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Milstrey A, Gartung S, Klimek M, Wermers J, Raschke MJ, Ochman S. Assessing the Need for Additional Syndesmotic Stabilization in Open Reduction of the Posterior Malleolus: A Biomechanical Study. J Bone Joint Surg Am 2025:00004623-990000000-01426. [PMID: 40245116 DOI: 10.2106/jbjs.23.01088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
Abstract
BACKGROUND The treatment of ankle fractures involving the posterior malleolus (PM) has changed in favor of open reduction and internal fixation (ORIF), and the need for additional syndesmotic stabilization has decreased; however, there are still doubts regarding the diagnosis and treatment of residual syndesmotic instability. The aim of the present study was to evaluate the effect of fixation of the PM and to assess the need for additional stabilization methods. We hypothesized that ORIF of the PM would not sufficiently stabilize the syndesmosis and that additional syndesmotic reconstruction would restore kinematics. METHODS Eight unpaired, fresh-frozen, cadaveric lower legs were tested in a 6-degrees-of-freedom robotic arm with constant loading (200 N) in the neutral position and at 10° dorsiflexion, 15° plantar flexion, and 30° plantar flexion. The specimens were evaluated in the following order: intact state; osteotomy of the PM; transection of the anterior inferior tibiofibular ligament (AITFL) and interosseous ligament (IOL); ORIF of the PM; additional syndesmotic screw; combination of syndesmotic screw and AITFL augmentation; and AITFL augmentation. RESULTS A complete simulated rupture of the syndesmosis (PM osteotomy with AITFL and IOL transection) caused translational (6.9 mm posterior and 1.8 mm medial displacement) and rotational instability (5.5° external rotation) of the distal fibula. ORIF of the PM could eliminate this instability in the neutral ankle position, whereas sagittal and rotational instability remained in dorsiflexion and plantar flexion. The remaining instability could be eliminated with an additional procedure, without notable differences between screw and AITFL augmentation. CONCLUSIONS In our model, isolated PM osteotomy and isolated AITFL and IOL rupture (after PM refixation) only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of PM osteotomy and AITFL and IOL rupture resulted in an unstable syndesmosis in all planes. CLINICAL RELEVANCE In complex ankle fractures, ORIF of the PM is essential to restore syndesmotic stability; however, residual syndesmotic instability can be detected by a specific posterior shift of the fibula on stress testing. In these cases, anatomical AITFL augmentation is biomechanically equivalent to the use of a syndesmotic screw.
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Affiliation(s)
- Alexander Milstrey
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany
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Cho T, Yan HR, Uematsu M, Harter C, Liu J. Syndesmotic Screw Fixation Versus Suture Button Versus Tibiotalocalcaneal Nail Treatment in Syndesmotic Ankle Fractures: A Meta-Analysis. Foot Ankle Spec 2025:19386400251318965. [PMID: 40018814 DOI: 10.1177/19386400251318965] [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] [Indexed: 03/01/2025]
Abstract
BACKGROUND Syndesmotic ankle fractures occur when damage to the syndesmosis complex is combined with a malleolar fracture. This can result in severe pain, weakness, and instability. Surgical interventions include syndesmotic screw fixation (SS), suture button fixation (SB), and tibiotalocalcaneal nail (TTC). This meta-analysis aims to compare the outcomes of these treatment methods for syndesmotic ankle fractures. METHODS A literature search was conducted on PubMed and Embase for comparison studies that included at least 2 surgical interventions and at least one of the relevant functional outcomes and/or complication metrics until June 2024. The Olerud-Molander Ankle Score (OMAS) was used to compare functional outcomes, and it is a self-reported outcome measure that evaluates the symptoms and function of those with ankle fractures, while infections and reoperations were reported to compare complication outcomes. Statistical analyses were performed using Review Manager 5.4. A P-value ≤ .05 was considered statistically significant. The risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale. RESULTS A total of 18 studies with a total of 1,040 patients were ultimately included in this study. The SS had a significantly higher OMAS 2-year follow-up compared to TTC. The TTC had a significantly lower infection rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than SS. The SB had a significantly lower reoperation rate compared to SS. The SB had a significantly higher OMAS at both 1-year and 2-year follow-ups than TTC. The SB had a significantly lower infection rate compared to TTC. CONCLUSION The SB emerges as the preferred treatment method for syndesmotic ankle fractures, while TTC stands as a viable alternative. The SB is recommended as the primary surgical intervention for patients with syndesmotic ankle fractures due to its superior clinical benefits when compared to TTC and SS. LEVELS OF EVIDENCE 3.
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Affiliation(s)
- Thomas Cho
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Helen R Yan
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Michael Uematsu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Christian Harter
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
| | - Jiayong Liu
- Department of Orthopaedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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Szatkowski JP. Out With the Old and in With the New: "Flexible" Syndesmotic Fixation. J Orthop Trauma 2024; 38:672-674. [PMID: 39745755 DOI: 10.1097/bot.0000000000002896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2025]
Affiliation(s)
- Jan P Szatkowski
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN
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Schweser K, Leary E, Levack AE, Marmor MT. Clinical relevance of current patient-reported outcome measures for ankle fracture: surgeons' perspective. OTA Int 2024; 7:e349. [PMID: 39479553 PMCID: PMC11524735 DOI: 10.1097/oi9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 08/26/2024] [Accepted: 09/22/2024] [Indexed: 11/02/2024]
Abstract
Objectives Determine the relevance of the most frequently used patient-reported outcome measures (PROMs) for monitoring patient recovery after ankle fracture, from the clinical perspective of orthopaedic trauma surgeons, given lack of validated PROMs. Design Prospective cohort. Setting Orthopaedic Trauma Association committee meetings, electronic correspondence. Patients/Participants Orthopaedic trauma surgeons. Intervention Delphi method for consensus activities. Level of Evidence IV. Main Outcome Measurements Most clinically relevant PROMs for ankle fracture recovery. Results Several English-language PROMs were identified based on use in literature and relevance to ankle fractures. 7 were selected by expert consensus. These are the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopaedic Surgeons (AAOS), Foot and Ankle Disability Index (FADI) Score, Lower Extremity Functional Scale (LEFS), Olerud-Molander Ankle Score (OMAS), and Patient-Reported Outcome Measurement Information System Physical Function (PROMIS PF). The most clinically relevant PROM is the A-FORM, followed by the AAOS, LEFS, PROMIS PF, FADI, and OMAS, and the least clinically relevant overall, the FAAM. Conclusions Understanding which PROM best matches physician expectations for tracking recovery is an important step toward a robust, evidence-based approach to patient care. The A-FORM was identified as the most clinically relevant among the most used PROMs. These results will aid surgeons, clinicians, and scientists to identify a uniformly, clinically relevant PROM for the treatment and study of outcomes and recovery after isolated ankle fracture.
