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Pavone V, Papotto G, Vescio A, Longo G, D’Amato S, Ganci M, Marchese E, Testa G. Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study. J Clin Med 2023; 12:3637. [DOI: https:/doi.org/10.3390/jcm12113637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024] Open
Abstract
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.
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95123 Catania, Italy
| | - Giacomo Papotto
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Andrea Vescio
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95123 Catania, Italy
| | - Gianfranco Longo
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Salvatore D’Amato
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95123 Catania, Italy
| | - Marco Ganci
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Emanuele Marchese
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95123 Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico—San Marco, University of Catania, 95123 Catania, Italy
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2
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Pavone V, Papotto G, Vescio A, Longo G, D'Amato S, Ganci M, Marchese E, Testa G. Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study. J Clin Med 2023; 12:jcm12113637. [PMID: 37297832 DOI: 10.3390/jcm12113637] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Vito Pavone
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
| | - Giacomo Papotto
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Andrea Vescio
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
| | - Gianfranco Longo
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Salvatore D'Amato
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
| | - Marco Ganci
- Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
| | - Emanuele Marchese
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical-Surgical Specialties, Section of Orthopaedics and Traumatology, A.O.U. Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
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McCormack DJ, Solan M, Aziz S, Faroug R, Kirmani S, Wright G, Mangwani J. Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study. World J Orthop 2022; 13:969-977. [PMID: 36439368 PMCID: PMC9685633 DOI: 10.5312/wjo.v13.i11.969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/01/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability.
AIM To investigate the anatomical basis for fracture instability in SER type ankle fractures.
METHODS Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt.
RESULTS All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt.
CONCLUSION If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.
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Affiliation(s)
- Daniel James McCormack
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Matthew Solan
- Department of Trauma and Orthopaedic Surgery, Royal Surrey City Hospital NHS Trust, University of Surrey, Guilford GU2 7XX, United Kingdom
| | - Sheweidin Aziz
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Radwane Faroug
- Department of Trauma and Orthopaedics, Stoke Mandeville Hospital, Aylesbury HP21 8AL, Buckinghampshire, United Kingdom
| | - Sayyied Kirmani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Georgina Wright
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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Meng S, Tong W, Han S. Application of X-ray image measurement in the early diagnosis of sports injury of ankle ligament. Pak J Med Sci 2021; 37:1580-1584. [PMID: 34712286 PMCID: PMC8520354 DOI: 10.12669/pjms.37.6-wit.4841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/08/2021] [Accepted: 07/07/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives: To study the value of X-ray analysis method of ankle fracture based on injury mechanism to improve the imaging diagnosis level of ankle fracture. Methods: This study was conducted from January 2016 to December 2019. It included 105 cases of fractures caused by sprained ankle joints. Their age was between 21-81 years with an average of 49.5 years, The traditional X-ray analysis method (Group-A) and the injury mechanism-based ankle fracture X-ray analysis method (Group-B) were used to analyze X-ray image data. Group-B also performed Weber classification and Lauge-Hansen classification on cases. Installment. Results: Of the 105 patients with ankle fractures, 97 patients in Group-B were able to make Lauge-Hansen classification. Of these 97 ankle fractures, 137 were found in Group-A, and 158 were found in Group-B. The wrong diagnosis of fracture in Group-A was 18%, and the wrong diagnosis of fracture in Group-B was 0.5%. There was a statistically significant difference between the two groups (P <0.05). Conclusion: The X-ray analysis method of ankle fractures based on injury mechanism can effectively improve the detection rate of hidden ankle fractures and high fibular fractures, and reduce the missed diagnosis, which is superior to the traditional X-ray analysis methods. At the same time, Weber classification, Lauge-Hansen classification and staging can be made for most cases, which is conducive to guiding clinical treatment.
