A retrospective study of deltoid ligament repair versus syndesmotic fixation in lateral malleolus fracture combined with both deltoid ligament injury and inferior tibiofibular syndesmotic disruption

The clinical outcome comparison between trans-syndesmotic fixation and anatomic deltoid ligament repair in unstable ankle fractures with medial clear space widening: A systematic review and meta-analysis

BACKGROUND

Due to the variability in evidence supporting either trans-syndesmosis fixation or deltoid ligament repair in unstable ankle fractures with medical clear space (MCS) widening makes it unclear which surgical technique leads to the best patient outcomes. The goal of our systematic review and meta-analysis was to compare clinical outcomes of trans-syndesmotic fixation versus anatomic deltoid ligament repair in the management of unstable ankle fractures with MCS widening.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized in this study. A comprehensive and systematic search was conducted using the PubMed, Embase, Web of Science and Cochrane Library databases. Outcomes investigated in this review included the rates of syndesmotic malreduction, removal of hardware, postoperative complications including wound issues, and functional/pain scores.

RESULTS

A total of five level-3 studies were selected in this review, with 280 unstable ankle fractures with MCS widening: 165 for the trans-syndesmotic fixation group and 115 for the anatomic deltoid ligament repair group. Three out of five studies evaluated syndesmotic malreduction using CT. Compared to the trans-syndesmosis fixation group, the deltoid repair group showed significant lower rates of syndesmotic malreduction rates and removal of hardware: 6.5 % (4/61) Vs. 27 % (16/59) (RR=0.26, 95 % CI=[0.10, 0.68]), and 2.6 % (3/115) Vs.54.5 % (90/165) (RR=0.06, CI=[0.02, 0.14]), respectively. No significant differences were found between the two groups in postoperative wound complications, reoperations, and functional scores including AOFAS and VAS pain score.

CONCLUSIONS

Based on our findings, anatomic deltoid ligament repair was associated with a lower rate of syndesmotic malreduction and the need for hardware removal while there was no significant difference in terms of postoperative wound complications, reoperation, AOFAS score, or VAS pain score. These results should be interpreted with caution due to limitations related to heterogeneity among the studies. Further high-level RCTs with larger sample sizes are necessary to establish a robust consensus.

Repair of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture by using suture anchors into the talus combined with the transosseous suture in the medial malleolar

Purpose

For deep deltoid ligament ruptures near the medial malleolar attachment, anchors were usually placed at the posterior colliculus and intercollicular groove. However, this procedure usually requires a prolonged surgical incision to fully expose the deep deltoid ligament, causing more trauma. In order to reduce surgical trauma, we explored the treatment outcomes of suture anchor into the talus combined with transosseous suture in the medial malleolar for the treatment of deep deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture.

Patients and methods

This is a retrospective study of patients who received suture anchor into the talus combined with transosseous suture in the medial malleolar for repairing deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture. The outcome measures include the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, visual analogue scale (VAS), and the active range of motion (ROM) of the ankle at the final follow-up visit after surgery. Medial malleolus gap was evaluated by radiographic examination.

Results

This study included 64 patients. The mean follow-up time was 36.3 ± 15.2 months. There were 43 patients with injuries on the medial malleolar side, and 21 cases on the midsubstance. The average AOFAS and VAS were 87.5 ± 4.9 and 0.7 ± 0.5, respectively. No significance in medial malleolus gap between the contralateral side and affected side was observed.

Conclusion

For deltoid ligament ruptures near the medial malleolar attachment or midsubstance rupture, suture anchor into the talus combined with transosseous suture in the medial malleolar yields good clinical effect and outcome, is an optimal management of ankle syndesmosis injuries.

Syndesmosis dislocation and ankle ligament stress in the posterior malleolus fracture fixated - "in vitro analysis"

PURPOSE

The objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM).

METHODS

Four internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups.

RESULTS

We found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed.

CONCLUSION

This study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament.