Sagittal instability with inversion is important to evaluate after syndesmosis injury and repair: a cadaveric robotic study

Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis

INTRODUCTION

The present meta-analysis evaluated current level I clinical trials which compared the use of a suture button (SB) versus syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. The outcomes of interest were to compare patient-reported outcome measures (PROMs) and complications. It was hypothesised that SB might achieve better PROMs along with a lower rate of complications.

METHODS

This study was conducted according to the 2020 PRISMA statement. In August 2023, PubMed, Web of Science, Google Scholar, and Embase were accessed. All the randomised controlled trials (RCTs) which compared SB versus SS fixation for syndesmosis injuries of the ankle were accessed. Data concerning the American Orthopaedic Foot & Ankle Society (AOFAS), and Olerud-Molander score (OMS) were collected at baseline and at last follow-up. Data on implant failure, implant removal, and joint malreduction were also retrieved.

RESULTS

Data from seven RCTs (490 patients) were collected. 33% (161 of 490) were women. The mean length of the follow-up was 30.8 ± 27.4 months. The mean age of the patients was 41.1 ± 4.1 years. Between the two groups (SB and SS), comparability was found in the mean age, and men:women ratio. The SS group evidenced lower OMS (P = 0.0006) and lower AOFAS (P = 0.03). The SS group evidenced a greater rate of implant failure (P = 0.0003), implant removal (P = 0.0005), and malreduction (P = 0.04).

CONCLUSION

Suture button fixation might perform better than the syndesmotic screw fixation in syndesmotic injuries of the ankle.

A Dynamic Elbow Testing Apparatus for Simulating Elbow Joint Motion in Varying Shoulder Positions

Purpose

To develop and evaluate the capabilities of a dynamic elbow testing apparatus that simulates unconstrained elbow motion throughout the range of humerothoracic (HTA) abduction.

Methods

Elbow flexion was generated by six computer-controlled electromechanical actuators that simulated muscle action, while six degree-of-freedom joint motion was measured using an optical tracking device. Repeatability of joint kinematics was assessed at four HTA angles (0°, 45°, 90°, 135°) and with two muscle force combinations (A1-biceps brachialis, brachioradialis and A2-biceps, brachioradialis). Repeatability was determined by comparing kinematics at every 10° of flexion over five flexion-extension cycles (0° to 100°).

Results

Multiple muscle force combinations can be used at each HTA angle to generate elbow flexion. Trials showed that the testing apparatus produced highly repeatable joint motion at each HTA angle and with varying muscle force combinations. The intraclass correlation coefficient was greater than 0.95 for all conditions.

Conclusions

Repeatable smooth cadaveric elbow motion was created that mimicked the in vivo situation.

Clinical relevance

These results suggest that the dynamic elbow testing apparatus can be used to characterize elbow biomechanics in cadaver upper extremities.

Multidirectional Chronic Ankle Instability: What Is It?

Not all ankle sprains are the same and not all ankles behave the same way after an injury. Although we do not know the mechanisms behind an injury producing an unstable joint, we do know ankle sprains are highly underestimated. While some of the presumed lateral ligament lesions might eventually heal and produce minor symptoms, a substantial number of patients will not have the same outcome. The presence of associated injuries, such as additional medial chronic ankle instability, chronic syndesmotic instability, has been long discussed as a possible reason behind this. To explain multidirectional chronic ankle instability, this article aims to present the literature surrounding the condition and its importance nowadays.

Current status of the management of isolated syndesmotic injuries in Germany

INTRODUCTION

Although non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany.

MATERIALS AND METHODS

An online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS.

RESULTS

Each question of the questionnaire was on average answered by 431 ± 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior-posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices.

CONCLUSIONS

While arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany.

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.