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Affiliation(s)
- Shuqiao Meng
- Shuqiao Meng, PhD. Physical Education College of Yangzhou University, Yangzhou, 225000, Jiangsu, China
| | - Wenxia Tong
- Wenxia Tong, PhD. Physical Education College of Yangzhou University, Yangzhou, 225000, Jiangsu, China
| | - Shanshan Han
- Shanshan Han, PhD. Shangqiu University, School of Sport and Physical Education, Shangqiu, 476000, Henan, China
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Julian TH, Broadbent RH, Ward AE. Surgical vs non-surgical management of Weber B fractures: A systematic review. Foot Ankle Surg 2020; 26:494-502. [PMID: 31266676 DOI: 10.1016/j.fas.2019.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/06/2019] [Accepted: 06/07/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND The aim of this systematic review was to compare surgical and non-surgical management of Weber B ankle fractures. METHODS A systematic computer-based search was conducted using the MEDLINE (via OvidSP), EMBASE (via OvidSP) and Central databases. Data were extracted regarding functional outcome, radiological union, range of motion (RoM), infection rate and quality of life (QoL). RESULTS There were no significant differences identified between surgical and non-surgical management of Weber B fractures with respect to functional outcome. There is a higher rate of complication following surgical management, including infection, reoperation, thromboembolic events and death. With respect to QoL and ankle RoM, this review identified no differences between surgical and non-surgical management. CONCLUSIONS There is a need for further published literature evaluating the most efficacious management as there is a poverty of high-level research available. Currently, the available literature does not overwhelmingly favour a particular approach to Weber B ankle fractures.
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Affiliation(s)
- Thomas Henry Julian
- The University of Sheffield, Western Bank, Sheffield S10 2TN, United Kingdom.
| | | | - Alex Elizabeth Ward
- The University of Sheffield, Western Bank, Sheffield S10 2TN, United Kingdom.
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Giordano V, Boni G, Godoy-Santos AL, Pires RE, Fukuyama JM, Koch HA, Giannoudis PV. Nailing the fibula: alternative or standard treatment for lateral malleolar fracture fixation? A broken paradigm. Eur J Trauma Emerg Surg 2020; 47:1911-1920. [PMID: 32144445 DOI: 10.1007/s00068-020-01337-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/25/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. PATIENTS AND METHODS Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. RESULTS The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). CONCLUSION In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification.
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Affiliation(s)
- Vincenzo Giordano
- Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro, Hospital Municipal Miguel Couto, Rua Mário Ribeiro 117/2º andar, Leblon, Rio de Janeiro, RJ, 22430-160, Brazil. .,Clínica São Vicente, Rede D'or São Luiz, Rio de Janeiro, RJ, Brazil.
| | - Guilherme Boni
- Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina (EPM), Sao Paulo, SP, Brazil
| | - Alexandre Leme Godoy-Santos
- Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo (USP), Sao Paulo, SP, Brazil.,Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Robinson Esteves Pires
- Departamento de Ortopedia, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Junji Miller Fukuyama
- Serviço de Ortopedia e Traumatologia, Hospital Geral Vila Penteado, Sao Paulo, SP, Brazil
| | - Hilton A Koch
- Departamento de Radiologia, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK
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Velasco BT, Miller CP, Ye MY, Kwon JY. Does fracture obliquity in Weber B fibula fractures correlate with mortise instability? Injury 2019; 50:2113-2115. [PMID: 31371168 DOI: 10.1016/j.injury.2019.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/20/2019] [Accepted: 07/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The diagnosis of instability in the apparent, isolated distal fibula fracture can be challenging and often necessitates stress radiography. Danis & Weber classified lateral malleolar fractures based on the level of the fracture in relation to the syndesmosis. While Weber B fractures occur at the level of the syndesmosis, some such injuries present with a long, oblique pattern extending well above the syndesmosis. Given the well-established literature demonstrating that fractures above the syndesmosis correlate with a higher level of concomitant syndesmotic and deltoid ligament injury, we hypothesize that increased fracture obliquity, length and height of Weber B fibula fractures similarly correlates with increased mortise instability. METHODS All patients with isolated Weber B fibula fractures who underwent gravity stress radiography met inclusion criteria. Fracture height was measured on mortise radiographs as: (1) the distance from the distal tip of the fibula to fracture apex, (2) the distance to the fracture apex as measured on a line drawn perpendicular to a line parallel to the plafond, (3) an angle subtended by a line drawn parallel to the plafond and a line drawn to the fracture apex and (4) a ratio of the absolute length as compared to fibular width. RESULTS 51 patients were included in the study. The group of 39 patients with stable ankles had a mean medial clear space of 3.12 ± 0.65 mm (range, 1.5 mm to 4.0 mm). The group of 12 patients with unstable ankles had a mean medial clear space of 6.29 ± 3.11 mm (range, 4.1 mm to 14.0 mm). These groups showed no significant difference in fracture angle (p = 0.93), fracture height from plafond (p = 0.49), fracture height from tip of fibula (p = 0.42), and as a ratio of absolute length to fibular width (p = 0.85). CONCLUSION Increased fracture obliquity, length and height of Weber B fibula fractures did not correlate with a higher incidence of mortise instability. Despite the lack of positive correlation, future studies should continue to investigate and identify radiographic parameters of distal fibula fractures that are most predictive of instability.