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Affiliation(s)
- Kyle Schweser
- Missouri Orthopaedic Institute and Department of Orthopaedic Surgery, School of Medicine, University of Missouri, Columbia, MO
| | - Emily Leary
- Missouri Orthopaedic Institute and Department of Orthopaedic Surgery, School of Medicine, University of Missouri, Columbia, MO
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, MO
| | - Ashley E. Levack
- Loyola University Stritch School of Medicine, Loyola University Medical Center, Maywood, IL
| | - Meir T. Marmor
- Zuckerberg San Francisco General Hospital, Orthopaedic Trauma Institute, University of California San Francisco, San Francisco, CA
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Black AT, Tran S, Haffner ZK, Spoer DL, Rahnama-Vaghef A, Stowers JM. Radiographic outcomes of flexible and rigid fixation techniques of syndesmotic injuries across various body mass indices: A retrospective analysis. J Foot Ankle Surg 2024:248-252. [PMID: 39521034 DOI: 10.1053/j.jfas.2024.11.002] [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: 02/11/2024] [Revised: 08/27/2024] [Accepted: 11/02/2024] [Indexed: 11/16/2024]
Abstract
In the setting of ankle trauma, surgical management of syndesmosis injury involves screw fixation and suture button technique. The efficacy of flexible (suture button) versus rigid (screw) fixation in the management of syndesmotic injury has been investigated extensively in current literature. There is sparse data comparing these two techniques across different body mass indices (BMI). In this study, two fellowship-trained foot and ankle surgeons at urban level-1 trauma centers reviewed blinded post-operative ankle radiographs of BMI-stratified patients undergoing syndesmotic fixation. A total of 79 patients were included for analysis based on inclusion and exclusion criteria. There were 42 patients in the screw fixation group and 37 patients in the suture button group. The average follow-up period was 5.5 months. No significant difference was found in the average radiographic measurements when comparing the two fixation types, regardless of BMI parameters. This was consistent when analyzing individual fixation types stratified by BMI, as well as when comparing BMI groups stratified by fixation type. Additionally, the distribution of body mass index was even across both fixation types. Our study demonstrates that both fixation groups achieved comparable anatomic ankle reduction regardless of body mass index. The authors suggest expanding the indication of suture button fixation to include the higher body mass index patients.
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Affiliation(s)
- Alexandra T Black
- Fellowship-Trained Foot and Ankle Surgeon, West Coast Foot and Ankle, Palm Springs, CA, USA
| | - Son Tran
- Fellow, Foot and Ankle Specialists of Central Ohio, Columbus, OH, USA.
| | - Zoë K Haffner
- Research Fellow, Georgetown University School of Medicine, Washington, DC, USA
| | - Daisy L Spoer
- Research Fellow, Georgetown University School of Medicine, Washington, DC, USA
| | - Ali Rahnama-Vaghef
- Fellowship-Trained Foot and Ankle Surgeon, Assistant Professor, Georgetown University School of Medicine, Washington, DC, USA
| | - Jered M Stowers
- Fellowship-Trained Foot and Ankle Surgeon, West Coast Foot and Ankle, Palm Springs, CA, USA
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Klepacki K, Kowal I, Konieczny G, Tomczyk Ł, Miękisiak G, Kochańska-Bieri J, Morasiewicz P. Post-treatment Functional Outcomes of Distal Tibiofibular Syndesmosis Injuries With Varying Duration and Method of Stabilization. J Foot Ankle Surg 2024; 63:735-741. [PMID: 39098652 DOI: 10.1053/j.jfas.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 06/19/2024] [Accepted: 07/25/2024] [Indexed: 08/06/2024]
Abstract
The purpose of this study was to assess whether the type and duration of screw fixation affects ankle joint functional scores and patient activity levels. We evaluated 55 patients who had undergone surgical treatment for ankle fracture with concomitant distal tibiofibular syndesmosis injury. The follow-up period ranged from 2 years to 4 years and 2 months (mean 36 months). Depending on the time of screw removal, patients were divided into 2 groups (the 8-15-week group-19 patients, and the 16-22-week group-36 patients). There were 17 patients with tricortical and 38 patients with quadricortical syndesmosis fixation. The following parameters were assessed: range of motion, rates of complications, level of pain in visual analogue scale (VAS), and function. In the quadricortical fixation group the range of plantar flexion p = .04 and adduction p = .043 were significantly lower in the operated than in the nonoperated limb. In the patients who had their syndesmotic screws removed after 16-22 weeks, the range of plantar flexion in the operated limb was significantly lower than that in the nonoperated limb. We observed no differences between the evaluated groups in terms of ankle joint mobility, VAS pain levels, functional outcomes, or complication rates. All the analyzed subgroups showed poorer ranges of some types of motion in the ankle and worse functional scale and VAS pain scores after treatment in comparison with those before the injury. We suggest removing the syndesmotic screws after 8-15 weeks, due to the possibility of earlier rehabilitation, faster return to work and physical activity and less burden on the health care system. Tricortical or quadricortical syndesmosis fixation is at the surgeon's discretion.
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Affiliation(s)
- Krzysztof Klepacki
- Provincial Specialist Hospital in Legnica, Orthopedic Surgery Department, Iwaszkiewicza 5, 59-220 Legnica, Poland
| | - Igor Kowal
- Provincial Specialist Hospital in Legnica, Orthopedic Surgery Department, Iwaszkiewicza 5, 59-220 Legnica, Poland
| | - Grzegorz Konieczny
- Faculty of Health Sciences and Physical Education, The Witelon State University of Applied Sciences in Legnica, Sejmowa 5A, 59-220 Legnica, Poland
| | - Łukasz Tomczyk
- Department of Food Safety and Quality Management, Poznan University of Life Sciences. Wojska Polskiego 31, 60-624 Poznań, Poland
| | - Grzegorz Miękisiak
- Institute of Medical Sciences, University of Opole. ul, Oleska 48 45-052 Opole, Poland
| | - Joanna Kochańska-Bieri
- Universitätsspital Basel, Universitätsspital CH, Petersgraben 4, 4031 Basel, Switzerland
| | - Piotr Morasiewicz
- Department of Orthopaedic and Trauma Surgery, Institute of Medical Sciences, University of Opole. al. Witosa 26, 45-401 Opole, Poland.
