Factors associated with adverse events after distal tibiofibular syndesmosis fixation

Peroneal artery injury potential due to different syndesmosis screw placement options: a simulation study with lower extremity computed tomography angiography

INTRODUCTION

The aim of this study is to assess the risk of peroneal artery injury of hardware placement at the fixation of syndesmotic injuries.

MATERIALS AND METHODS

The lower extremity computed tomography angiography was used to design the study. The syndesmosis screw placement range was simulated every 0.5 cm, from 0.5 to 5 cm proximal to the ankle joint. The screw axes were drawn as 20°, 30° or individual angle according to the femoral epicondylar axis. The proximity between the screw axis and the peroneal artery was measured in millimeters. Potential peroneal artery injury was noted if the distance between the peroneal artery to the axis of the simulated screw was within the outer shaft radius of the simulated screw. The Pearson chi-square test was used and a p-value < 0.05 was considered significant.

RESULTS

The potential for injury to the peroneal artery increased as the syndesmosis screw level rose proximally from the ankle joint level or as the diameter of the syndesmosis screw increasds. In terms of syndesmosis screw trajection, the lowest risk of injury was observed with the syndesmosis screw angle of 20°. Simulations with a screw diameter of 3.5 mm exhibited the least potential for peroneal artery injury.

CONCLUSION

Thanks to this radiological anatomy simulation study, we believe that we have increased the awareness of the peroneal artery potential in syndesmosis screw application. Each syndesmosis screw placement option may have different potential for injury to the peroneal artery. To decrease the peroneal artery injury potential, we recommend the followings. If individual syndesmosis screw angle trajection can be measured, place the screw 1.5 cm proximal to the ankle joint using a 3.5 mm screw shaft. If not, fix it with 30° trajection regardless of the screw diameter at the same level. If the most important issue is the peroneal artery circulation, use the screw level up to 1 cm proximal to the ankle joint regardless of the screw angle trajection and screw diameter.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of Interosseous Suture and Endobutton Across Age Groups

Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.

Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation

BACKGROUND

The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis.

METHODS

Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software.

RESULTS

On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond.

CONCLUSION

Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most.

CLINICAL RELEVANCE

This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.

Comparison of Suture-Button Versus Syndesmotic Screw in the Treatment of Distal Tibiofibular Syndesmosis Injury: A Meta-analysis

Traditionally screw fixation is an effective surgical procedure for the treatment of unstable syndesmosis injuries. However, it is still a controversy whether suture-button (SB) device can achieve better clinical outcomes and decrease the risk of complications compared with syndesmotic screw (SS). The present meta-analysis was conducted to figure out whether SB fixation was superior to traditionally screw fixation. Twelve clinical studies were identified, involving 320 patients in the SB group and 334 patients in the SS group. Among patients treated with SB, the American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher at 3-month follow-up (p = .01) and 2-year follow-up (p = .02), and the Olerud-Molander Ankle (OMA) score at 1-year follow-up (p = .002). In addition, the SB group had significantly better results in the malreduction (p = .0008), implant failure (p < .01), implant removal (p < .01), and local irritation (p = .004). No statistical differences were found in the AOFAS at 6 months follow-up (p = .33) and 1-year follow-up (p = .33), OMA at 3 months follow-up (p = .09), 6 months follow-up (p = .14) and 2 years follow-up (p = .36), the Foot and Ankle Disability Index (p = .73), Euro Qol 5-dimension questionnaire (p = .33), dorsiflexion (DF; p = .91), plantarflexion (p = .23), medial clear space (p = .42), tibiofibular clear space (p = .60), tibiofibular overlap (p = .84), and other complications (p = .95). Based on this meta-analysis, there was no significant difference in postoperative radiological measurements, and no sufficient evidence was found to support the improved clinical outcomes compared with SS fixation group. However, SB technique could improve functional outcomes, reduce the rate of implant removal, implant failure, local irritation, and malreduction without increasing risk of other complications. Therefore, the SB technique should be recommended in the treatment of syndesmosis injuries.

Getting the Starting Point Right: Prevention of Skiving and Fibular Cortical Breach During Suture Button Placement for Syndesmotic Ankle Injuries

The use of suture button (SB) devices in the treatment of syndesmotic ankle injuries is increasing. These constructs have demonstrated better syndesmotic reduction, improved clinical outcomes, and lower rates of hardware removal compared with screw fixation. However, placing a SB device without a fibular plate can be technically challenging. In this technique tip, we use an illustrative case to demonstrate a technique tip that minimizes the risk of anterior or posterior cortical breach of the fibula and helps facilitate more accurate placement of a SB device.Levels of Evidence: Level V: Expert opinion.