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Affiliation(s)
- Brian T Velasco
- Beth Israel Deaconess Medical Center, Boston, MA, United States; Geisinger Commonwealth School of Medicine, Scranton, MA, United States.
| | | | - Michael Y Ye
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - John Y Kwon
- Beth Israel Deaconess Medical Center, Boston, MA, United States.
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Ankle Fracture Stability-Based Classification: A Study of Reproducibility and Clinical Prognostic Ability. J Orthop Trauma 2019; 33:465-471. [PMID: 31188253 DOI: 10.1097/bot.0000000000001507] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the reproducibility and prognostic capacity of 2 commonly used ankle fracture classifications to the stability-based classification. METHODS One hundred ninety-three consecutive rotational-type ankle fractures treated during a year at our institution in patients older than 18 years were retrospectively analyzed. Pilon and pathologic fractures were excluded. The fractures were treated by attending physicians who were unaware of the stability-based classification system. Three observers classified injury radiographs using the Lauge-Hansen, Weber/AO, and stability-based classifications systems. Reproducibility (interobserver variation) of each classification system was calculated using kappa statistics. Prognostic values were evaluated by calculating the area under the curve for the receiver-operating characteristic curves (using surgery as the positive outcome). RESULTS The stability-based and Weber/AO classifications showed better reproducibility [kappa 0.938 (95% confidence interval 0.921-0.952), kappa 0.97 (0.961-0.976)], respectively, than the Lauge-Hansen [kappa 0.74 (0.664-0.795); P < 0.05]. The stability-based classification was more accurate (P < 0.001) in predicting surgical treatment [area under the curve 0.883 (95% confidence interval 0.852-0.914)] compared with the other 2 classifications [0.626 (0.576-0.675) and 0.698 (0.641-0.755)], respectively. CONCLUSIONS The stability-based classification was both highly reproducible (kappa 0.938) and had superior prognostic capacity to identify patients who needed surgical intervention compared with both the Lauge-Hansen and AO/Weber classification systems. Importantly, there were no patients who were classified as stable who failed nonoperative treatment. This extends earlier studies by directly demonstrating its prognostic advantage to other classification systems.
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Chun DI, Kim J, Kim YS, Cho JH, Won SH, Park SY, Yi Y. Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures. Injury 2019; 50:1382-1387. [PMID: 31174871 DOI: 10.1016/j.injury.2019.05.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/24/2019] [Accepted: 05/21/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). METHODS All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided. RESULTS A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively. CONCLUSIONS CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.
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Affiliation(s)
- Dong-Il Chun
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Jahyung Kim
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Yoon Seok Kim
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
| | - Jae-Ho Cho
- Department of Orthopedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, College of Medicine, 77, SakJu-Ro, Gyo-dong, Chun-Cheon, 24262, Republic of Korea.
| | - Sung-Hun Won
- Department of Orthopedic Surgery, Soonchunhyang University Seoul Hospital, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Su-Yeon Park
- Department of biostatistics, Soonchunhyang University Hospital, College of medicine, 657-52 Hannam-dong Yong-San Gu, Seoul, Republic of Korea.
| | - Young Yi
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University, 85, 2-ga, Jeo-dong, Jung-gu, Seoul, 100-032, Republic of Korea.