Biomechanics of the Distal Tibiofibular Syndesmosis: A Systematic Review of Cadaveric Studies

Background:

This investigation’s purpose was to perform a systematic review of the literature examining the biomechanics of the ligaments comprising the distal tibiofibular syndesmosis with specific attention to their resistance to translational and rotational forces. Although current syndesmosis repair techniques can achieve an anatomic reduction, they may not reapproximate native ankle biomechanics, resulting in loss of reduction, joint overconstraint, or lack of external rotation resistance. Armed with a contemporary understanding of individual ligament biomechanics, future operative strategies can target key stabilizing structure(s), translating to a repair better equipped to resist anatomic displacing forces.

Study design:

Systematic review.

Methods:

A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Biomechanical studies testing cadaveric lower limb specimens in the intact and injured state measuring the distal tibiofibular syndesmosis resistance to translational and rotational forces were included in this review. Only studies that included numerical data were included in this review; studies that only reported figures and graphs were excluded.

Results:

Twelve studies met the inclusion and exclusion criteria. Two studies determined the mechanical properties of syndesmotic ligaments, finding superior strength and stiffness of the interosseous ligament (IOL), as compared to the anterior (AITFL) or posteroinferior tibiofibular ligament (PITFL). Four studies examined native ankle biomechanics establishing physiologic range of motion of the fibula relative to the tibia. Fibular range of motion was found to be up to 2.53 mm of posterior translation (Markolf et al), 1.00 mm lateral translation (Xenos et al), 3.6 degrees of external rotation (Burssens et al), and 1.4 degrees of internal rotation (Clanton et al). Four studies evaluated syndesmotic biomechanics under physiological loading and found that the AITFL, IOL, and PITFL provide the majority of resistance to external rotation, diastasis, and internal rotation, respectively. Two studies investigated the biomechanics of clinically and intraoperatively used tests for syndesmotic injuries and found increased sensitivity of sagittal plane posterior fibular translation, as opposed to coronal plane lateral fibular translation for unstable injuries.

Conclusions:

Study findings suggest that although the IOL is the strongest syndesmotic ligament, the AITFL has a dominant role stabilizing the distal tibiofibular syndesmosis to external rotation force. Because of these characteristics, operative repair of the AITFL along its native vector may provide a more biomechanically advantageous construct and should be investigated clinically. Additionally, evaluation of clinical stress tests revealed that the external rotation stress test is the most sensitive test to recognize an AITFL tear, and that a 3-ligament disruption is needed to cause diastasis greater than 2 mm.

Delayed ankle muscle reaction time in female amateur footballers after the first 15 min of a simulated prolonged football protocol

PURPOSE

Ankle sprain injury rate is reported to be higher towards the end of a football match. Muscle fatigue may contribute to the delayed muscle reaction and subsequent injury. This study investigated the ankle muscle reaction time during a simulated, prolonged football protocol.

METHODS

Seven amateur female football players participated in a 105-min simulated, prolonged football protocol. An ankle muscle reaction test was conducted with a pair of ankle sprain simulators at a scheduled interval every 15-min. The reaction times of peroneus longus, tibialis anterior, and lateral gastrocnemius were collected using an electromyography system sampling at 1000 Hz. Repeated measures one-way multivariate analysis of variance with post-hoc paired t-tests were conducted to evaluate if the reaction time at each time point significantly differed from baseline. Statistical significance was set at p < 0.05 level.

RESULTS

Reaction times started from 40.5-47.7 ms at baseline and increased to 48.6-55.7 ms at the end. Reaction times significantly increased in all muscles after the first 15 min except for the dominant lateral gastrocnemius. Increased reaction times were seen in the non-dominant limb after 60 min for tibialis anterior, after 75 min for peroneus longus, and after 90 min for the lateral gastrocnemius.

CONCLUSIONS

Delayed reaction time of the ankle muscles were found after the first 15 min and in the final 45 min of a simulated prolonged football protocol. Strategies for injury prevention should also focus on tackling the delayed ankle muscle reaction time in the acute phase (the first 15 min), in addition to the latter minutes in the second half.

LEVEL OF EVIDENCE

Controlled laboratory study, Level V.