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El-Azab H, Hafez AR, Mohamed MA, Elsayed M. Outcome of flexible fixation for acute isolated syndesmotic injuries. BMC Musculoskelet Disord 2024; 25:780. [PMID: 39363345 PMCID: PMC11448049 DOI: 10.1186/s12891-024-07849-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 09/05/2024] [Indexed: 10/05/2024] Open
Abstract
BACKGROUND Management of syndesmotic injuries with screw fixation has potential disadvantages, which may lead to the loss of some of the ankle functions. The use of the suture-button system instead can overcome these disadvantages. PATIENTS AND METHODS In a prospective study, 32 patients with acute isolated syndesmotic injuries were treated with a suture-button device. Follow-up was for a minimum of 2 years, regarding the Visual Analogue Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, patient satisfaction at 3, 12, and 24 months, and radiological assessment. RESULT A significant improvement regarding pain (VAS during rest 5.6 and during walking 6.1 preoperative improved to 0.1 and 0.2 postoperatively, respectively. (P values were < 0.0001 for both pain during rest and walking) and AOFAS score (improved significantly from 44 ± 7.5 pre- to 99 ± 8.7 points postoperatively (P value was 0.0034). The improved VAS and AOFAS scores of the repaired ankles gradually reached the values of the contralateral uninjured ankle (evaluated at 3,12, and 24 months, postoperatively). Radiographs and CT of both ankles - repaired and healthy ankles - were similar at the 3 months follow-up. Early full weight-bearing and early return to work and sport characterized all patients. There was no need for hardware removal. CONCLUSION Suture-button treatment for acute isolated ankle syndesmotic injuries leads to favorable clinical and radiological outcomes. Postoperative radiographs and CT denoted maintained ankle stability. Patients can do early full weight-bearing and early return to work and sport.
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Affiliation(s)
- Hossam El-Azab
- Department of Orthopedics and Traumatology, Sohag Faculty of medicine, Sohag University, Sohag, Egypt.
- Clinic, Behind Luxor International Hospital, Luxor, Egypt.
| | - Abdel Rhman Hafez
- Department of Orthopedics and Traumatology, Sohag Faculty of medicine, Sohag University, Sohag, Egypt
| | - Mohamed A Mohamed
- Department of Orthopedics and Traumatology, Sohag Faculty of medicine, Sohag University, Sohag, Egypt
| | - Moustafa Elsayed
- Department of Orthopedics and Traumatology, Sohag Faculty of medicine, Sohag University, Sohag, Egypt
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Cho T, Waters A, Senthilkumar S, Shendge S, Liu J. Comparison of the outcomes of syndesmotic ankle fractures treated with dynamic fixation versus static fixation versus fibular nail: a meta-analysis and systematic review. ANNALS OF JOINT 2024; 9:36. [PMID: 39540066 PMCID: PMC11558278 DOI: 10.21037/aoj-24-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 08/02/2024] [Indexed: 11/16/2024]
Abstract
Background Syndesmotic ankle fractures occur when there is damage to the syndesmosis complex, resulting in severe pain and instability. Treatment methods include static fixation, dynamic fixation, and fibular nailing. This systematic review and meta-analysis aims to compare the outcomes of these surgical interventions for syndesmotic ankle fractures. Methods PubMed and Embase were searched up until April 2024 for comparison studies that included at least two of the treatment methods and relevant functional outcomes and complication metrics. Review Manager 5.4 was used for statistical analyses, and a P value ≤0.05 was considered statistically significant. Risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale. Results Nineteen studies with a total of 1,182 patients met the inclusion criteria. Compared to static fixation, dynamic fixation had a significantly higher Olerud-Molander Ankle Score (OMAS) at both 1-year [standardized mean difference (SMD) =0.43; 95% confidence interval (CI): 0.22 to 0.65; P<0.05] and 2-year post-operation (SMD =0.76; 95% CI: 0.33 to 1.20; P<0.05). Dynamic fixation had a significantly lower reoperation rate than static fixation [risk ratio (RR) =0.55; 95% CI: 0.36 to 0.83; P=0.004]. Compared to static fixation, fibular nail had a significantly higher OMAS at 1-year post-operation (SMD =0.28; 95% CI: 0.03 to 0.53; P=0.03). Fibular nails had significantly lower infection (RR =0.12; 95% CI: 0.04 to 0.37; P<0.05) and reoperation rates (RR =0.22; 95% CI: 0.06 to 0.86; P=0.03) than static fixation. Compared to fibular nail, dynamic fixation had a significantly higher OMAS at both 1-year (SMD =1.07; 95% CI: 0.83 to 1.31; P<0.05) and 2-year post-operation (SMD =1.03; 95% CI: 0.60 to 1.47; P<0.05). Dynamic fixation had a significantly higher reoperation rate compared to fibular nail (RR =20.41; 95% CI: 2.81 to 148.21; P=0.003). Conclusions Dynamic fixation seems to be the superior treatment method, displaying better outcomes than static fixation and fibular nailing, with the fibular nail proving to be a viable alternative. Dynamic fixation should be the first choice of treatment for those with syndesmotic ankle fractures due to its clinical advantages compared to static fixation and fibular nailing. Level of Evidence 3.
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Affiliation(s)
- Thomas Cho
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Amy Waters
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Shiva Senthilkumar
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Shradha Shendge
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
| | - Jiayong Liu
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA
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Choufani C, Bilichtin E, Demory D, Tannyeres P, Teixeira P, Rassat R, De Geofroy B, Barbier O. Value of arthroscopy in the management of acute lesions of the distal tibiofibular joint. INTERNATIONAL ORTHOPAEDICS 2024; 48:2439-2443. [PMID: 38772936 DOI: 10.1007/s00264-024-06222-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/16/2024] [Indexed: 05/23/2024]
Abstract
PURPOSE Managing the distal tibiofibular (DTF) joint remains a challenge despite recent developments. Ankle arthroscopy is emerging as a diagnostic and therapeutic means. Our study aimed to compare preoperative imaging data and arthroscopic data, with the hypothesis that imaging alone is insufficient to evaluate acute laxity, and with arthroscopy as the reference examination. METHODS All patients treated in 2023 in our department for an acute isolated DTF lesion were included prospectively. Preoperative radiographic and MRI imaging were compared with arthroscopic data. RESULTS Ten patients were treated. For five patients, the instability was doubtful after carrying out an appropriate imaging assessment (X-rays of both ankles, MRI). For four of these five patients, instability was confirmed by arthroscopy. Arthroscopy was useful for suturing the anterior bundle of the DTF joint for two patients and allowed for verifying the reduction in the sagittal and coronal planes for two patients. No complications were detected. CONCLUSIONS Arthroscopy in isolated acute DTF lesions seems to provide a diagnostic and therapeutic advantage. Its use may allow for exhaustive assessment and complete repair of lesions. It must be offered as soon as possible; a delay in specialized imaging may delay therapeutic care.