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10
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Briet JP, Hietbrink F, Smeeing DP, Dijkgraaf MGW, Verleisdonk EJ, Houwert RM. Ankle Fracture Classification: An Innovative System for Describing Ankle Fractures. J Foot Ankle Surg 2019; 58:492-496. [PMID: 30795890 DOI: 10.1053/j.jfas.2018.09.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 02/03/2023]
Abstract
A good classification system is important for clinical handoffs, research, and clinical treatment guidelines. A reliable classification system shows good interobserver and intraobserver agreement. This study analyzed the interobserver and intraobserver agreement of a descriptive system for ankle fractures and the Lauge-Hansen classification. Three groups of observers (experts, semiexperts, and novices) scored a total of 20 ankle radiographs. All ankle radiographs were classified according to the Lauge-Hansen and Danis-Weber classifications. The ankle fractures were subsequently reviewed in a descriptive manner for the following features: number of affected malleoli, type of fracture of the lateral and medial malleolus, and congruence of the ankle joint. After 2 weeks, the same set of radiographs were reviewed. For interobserver and intraobserver variability, the separate groups were used for analysis, and the Fleiss (multirater) κ values were calculated. The interobserver agreement for the Lauge-Hansen classification was moderate for the experts, fair for semiexperts, and slight for novices (κ = 0.45, κ = 0.37, and κ = 0.16). All factors of the descriptive system had better interobserver agreement than the Lauge-Hansen classification, except for the agreement on the type of fracture of the lateral malleolus. The intraobserver agreement of the Lauge-Hansen classification was substantial for the experts, moderate for the semiexperts, and fair for the novice observers (κ = 0.70, κ = 0.49, and κ = 0.26). The intraobserver agreement was better for all factors of the descriptive system compared with the Lauge-Hansen classification. The descriptive system presented in this study shows less variability between observers than the Lauge-Hansen classification. This system has clinical implications and is easy to use for clinicians with mixed levels of experience. It has the potential to improve clinical and research handoffs and overcome the limitations of current classification systems.
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Affiliation(s)
- Jan Paul Briet
- Surgical Resident, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, the Netherlands.
| | - Falco Hietbrink
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Marcel G W Dijkgraaf
- Statistician, Clinical Research Unit, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Egbert Jan Verleisdonk
- Trauma Surgeon, Department of Surgery, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - R Marijn Houwert
- Trauma Surgeon, Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands; Trauma Surgeon, Utrecht Traumacenter, Utrecht, the Netherlands
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Abstract
Isolated lateral malleolus fractures represent one of the most common injuries encountered by orthopaedic surgeons. Nevertheless, appropriate diagnosis and management of these injuries are not clearly understood. Ankle stability is maintained by ligamentous and bony anatomy. The deep deltoid ligament is considered the primary stabilizer of the ankle. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Clinical examination findings are important but less reliable. Advanced imaging may not be accurate for guiding management. If the ankle is stable, nonsurgical management produces excellent outcomes. In the case that clinical/radiographic findings are indicative of ankle instability, surgical fixation options include lateral or posterolateral plating or intramedullary fixation. Locking plates and small or minifragment fixation are important adjuncts for the surgeon to consider based on individual patient needs.
