.R.A. and W.F.), and the Institute of Clinical Medicine, University of Oslo (M.R.A.), Oslo, Norway
| | - Frede Frihagen
- Division of Orthopaedic Surgery (F.F. and J.E.M.) and Department of Radiology and Nuclear Medicine (J.C.H.), Oslo University Hospital, Oslo, Norway
| | - Johan Castberg Hellund
- Division of Orthopaedic Surgery (F.F. and J.E.M.) and Department of Radiology and Nuclear Medicine (J.C.H.), Oslo University Hospital, Oslo, Norway
| | - Jan Erik Madsen
- Division of Orthopaedic Surgery (F.F. and J.E.M.) and Department of Radiology and Nuclear Medicine (J.C.H.), Oslo University Hospital, Oslo, Norway
| | - Wender Figved
- Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Health Trust (M.R.A. and W.F.), and the Institute of Clinical Medicine, University of Oslo (M.R.A.), Oslo, Norway
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