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Affiliation(s)
- Camille Choufani
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France.
| | - Emilie Bilichtin
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France
| | | | - Paul Tannyeres
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France
| | - Paul Teixeira
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France
| | - Robin Rassat
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France
| | - Bernard De Geofroy
- Orthopaedic Surgical Department, Military Teaching Hospital Laveran, Marseille, France
| | - Olivier Barbier
- Orthopaedic Surgical Department, Military Teaching Hospital Sainte-Anne, 2 Boulevard Ste Anne, 83000, Toulon, France
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Mick P, Doll J, Müller M, Schmidmaier G, Renkawitz T, Campos S, Wolf SI, Tsitlakidis S. Differences in gait analysis and clinical outcome after dynamic fixation or screw fixation in acute syndesmosis tear: a prospective randomized pilot study. Arch Orthop Trauma Surg 2024; 144:4355-4363. [PMID: 39259306 DOI: 10.1007/s00402-024-05535-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 09/01/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Acute syndesmosis tears can be treated by static screw or dynamic fixation. Various studies have compared these techniques regarding postoperative outcome. However, to our knowledge, no study has used 3D-instrumented gait analysis (IGA). We hypothesized that a dynamic fixation would perform non-inferior to screw fixation in terms of biomechanical and clinical outcomes. MATERIALS AND METHODS Patients were prospectively randomized to both groups. All patients received the same follow-up rehabilitation and consultations (6 and 12 weeks; 6 and 12 months) postoperatively. Standardized questionnaires were used to objectify pain and ankle function. At 6 months follow-up, IGA was conducted additionally to objectify the biomechanical outcome. RESULTS Twenty-five patients in the dynamic fixation (DF) group using TightRope® and twenty-five in the screw fixation group (SF) completed gait analysis. The DF group showed significantly higher mean values for maximum moment in the affected ankle joint (DF: 1.40 ± 0.21 Nm, SF: 1.23 ± 0.30 Nm; p = 0.023) and the unaffected ankle joint (DF: 1.52 ± 0.20 Nm, SF: 1.37 ± 0.27 Nm; p = 0.035). The difference between the affected and unaffected ankle joint was significantly higher in the SF group for active plantarflexion (DF: 1.52 ± 0.20°, SF: 1.37 ± 0.27°; p = 0.035). Both dynamic and screw fixation groups exhibited significantly reduced plantarflexion during the push-off and early swing phase, with moments and powers in the ankle joint also significantly impaired. CONCLUSIONS Our study demonstrated that dynamic fixation has better or similar biomechanical and clinical outcomes compared to screw fixation. Future research should focus on biomechanical differences during gait as well as clinical outcomes in case of earlier weight-bearing after dynamic fixation. TRIAL REGISTRATION NUMBER (TRN) DRKS00013562 Date of Registration: 07/12/2017.
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Affiliation(s)
- Paul Mick
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Julian Doll
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Michelle Müller
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Gerhard Schmidmaier
- Department for Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Tobias Renkawitz
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Sarah Campos
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Sebastian I Wolf
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - Stefanos Tsitlakidis
- Department for Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany.
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Wójtowicz BG, Chawrylak K, Lesman J, Domżalski M. Is There Any Purpose in Routine Syndesmotic Screw Removal? Systematic Literature Review. J Clin Med 2024; 13:4805. [PMID: 39200947 PMCID: PMC11355342 DOI: 10.3390/jcm13164805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 08/10/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: The aim of this systematic review is to examine the recent evidence comparing the removal and non-removal of syndesmotic screws in tibiofibular syndesmosis injuries in terms of functional, clinical, and radiographic outcomes. Methods: A comprehensive literature review was conducted to identify clinical studies on syndesmotic screw removal and its outcomes, searching the Cochrane Library and PubMed Medline for publications from 1 January 2004 to 12 February 2024. Studies were included if they involved tibiofibular syndesmotic screw fixation, assessed screw removal or retention, described clinical outcomes, and were original research with at least fifteen patients per group. Results: Most reviewed articles (18 out of 27; 67%) found no significant differences between the routine removal and retention of syndesmotic screws post-fixation. Four retrospective studies (15%) suggested that retaining screws might result in worse outcomes compared to removal. Two studies (7%) indicated that removing screws could introduce additional risks. One study (4%) observed that post-removal, there is some fibula-tibia separation without affecting the medial clear space. Another study (4%) noted that intraosseous screw breakage might increase the need for implant removal due to pain. Additionally, no significant differences in ankle function were found among groups with varying intervals of screw removal. Conclusions: The current literature does not definitively support routine removal of syndesmotic screws. Given the potential complications and financial costs, routine removal should not be performed unless specifically indicated.
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Affiliation(s)
- Błażej G. Wójtowicz
- Department of Orthopedics and Traumatology of the Musculoskeletal System, WAM University Clinical Hospital, Central Veterans Hospital, Żeromskiego 113 St., 90-549 Lodz, Poland; (J.L.); (M.D.)
| | - Katarzyna Chawrylak
- Department of Surgical Oncology, Medical University of Lublin, Radziwiłłowska 13 St., 20-080 Lublin, Poland;
| | - Jędrzej Lesman
- Department of Orthopedics and Traumatology of the Musculoskeletal System, WAM University Clinical Hospital, Central Veterans Hospital, Żeromskiego 113 St., 90-549 Lodz, Poland; (J.L.); (M.D.)
| | - Marcin Domżalski
- Department of Orthopedics and Traumatology of the Musculoskeletal System, WAM University Clinical Hospital, Central Veterans Hospital, Żeromskiego 113 St., 90-549 Lodz, Poland; (J.L.); (M.D.)
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Shevate I, Salunkhe R, Pervez F, Pawar P. A Prospective Study on Fixation of Syndesmotic Ankle Injury: Tight Rope Versus Screw Fixation. Cureus 2024; 16:e67172. [PMID: 39295653 PMCID: PMC11409161 DOI: 10.7759/cureus.67172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Accepted: 08/18/2024] [Indexed: 09/21/2024] Open
Abstract
Background Syndesmotic injury can result in significant instability and long-term complications if not treated correctly. Traditional management has involved transyndesmotic screw fixation, but a newer technique, the tight rope system, has been developed to mitigate some of the issues related to screw fixation, such as hardware discomfort and the necessity for hardware removal. Methods In this randomized, prospective study, 32 patients with ankle injuries requiring syndesmotic fixation were equally divided into two groups: one receiving the tight rope system (n=16) and the other undergoing screw fixation (n=16). The patients were monitored for six months following surgery. The study measured outcomes such as time to weight-bearing, range of motion, pain levels, functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, and complication rates. Results Both groups had comparable demographic and injury profiles. The tight rope group achieved weight-bearing significantly earlier (6.19 ± 0.9 weeks vs. 7.13 ± 0.95 weeks, p=0.008) and had better functional outcomes at six months (87.5% excellent AOFAS scores vs. 37.5%, p=0.003) compared to the screw fixation group. The range of motion and pain scores were similar between the groups. Different complications were observed: screw breakage was more common in the screw fixation group, while the tight rope group experienced more laxity. Overall complication rates were similar. Conclusion Both techniques were effective in reducing pain and maintaining range of motion. However, the tight rope system allowed for earlier weight-bearing and better functional outcomes at six months. These results indicate that the tight rope system may provide certain advantages in treating syndesmotic injuries, although the choice of technique should be tailored to the specific injury and patient factors.
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Affiliation(s)
- Ishan Shevate
- Orthopaedics, Dr. D. Y. Patil Medical College, Hospital and Research Center, Pune, IND
| | - Rahul Salunkhe
- Orthopaedics, Dr. D. Y. Patil Medical College, Hospital and Research Center, Pune, IND
| | - Faiz Pervez
- Orthopaedics, Dr. D. Y. Patil Medical College, Hospital and Research Center, Pune, IND
| | - Prashant Pawar
- Orthopaedics, Dr. D. Y. Patil Medical College, Hospital and Research Center, Pune, IND
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Yang H, Zhong Q, Huai C, Zhan J. Application of a new method of Nice Knot elastic fixation for distal tibiofibular syndesmosis injury. Asian J Surg 2024:S1015-9584(24)01488-X. [PMID: 39034253 DOI: 10.1016/j.asjsur.2024.07.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/05/2024] [Indexed: 07/23/2024] Open
Affiliation(s)
- Hu Yang
- Department of Orthopeaedics, The Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Qigang Zhong
- Department of Orthopeaedics, Maanshan People's Hospital, Maanshan, 243099, China
| | - Chaoyue Huai
- Department of Orthopeaedics, The Second Hospital of Anhui Medical University, Hefei, 230601, China
| | - Junfeng Zhan
- Department of Orthopeaedics, The Second Hospital of Anhui Medical University, Hefei, 230601, China.
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Migliorini F, Maffulli N, Cocconi F, Schäfer L, Bell A, Katusic D, Vaishya R. Better outcomes using suture button compared to screw fixation in talofibular syndesmotic injuries of the ankle: a level I evidence-based meta-analysis. Arch Orthop Trauma Surg 2024; 144:2641-2653. [PMID: 38740648 DOI: 10.1007/s00402-024-05354-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy.
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke On Trent, ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Federico Cocconi
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
| | - Luise Schäfer
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St. Brigida, Simmerath, Germany
| | - Dragana Katusic
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
| | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospitals, New Delhi, India
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Obey MR, Schafer K, Matheny LM, McAndrew CM, Gardner MJ, Ricci WM, Clanton TO, Backus JD. Syndesmotic Suture Button Fixation Results in Higher Tegner Activity Scale Scores When Compared to Screw Fixation: A Multicenter Investigation. Foot Ankle Spec 2024; 17:270-276. [PMID: 37232097 DOI: 10.1177/19386400231174829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Suture buttons and metal screws have been used and compared in biomechanical, radiographic, and clinical outcome studies for syndesmotic injuries, with neither implant demonstrating clear superiority. The aim of this study was to compare clinical outcomes of both implants. METHODS Patients who underwent syndesmosis fixation at 2 separate academic centers from 2010 through 2017 were compared. Thirty-one patients treated with a suture button and 21 patients treated with screws were included. Patients in each group were matched by age, sex, and Orthopaedic Trauma Association fracture classification. Tegner Activity Scale (TAS), Foot and Ankle Ability Measure (FAAM), patient satisfaction score, surgical failure, and reoperation rates were compared. RESULTS Patients who underwent suture button fixation had significantly higher TAS scores than those who underwent screw fixation (p < 0.001). There was no significant difference in FAAM ADL scores between cohorts (p = 0.08). Symptomatic hardware removal rates were similar (3.2% suture button cohort vs 9.0% in screw cohort). One patient (4.5%) underwent revision surgery secondary to syndesmotic malreduction after screw fixation, for a reoperation rate of 13.5%. CONCLUSION Patients with unstable syndesmotic injuries treated with suture button fixation had higher mean TAS scores compared to patients treated with screws. Foot and Ankle Ability Measure and ADL scores in these cohorts were similar.Level of Evidence: Level 3 Retrospective Matched Case-Cohort.
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Affiliation(s)
| | - Kevin Schafer
- Washington University in St. Louis, St. Louis, Missouri
| | - Lauren M Matheny
- School of Data Science and Analytics, Kennesaw State University, Kennesaw, Georgia
| | | | | | | | | | - Jonathon D Backus
- Washington University in St. Louis, St. Louis, Missouri
- School of Medicine, Washington University in St. Louis, St. Louis, Missouri
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16
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Verlinsky L, Heath DM, Momtaz DA, Christopher B, Singh A, Gibbons SD. A comparison of screw and suture button fixation in the management of adolescent ankle syndesmotic injuries. J Child Orthop 2024; 18:295-301. [PMID: 38831850 PMCID: PMC11144380 DOI: 10.1177/18632521241238889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/26/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Ankle injuries involving the tibiofibular syndesmosis often necessitate operative fixation to restore stability to the ankle. Recent literature in the adult population has suggested that suture button fixation may be superior to screw fixation. There is little evidence as to which construct is preferable in the pediatric and adolescent population. This study investigates outcomes of suture button and screw fixation in adolescent ankle syndesmotic injuries. Methods A retrospective matched cohort study over 10 years of pediatric patients who underwent ankle syndesmotic fixation at a large Level 1 Trauma Center was conducted. Both isolated syndesmotic injuries and ankle fractures with syndesmotic disruption were included. Preoperative variables collected include basic patient demographics, body mass index, and fracture type. Suture button and screw cohorts were matched based on age, race, sex, and open fracture utilizing propensity scores. Outcomes assessed include reoperation and implant failure. Results A total of 44 cases of operative fixation of the ankle syndesmosis were identified with a mean age of 16 years. After matching cohorts based on age, sex, race, and open fracture status, there were 17 patients in the suture button and screw cohorts, respectively. Patients undergoing screw fixation had a six times greater risk of reoperation (p = 0.043) and 13 times greater risk of implant failure (p < 0.001). Out of six cases of reoperation in the screw cohort, five were unplanned. Conclusion Our findings favor suture button fixation in operative management of adolescent tibiofibular syndesmotic injuries. Compared with screws, suture buttons are associated with lower risk of both reoperation and implant failure. Level of evidence level III therapeutic.