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Xie L, Xie H, Wang J, Chen C, Zhang C, Chen H, Zheng W. Comparison of suture button fixation and syndesmotic screw fixation in the treatment of distal tibiofibular syndesmosis injury: A systematic review and meta-analysis. Int J Surg 2018; 60:120-131. [PMID: 30439535 DOI: 10.1016/j.ijsu.2018.11.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 10/24/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE This systematic review and meta-analysis was performed to investigate the outcomes of syndesmotic screw fixation versus suture button fixation in the treatment of distal tibiofibular syndesmosis injury from the current literature. METHODS The electronic literature database of PubMed, Embase, and Cochrane library were searched in August 2018. The data on medial clear space, tibiofibular clear space, tibiofibular overlap, American Orthopaedic Foot and Ankle Society (AOFAS) scores and complications (including wound infection, local irritation or discomfort, screw loosening and screw breakage) were extracted. Stata 14.0 software was used for our meta-analysis. RESULTS A total of 11 studies including 5 randomized controlled trials (RCTs) and 6 cohort studies met our inclusion criteria. This meta-analysis showed that there was no significant difference between the two groups regarding medial clear space (P = 0.54), tibiofibular clear space (P = 0.23) and tibiofibular overlap (P = 0.88) postoperatively. However, the present meta-analysis demonstrated that the suture button fixation group had significantly higher AOFAS scores than the syndesmotic screw fixation group at 3rd, 6th, 12th and 24th months postoperatively (P = 0.001, P = 0.006, P = 0.000 and P = 0.049 respectively). Besides, the time to full weight bearing in the suture button fixation group was significantly earlier than that in the syndesmotic screw fixation group (P = 0.000). As for the complications, the suture button fixation group had a lower rate of post-operative complication (screw loosening and screw breakage) compared with the syndesmotic screw fixation group (P = 0.048 and P = 0.000 respectively). CONCLUSION Our meta-analysis suggested that suture button fixation could achieve significant higher AOFAS scores with a lower rate of postoperative complications and earlier time to full weight bearing in distal tibiofibular syndesmosis injury. More RCTs are required for further research.
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Affiliation(s)
- Linzhen Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Huanguang Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chunhui Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chuanxu Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Hua Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Wenhao Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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Abdelgaid SM, Moursy AF, Elgebaly EAA, Aboelenien AM. Minimally Invasive Treatment of Ankle Fractures in Patients at High Risk of Soft Tissue Wound Healing Complications. J Foot Ankle Surg 2018; 57:557-571. [PMID: 29685567 DOI: 10.1053/j.jfas.2017.11.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Indexed: 02/03/2023]
Abstract
The complex nature of ankle fractures is magnified when seen in patients at high risk of soft tissue wound healing complications. The major categories include associated soft tissue injury, diabetes, tobacco use, peripheral vascular disease, malnutrition, alcoholism, and corticosteroid use. Because of the potential for wound dehiscence and infection with open reduction and internal fixation of ankle fractures in these patients, minimally invasive procedures have been described. The aims of the present study were to assess the possibility for, and evaluate the results and complications of, minimally invasive techniques for different types of malleolar fractures in high-risk patients. We report the clinical results of 47 high-risk patients who presented with malleolar fractures from January 2007 to December 2012 and underwent minimally invasive reduction and fixation. One patient (0.5%) developed a superficial infection; however, none of the patients displayed wound dehiscence or deep infection. Five patients (10.6%) required open reduction because of intraoperative failure to achieve anatomic reduction. Using the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, 15 of the patients (36%) treated with minimally invasive techniques experienced an excellent outcome. In contrast, 23 patients (55%) had a good, 3 (7%) a fair, and 1 (2.5%) a poor outcome. The results of our study have shown that minimally invasive fixation appears to be a satisfactory method for the management of malleolar fractures in high-risk patients and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation.
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Abstract
OBJECTIVES The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several clinical questions that arise in the treatment of such injuries. DATA SOURCES The English language literature was searched using PubMed, EMBASE, and Web of Science. The search terms were "syndesmosis" or "syndesmotic" in combination with the terms "ankle fracture" or "fracture." The included dates were between 1967 and July 2015. STUDY SELECTION Inclusion criteria were number of patients >20, patient age ≥18 years, follow-up ≥1 year, ankle fracture classification was reported, criteria for surgery was reported, technique of surgery was reported, and a validated outcome measure was used. Studies limited to biomechanical or imaging investigations were excluded. DATA EXTRACTION Information was abstracted using a standardized template, which encompassed the inclusion criteria together with the study type, postoperative regimen, and complications. Study quality was evaluated using the modified CONSORT statement and Coleman criteria. Study bias was assessed, and methodological quality was rated. Any difference in ratings was resolved by consensus. DATA SYNTHESIS None. CONCLUSIONS The overall quality of the studies was poor. The number or placement of syndesmotic screws or the breakage of trans-syndesmotic screws postoperatively had no adverse effect on outcomes (both with moderate strength of evidence). The use of alternative fixation devices (bioabsorbable and endobutton) had poor strength of evidence, as did the opinion that nondisplaced, unstable by stress test, syndesmotic injuries required fixation. There are insufficient data that link subtle rotational syndesmotic malreduction to clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.
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Affiliation(s)
- Matthew C Solan
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK; Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK.
| | - Mark S Davies
- London Foot and Ankle Centre, Hospital of St John and St Elizabeth, 60 Grove End Road, London NW8 9NH, UK
| | - Anthony Sakellariou
- Surrey Foot and Ankle Clinic, Mount Alvernia Hospital, Harvey Road, Guildford, Surrey, GU1 3LX, UK
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Kocadal O, Yucel M, Pepe M, Aksahin E, Aktekin CN. Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries. Foot Ankle Int 2016; 37:1317-1325. [PMID: 27535086 DOI: 10.1177/1071100716661221] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans. METHODS Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2. RESULTS There was a statistically significant decrease in the degree of fibular rotation (P = .03) and an increase in the upper syndesmotic area (P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area (P = .02) and distal tibiofibular volumes (P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups. CONCLUSION Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Onur Kocadal
- Ankara Education and Research Hospital, Orthopedics and Traumatology Department, Ankara, Turkey
| | - Mehmet Yucel
- Department of Orthopedics and Traumatology, Dr. Nafiz Korez Sincan State Hospital, Ankara, Turkey
| | - Murad Pepe
- Ankara Education and Research Hospital, Orthopedics and Traumatology Department, Ankara, Turkey
| | - Ertugrul Aksahin
- Department of Orthopedics and Traumatology, Medical Park Hospital, Ankara, Turkey
| | - Cem Nuri Aktekin
- Ankara Education and Research Hospital, Orthopedics and Traumatology Department, Ankara, Turkey
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Sculco PK, Lazaro LE, Little MM, Berkes MB, Warner SJ, Helfet DL, Lorich DG. Dislocation is a risk factor for poor outcome after supination external rotation type ankle fractures. Arch Orthop Trauma Surg 2016; 136:9-15. [PMID: 26506829 DOI: 10.1007/s00402-015-2353-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Ankle fractures are one of the most common fractures requiring surgical treatment. Ankle fracture-dislocations are significant injuries to the osseous and soft tissue envelope, but studies focused on the effect of dislocation on radiographic and functional outcomes are lacking. The objective of this study was to evaluate the effect of dislocations on postoperative outcomes in SER IV ankle fracture patients. MATERIALS AND METHODS From 2004 through 2010, all operative SER IV ankle fractures treated by a single surgeon were enrolled in a prospective database. SER IV ankle fractures were separated into two groups based on clinical or radiographic evidence of dislocation. The primary and secondary functional outcomes measures were the Foot and Ankle Outcome Score (FAOS) and ankle and subtalar range of motion (ROM) with a minimum of 1-year follow-up, respectively. RESULTS 108 patients with SER IV ankle fractures were identified, with 73 in the non-dislocation group (68%) and 35 patients in the dislocation group (32%). Patient demographics and co-morbidities were similar between the two groups. The incidence of open fractures and the application of an external fixator were significantly higher in the dislocation group (p = 0.037 and p = 0.003, respectively). The dislocation group showed a significant decrease in the accuracy of articular reduction (p = 0.003). At a mean follow-up of 21 months, ankle fracture-dislocation patients had increased pain (p = 0.005) and decreased activities of daily living (p = 0.014) on FAOS outcome measures and significantly worse ankle and subtalar ROM. CONCLUSIONS The results of this study suggest that concurrent dislocation at time of ankle fracture is associated with worse radiographic and functional outcomes, but not an increase in superficial or deep infection. The results from this study may be helpful in counseling patients regarding expected clinical outcomes after ankle fracture-dislocation and in the surgical management of this complex injury.