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Affiliation(s)
- Luke Verlinsky
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - David M Heath
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - David A Momtaz
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - Boris Christopher
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - Aaron Singh
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
| | - Steven D Gibbons
- Department of Orthopaedics, UT Health San Antonio, San Antonio, TX, USA
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Murphy SC, Murphy B, O'Loughlin P. Syndesmotic injury with ankle fracture: A systematic review of screw vs dynamic fixation. Ir J Med Sci 2024; 193:1323-1330. [PMID: 38282112 DOI: 10.1007/s11845-024-03619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 01/30/2024]
Abstract
Cortical screw fixation across the tibiofibular joint is the mainstay of treatment for syndesmotic injury. Dynamic fixation devices have been developed offering similar advantages to screw fixation in terms of reduction and stability of the syndesmosis. Dynamic fixation may also facilitate a more physiological movement between the tibiofibular joint and thus incur less morbidity. Patient's rehabilitation potential is enhanced and reduces the need for hardware removal. Our systematic review aims to analyse the relevant current literature and compare screw fixation to dynamic fixation in the treatment of syndesmotic injury associated with acute ankle fractures. A literature search was performed on Pubmed and Ovid Medline to find scientific papers relating to syndesmotic fixation in acute ankle fractures. Papers were screened and included dependent on predetermined criteria. Risk of bias was assessed after screening full papers by two independent reviewers. Tables and analysis were made using Microsoft excel. A total of 8 papers with 673 patients were included. We found no functional difference between screw fixation or dynamic fixation groups at final follow-up. Three papers showed statistically significant lower rates of reoperation in the dynamic fixation group. Dynamic fixation may offer lower post operative complications and reoperation rates. Therefore, dynamic fixation may be a beneficial alternative treatment compared to traditionally used syndesmotic screws.
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Affiliation(s)
| | - Ben Murphy
- Department of Trauma and Orthopaedic Sugery, Cork University Hospital, Cork, Ireland
| | - Padhraig O'Loughlin
- Department of Trauma and Orthopaedic Sugery, Cork University Hospital, Cork, Ireland
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Jlidi M, Bouaicha W, Sbaihi S, Gharbi H, Lamouchi M, Mallek K, Jaziri S, Daas S. Comparative Study for Surgical Treatment of Acute Distal Tibiofibular Syndesmotic Lesions Using the Modified Suture-Button Fixation Versus Static Syndesmotic Screw Fixation. Foot Ankle Spec 2024:19386400241256440. [PMID: 38814001 DOI: 10.1177/19386400241256440] [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] [Indexed: 05/31/2024]
Abstract
INTRODUCTION Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation. METHODS It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months. RESULTS Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications. CONCLUSIONS The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- Mohamed Jlidi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Walid Bouaicha
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Siwar Sbaihi
- Department of Radiology, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hedi Gharbi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Mouldi Lamouchi
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Karim Mallek
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
| | - Salma Jaziri
- Department of Anaesthesia and Intensive Care, Mohamed Bourguiba Hospital, Kef, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Selim Daas
- Orthopedics and Traumatology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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Shah NV, Lettieri MJ, Kim D, Zhou JJ, Pineda N, Diebo BG, Woon CYL, Naziri Q. The impact of asymptomatic human immunodeficiency virus (HIV)-positive disease status on inpatient complications following total joint arthroplasty: a propensity score-matched analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1939-1944. [PMID: 38472434 DOI: 10.1007/s00590-024-03872-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE The number of patients with asymptomatic human immunodeficiency virus (AHIV) is increasing as the efficacy of antiretroviral therapy improves. While there is research on operative risks associated with having HIV, there is a lack of literature describing the impact of well-controlled HIV on postoperative complications. This study seeks to elucidate the impact of AHIV on postoperative outcomes after total hip (THA) and knee (TKA) arthroplasty. METHODS The Nationwide Inpatient Sample was retrospectively reviewed for patients undergoing TKA and THA from 2005 to 2013. Subjects were subdivided into those with AHIV and those without HIV (non-HIV). Patient demographics, hospital-related parameters, and postoperative complications were all collected. One-to-one propensity score-matching, Chi-square analysis, and multivariate logistical regressions were performed to compare both cohorts. RESULTS There were no significant differences between AHIV and non-HIV patients undergoing TKA or THA in terms of sex, age, insurance status, or total costs (all, p ≥ 0.081). AHIV patients had longer lengths of stay (4.0 days) than non-HIV patients after both TKA (3.3 days) and THA (3.1 days) (p ≤ 0.011). Both TKA groups had similar postoperative complication rates (p > 0.081). AHIV patients undergoing THA exhibited an increased rate of overall surgical complications compared non-HIV patients (0 vs. 4.5%, p = 0.043). AHIV was not associated with increased complications following both procedures. CONCLUSION Despite lengthier hospital stays among AHIV patients, baseline AHIV was not associated with adverse outcomes following TKA and THA. This adds to the literature and warrants further research into the impact of asymptomatic, well-controlled HIV infection on postoperative outcomes following total joint arthroplasty.
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Affiliation(s)
- Neil V Shah
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA.
| | - Matthew J Lettieri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - David Kim
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Jack J Zhou
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | | | - Bassel G Diebo
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
- Department of Orthopaedic Surgery, Warren Alpert Medical School at Brown University, East Providence, RI, USA
| | - Colin Y L Woon
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
| | - Qais Naziri
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Ave, MSC 30, Brooklyn, NY, 11203, USA
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Baker HP, Gerak S, Muir S, Rizzieri TJ, Straszewski A, Erdman MK, Dillman DB. All-suture fixation of syndesmotic injuries: a case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1279-1286. [PMID: 38070017 DOI: 10.1007/s00590-023-03797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/19/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. METHODS This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. RESULTS In the patients with 6 weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. CONCLUSIONS In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure. LEVEL OF EVIDENCE 4
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA.
| | - Samuel Gerak
- The University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Sean Muir
- Edward Via College of Osteopathic Medicine, Spartanburg, SC, 29303, USA
| | | | - Andrew Straszewski
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Mary-Kate Erdman
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
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Sun S, Tang T, Shi P, Yang C, Wang W, Chen L, Wei M. Standing on single foot-binding test yields satisfactory results as a novel method for the diagnosis of distal tibiofibular syndesmosis instability: a prospective, cross-sectional diagnostic-accuracy study. BMC Musculoskelet Disord 2024; 25:53. [PMID: 38216973 PMCID: PMC10785373 DOI: 10.1186/s12891-023-07155-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 12/26/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Non-invasive diagnosis of distal tibiofibular syndesmosis instability (DTSI) was a great challenge to clinicians. We designed a new method, the Standing on single foot-Binding test, and investigated the accuracy of the test in the diagnosis of distal tibiofibular syndesmosis instability in adults with a history of ankle injury. METHODS 85 participants with ankle injury were subjected to the Standing on single foot-Binding test, MRI and palpation to detect the distal tibiofibular syndesmosis instability (DTSI) and the findings were compared with ankle arthroscopic results. Both participants and arthroscopist were blind to the predicted results of the clinical tests. Sensitivity, specificity, PPV, NPV, LR+, LR - and their 95% CIs were calculated for each of the clinical tests as well as for the positive clinical diagnosis. RESULTS The Standing on single foot-Binding test (SOSF-B test) outperformed MRI and palpation, in terms of sensitivity (87.5%/84.38%), specificity (86.79%/86.79%), PPV (80%/79.41%), NPV (92%/91.2%), LR+ (6.625/6.39), LR- (0.14/0.18) and diagnostic accuracy (87.06/85.88), among others, in the diagnosis of distal tibiofibular syndesmosis instability (DTSI). The diagnostic performance of 20° SOSF-B test was virtually identical to that of 0° SOSF-B test. According to the prevalence (28.7%) of DTSI and LR of four tests, the post-test probability could be used in clinical practice for the prediction of DTSI. CONCLUSION This prospective and double-blind diagnostic test showed that the SOSF-B test is clinically feasible for the diagnosis of distal tibiofibular syndesmosis instability (DTSI), and new diagnostic tools for rapid screening of distal tibiofibular syndesmosis instability (DTSI). LEVEL OF EVIDENCE II.
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Affiliation(s)
- Shouqi Sun
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Tianshi Tang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Pengtao Shi
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Chen Yang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China
| | - Wenjuan Wang
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
| | - Lei Chen
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
| | - Min Wei
- Medical School of Chinese PLA, (BEIJING, Chinese PLA General Hospital, Beijing, China.
- Department of Orthopedics, the Fourth Medical Center, Chinese PLA General Hospital (BEIJING, Beijing, China.
- Department of Orthopedics/Chinese National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation (BEIJING, Chinese PLA General Hospital, Beijing, China.
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22
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Duggan SP, Chong AC, Uglem TP. Center-Center Surgical Technique With Dynamic Syndesmosis Fixation: A Cadaveric Pilot Study. J Foot Ankle Surg 2024; 63:92-96. [PMID: 37709189 DOI: 10.1053/j.jfas.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/26/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
The objective of this cadaveric biomechanical study was to evaluate if the center-center surgical technique is a reliable and repeatable method of achieving proper syndesmotic reduction when using dynamic syndesmotic fixation. Nine fresh frozen above-knee cadaveric lower extremities were used. Computerized tomography (CT) scans were first obtained for each intact specimen as the baseline for comparison. A simulated complete syndesmotic disruption was created by transection of all deltoid and syndesmotic ligaments. Instability of the ankle was confirmed with stress imaging using fluoroscopy. Each unstable specimen was repaired using the center-center surgical technique with dynamic syndesmosis fixation. A series of measurements from the axial CT images of intact and repaired specimens were used to determine the anatomic distal tibiofibular relationships for comparison of changes from intact to postfixation. All radiographic measurements were performed by 4 independent foot and ankle surgeons. The level of inter-rater reliability for all the measurements was found to be "moderate" to "excellent" agreement (ICC value: 0.865-0.983, 95% confidence interval: 0.634-0.996). There was no statistical difference found between rotational alignment of native and postfixation (a/b: p = .843; b-a: p = .125; θ: p = .062). There was a statistical difference detected for lateral alignment at the center of fibularis incisura between native and postfixation (average: -0.6 ± 0.8 mm, range: -2.3 to 1.2 mm, p < .001). There was no statistical difference found for the anteroposterior translation alignment between native and postfixation (d/e: p = .251; f: p = .377). This study demonstrated the use of the center-center surgical technique as a viable and repeatable method for achieving anatomical reduction of the tibiofibular syndesmosis when used with dynamic fixation modalities.
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Affiliation(s)
- Shane P Duggan
- Sanford Health Podiatric Medicine and Surgery Residency, Fargo, ND
| | - Alexander Cm Chong
- Sanford Health Podiatric Medicine and Surgery Residency, Fargo, ND; Department of Graduate Medical Education, Sanford Health, Fargo, ND.
| | - Timothy P Uglem
- Sanford Health Podiatric Medicine and Surgery Residency, Fargo, ND
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23
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Kawabata S, Nakasa T, Ikuta Y, Sumii J, Nekomoto A, Sakurai S, Moriwaki D, Adachi N. Safe Insertion Angle of the Suture Button to Avoid Saphenous Structure in Syndesmosis Injury. Foot Ankle Spec 2023:19386400231213761. [PMID: 38018519 DOI: 10.1177/19386400231213761] [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] [Indexed: 11/30/2023]
Abstract
In placing the medial suture button for syndesmosis injury, the risk of great saphenous vein and saphenous nerve injury has been reported. This study aimed to determine the safe insertion angle of the guide pin to avoid saphenous structure injury during suture button fixation. The incidence of saphenous structure injury was investigated using 8 legs of cadavers. The greater saphenous vein was depicted on the skin using near-infrared light (VeinViewer® Flex) and the distance between the greater saphenous vein and the posterior edge of the tibia at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint was measured in the 60 legs of healthy participants. On computed tomography (CT) images, the angles between the greater saphenous vein and transmalleolar axis at levels of 10, 20, and 30 mm from the joint line of the tibiotalar joint were measured. The cadaveric study revealed that the percentages of contact with the saphenous nerve were 8.3% to 16.7%. Using near-infrared light, the vein and tibia distance was 32.9 ± 6.8 mm of 10 mm, 26.6 ± 6.4 mm of 20 mm, and 20.4 ± 6.4 mm of 30 mm. The angle between the vein and transmalleolar axis was 1.0° to 9.4°, and more proximal, the angle was smaller. The veins depicted by near-infrared light can be a landmark to identify great saphenous vein, and injury of the saphenous structure can be prevented using VeinViewer Flex or considering the insertion angle defined in this study when placing the suture button for syndesmosis injuries.Level of Evidence: Level IV.
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Affiliation(s)
- Shingo Kawabata
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tomoyuki Nakasa
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Department of Artificial Joints and Biomaterials, Graduate School of Biomedical and Health Sciences, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasunari Ikuta
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Junichi Sumii
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akinori Nekomoto
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Satoru Sakurai
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Dan Moriwaki
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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24
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Lim CM, Choi SW, Kim BS, Lee SJ, Kang HS. Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study. Malays Orthop J 2023; 17:48-58. [PMID: 38107359 PMCID: PMC10723001 DOI: 10.5704/moj.2311.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 12/02/2022] [Indexed: 12/19/2023] Open
Abstract
Introduction The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures. Materials and methods Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups. Results There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost. Conclusion Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.
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Affiliation(s)
- C M Lim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
| | - S W Choi
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
| | - B S Kim
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
| | - S J Lee
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
| | - H S Kang
- Department of Orthopaedic Surgery, Jeju National University Hospital, Jeju, South Korea
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25
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Hong CC, Harrison WD, Clough T, Calder J. Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes. Orthop J Sports Med 2023; 11:23259671231206185. [PMID: 37927967 PMCID: PMC10625313 DOI: 10.1177/23259671231206185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 11/07/2023] Open
Abstract
Background Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury. Purpose To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex). Study Design Case series; Level of evidence, 4. Methods Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed. Results Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports. Conclusion Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.