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Affiliation(s)
- Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Lionel E Lazaro
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Milton M Little
- Orthopaedic Trauma Service, Cedar Sinai Medical Center, Los Angeles, CA, USA
| | | | - Stephen J Warner
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - David L Helfet
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Dean G Lorich
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Kaftandziev I, Spasov M, Trpeski S, Zafirova-Ivanovska B, Bakota B. Fate of the syndesmotic screw--Search for a prudent solution. Injury 2015; 46 Suppl 6:S125-9. [PMID: 26582218 DOI: 10.1016/j.injury.2015.10.062] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ankle fractures are common injuries. Since the recognition of the importance of syndesmotic injury in ankle fractures, much of the scientific work has been focused on concomitant syndesmotic injury. Despite the invention of novel devices for restoration and maintenance of the congruent syndesmosis following syndesmotic injury, the metallic syndesmotic screw is still considered to be the "gold standard". The aim of this study was to compare the clinical results in patients who retained the syndesmosis screw with those in whom the screw was removed following open reduction and internal fixation of the malleolar fracture associated with syndesmosis disruption. MATERIALS AND METHODS This was a retrospective study of 82 patients. Minimum follow-up was 12 months. Clinical evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analogue Scale (VAS) for patient general satisfaction. The condition of the screw (removed, intact or broken), presence of radiolucency around the syndesmotic screw and the tibiofibular clear space were recorded using final follow-up radiographs. RESULTS Three cortices were engaged in 66 patients (80%) and quadricortical fixation was performed in the remaining 16 patients (20%). The number of engaged cortices did not correlate with the clinical outcome and screw fracture. A single syndesmotic screw was used in 71 patients (86%. The mean AOFAS score in the group with intact screw (I) was 83; the scores in the group with broken screw (B) and removed screw (R) were 92.5 and 85.5, respectively. There was a statistically significant difference between the three groups: this was due to the difference between groups I and B; the difference between groups I and R and groups B and R were not statistically significant. There were no statistically significant differences in VAS results. CONCLUSION There were no statistically significant differences in clinical outcome between the group with the screw retained and the group in which the screw was removed; however, the group with broken screws had the best clinical outcome based on AOFAS score. Widening of the syndesmosis after screw removal was not evident. We do not recommend routine syndesmosis screw removal.
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Affiliation(s)
- Igor Kaftandziev
- University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia.
| | - Marko Spasov
- University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia
| | - Simon Trpeski
- University Clinic of Traumatology, Medical Faculty of Skopje, Skopje, Macedonia
| | | | - Bore Bakota
- Orthopaedics and Traumatology Department, Our Lady of Lourdes Hospital, Drogheda, Louth, Ireland
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van Vlijmen N, Denk K, van Kampen A, Jaarsma RL. Long-term Results After Ankle Syndesmosis Injuries. Orthopedics 2015; 38:e1001-6. [PMID: 26558664 DOI: 10.3928/01477447-20151020-09] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 02/23/2015] [Indexed: 02/03/2023]
Abstract
Syndesmotic disruption occurs in more than 10% of ankle fractures. Operative treatment with syndesmosis screw fixation has been successfully performed for decades and is considered the gold standard of treatment. Few studies have reported the long-term outcomes of syndesmosis injuries. This study investigated long-term patient-reported, radiographic, and functional outcomes of syndesmosis injuries treated with screw fixation and subsequent timed screw removal. A retrospective cohort study was carried out at a Level I trauma center. The study group included 43 patients who were treated for ankle fractures with associated syndesmotic disruptions between December 2001 and May 2011. The study included case file reviews, self-reported questionnaires, radiologic reviews, and clinical assessments. At 5.1 (±1.76) years after injury, 60% of participants had pain, 26% had degenerative changes, 51% had loss of tibiofibular overlap, and 33% showed medial clear space widening. Retained syndesmotic positions on radiographs were linked to better self-reported outcomes. There is an inversely proportional relation between age at the time of injury and satisfaction with the outcome of the ankle fracture as well as a directly proportional relation between age at the time of injury and pain compared with the preinjury state. Optimal restoration and preservation of the syndesmosis is crucial. Syndesmotic disruption is associated with poor long-term outcomes after ankle fracture. Greater age is a risk factor for chronic pain and dissatisfaction with the outcome of ankle fracture and syndesmosis injury. Therefore, patient education to facilitate realistic expectations about recovery is vital, especially in older patients.
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Xie B, Jing YF, Xiang LB, Zhou DP, Tian J. A modified technique for fixation of chronic instability of the distal tibiofibular syndesmosis using a wire and button. J Foot Ankle Surg 2014; 53:813-6. [PMID: 25027623 DOI: 10.1053/j.jfas.2014.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Indexed: 02/03/2023]
Abstract
Distal tibiofibular syndesmosis injury accounts for 1% to 11% of soft tissue injuries of the ankle. Some acute syndesmotic injuries will fail to heal effectively owing to inadequate treatment or misdiagnosis, eventually resulting in chronic instability, which can destroy the stability of the ankle joint. Various surgical techniques have been described for fixation of the syndesmosis. Among the existing methods, the suture button has the advantage of allowing for physiologic micromotion at the syndesmosis by maintaining the reduction and preventing the risk of screw breakage. However, the "relatively" long suture between buttons can gradually relax under continuous loading, resulting in fixation failure, which we have termed electric wire phenomenon. In the present report, we have described a modified technique for flexible fixation using the Endobutton CL ULTRA fixation device by tricortical fixation, instead of quadricortical fixation, to allow for robust and reliable fixation of the distal tibiofibular syndesmosis. The modified technique is devoid of the concern regarding the use of screw fixation and can reduce the risk of displacement or elongation and skin irritation associated with the suture button.
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Affiliation(s)
- Bing Xie
- Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, Liaoning Province, People's Republic of China
| | - Yan-feng Jing
- Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, Liaoning Province, People's Republic of China
| | - Liang-bi Xiang
- Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, Liaoning Province, People's Republic of China
| | - Da-peng Zhou
- Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, Liaoning Province, People's Republic of China
| | - Jing Tian
- Department of Orthopedics, Shenyang Military Region General Hospital, Shenyang, Liaoning Province, People's Republic of China.
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Internal fixation of distal tibiofibular syndesmotic injuries: a systematic review with meta-analysis. INTERNATIONAL ORTHOPAEDICS 2013; 37:1755-63. [PMID: 23873173 DOI: 10.1007/s00264-013-1999-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/20/2013] [Indexed: 12/13/2022]
Abstract
No consensus had been reached about the optimal method for syndesmotic fixation. The present study analysed syndesmotic fixation based on the highest level of clinical evidence in order to obtain more reliable results. Medline, Embase and Cochrane database were searched through the OVID retrieval engine. Manual searching was undertaken afterward to identify additional studies. Only randomized controlled trials (RCT) and prospective comparative studies were selected for final inclusion. Study screening and data extraction were completed independently by two reviewers. All study characteristics were summarized into a table. The extracted data were used for data analysis. Twelve studies were finally included: six of them were RCTs, two were quasi-randomized studies and four were prospective comparative studies. Four comparisons with traditional metallic screw were identified in terms of bioabsorbable screws, tricortical fixation method, suture-button device as well as non-fixation choice in low syndesmotic injuries. Both absorbable screws and the tricortical fixation method showed almost no better results than traditional quadricortical metallic screw (p > 0.05). Additionally, existing studies could not illustrate their efficiency of reducing hardware removal rate. The suture button technique had significantly better functional score (p = 0.003), ankle motion (p = 0.02), time to full weightbearing (p < 0.0001) and much less complications (p = 0.0008) based on short and intermediate term follow-up data. Transfixation in low syndesmotic injuries showed poorer results than the non fixed group in all outcome measurements, but didn't reach a significant level (p > 0.05). The present evidence still couldn't find superior performance of the bioabsorbable screw and tricortical fixation method. Their true effects in decreasing second operation rate need further specific studies. Better results of the suture-button made it a promising technique, but it still needs long-term testing and cost-efficiency studies. The patients with low syndemotic injuries should be well assessed before fixation determination and the indication of screw placement in such conditions needs to be further defined.
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