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Affiliation(s)
- Choon Chiet Hong
- Fortius Clinic (FIFA Medical Centre of Excellence), London, UK
- Department of Orthopaedic Surgery, National University Hospital, National University Health System, Singapore
- Department of Orthopaedic Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Tim Clough
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - James Calder
- Fortius Clinic (FIFA Medical Centre of Excellence), London, UK
- Department of Bioengineering, Imperial College London, London, UK
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26
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Kibble KM, Cunningham BP, Rivard RL, Vang S, Nguyen MP. Ankle fractures: High implant cost is not associated with better patient reported outcomes. Injury 2023; 54:110963. [PMID: 37542790 DOI: 10.1016/j.injury.2023.110963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.
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Affiliation(s)
- Kendra M Kibble
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, United States of America; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, United States of America
| | - Rachael L Rivard
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America.
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27
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Saraglis G, Khan A, Chaudhari H, Pyakurel S, Elahi Rabbani SF, Arafa M. Radiographic Evaluation of Syndesmosis Stabilisation Using the TightRope System Versus Syndesmotic Screw Fixation for the Management of Ankle Fractures With a Syndesmotic Injury. Cureus 2023; 15:e45910. [PMID: 37885534 PMCID: PMC10599197 DOI: 10.7759/cureus.45910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
Background Ankle syndesmotic injuries represent complex orthopaedic injuries, commonly requiring open reduction and fixation. Several techniques have been described for fixation, with syndesmotic screw fixation being traditionally considered as the 'gold standard'. Among the relatively new techniques developed, the TightRope system stabilisation provides 'dynamic' stabilisation with promising results. We aimed to evaluate the radiographic performance of these two different surgical techniques in the management of ankle fractures with an underlying syndesmotic injury. Methods A total of 85 cases were included in the study and were divided into two groups: syndesmotic screw fixation (48 cases) and TightRope system (37 cases). Patient demographics, type of ankle fracture and type of implant used were recorded for all the cases, and evaluation of the postoperative radiographs was performed for all. For all patients, the radiographic parameters assessed included the medial clear joint space (MCS), tibiofibular overlap (TFO), and anterior and posterior tibiofibular interval in order to calculate the anterior tibiofibular ratio (ATFR). Results Statistical analysis revealed no statistically significant differences in the radiographic parameters of the postoperative radiographs between the two groups. However, in the syndesmotic screw group, a higher incidence of radiographic malreduction was seen, as indicated by the MCS and ATFR parameters, in comparison to the TightRope fixation group. An equal distribution of radiographic abnormal parameters was noted among the different types of ankle fractures included in the study (trimalleolar, bimalleolar and isolated fibula fractures with syndesmotic injury) with no obvious positive correlation noted (Pearson correlation test). Conclusion Both surgical techniques seem to provide adequate reduction of the syndesmosis, with no statistical significant differences detected from the radiographic evaluation of both groups. In our study though, the syndesmotic screw group was associated with a higher incidence of radiographic malreduction as indicated by the MCS and ATFR parameters. The TightRope system seems to have a lower rate of radiographic malreduction and provides an equally effective way of syndesmosis fixation based on a dynamic mode of stabilisation.
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Affiliation(s)
- Georgios Saraglis
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Bedford, GBR
| | - Anwar Khan
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Luton, GBR
| | - Harsh Chaudhari
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Luton, GBR
| | - Sagar Pyakurel
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Luton, GBR
| | | | - Mohamed Arafa
- Department of Trauma and Orthopaedics, Bedfordshire NHS Foundation Trust, Luton, GBR
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28
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Ataoğlu MB, Tokgöz MA, Özer M, Köktürk A, Yaka H, Ergişi Y. Radiological Evaluation of Distal Tibiofibular Joint Anatomy Variations in Patients with and Without Syndesmotic Injury. Indian J Orthop 2023; 57:1473-1477. [PMID: 37609029 PMCID: PMC10441950 DOI: 10.1007/s43465-023-00952-0] [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: 11/20/2021] [Accepted: 07/10/2023] [Indexed: 08/24/2023]
Abstract
Introduction Syndesmosis injuries are a common and debilitating problem affecting the ankle joint, but the precise causes of these injuries remain unclear. In the current retrospective study, it was aimed to investigate the relationship between variations in the distal tibiofibular syndesmosis and surgically proven syndesmosis injuries. Patients and Method A total of 57 patients with surgically proven syndesmosis injuries and 51 patients without syndesmosis injuries were included as the control group. Computed tomography (CT) scans were used to measure six anatomical features 1 cm proximal to the tibiotalar joint, including the anterior facet length (a), posterior facet length (b), angle between the anterior and posterior facets (c), fibular incisura depth (d), tibia thickness (e), and fibula thickness (f). Results Comparing the measurements of the patients with and without syndesmosis injury, it was demonstrated that the anterior facet length (a) (p = 0.022) was shorter and the a-b difference (anterior facet length-posterior facet length difference) (p = 0.010) tended toward negative values. Pearson correlation analysis demonstrated that a (r = - 0.211, p < 0.033) and a-b (r = - 0.254, p = 0.010) measurements were strongly negatively correlated with syndesmosis injury. Discussion Our study findings suggest that the shortness of the anterior facet and the difference in length are related to syndesmosis injuries. To the best of our knowledge, this is the first study to report this relationship with syndesmosis. This study sheds light on the underlying mechanisms of syndesmosis injury, which could help clinicians in the diagnosis, treatment, and prevention of this common ankle injury.Level of evidence: Level 4: case-control study.
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Affiliation(s)
- Muhammet Baybars Ataoğlu
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mh. Gazi Üniversitesi Tıp Fakültesi, Ankara, 06560 Turkey
| | - Mehmet Ali Tokgöz
- Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Emniyet Mh. Gazi Üniversitesi Tıp Fakültesi, Ankara, 06560 Turkey
| | - Mustafa Özer
- Department of Orthopaedics and Traumatology, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Anıl Köktürk
- Department of Orthopaedics and Traumatology, Medical Park Ankara Hospital, Ankara, Turkey
| | - Haluk Yaka
- Department of Orthopaedics and Traumatology, Necmettin Erbakan University Faculty of Medicine, Konya, Turkey
| | - Yılmaz Ergişi
- Department of Orthopaedics and Traumatology, Karabuk University Faculty of Medicine, Karabük, Turkey
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29
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Wixted CM, Luo EJ, Stauffer TP, Wu KA, Adams SB, Anastasio AT. Biomechanical profile of varying suture button constructs in cadaveric specimens: a systematic review and meta-analysis. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:344. [PMID: 37675292 PMCID: PMC10477643 DOI: 10.21037/atm-23-1527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 06/21/2023] [Indexed: 09/08/2023]
Abstract
Background Suture button fixation of syndesmotic injuries allows for more physiologic motion of the ankle joint while maintaining adequate reduction and may avoid the need for additional surgeries, given the lower risk of syndesmotic diastasis and implant failure. Few studies have examined the optimal number and configuration of suture buttons for syndesmotic disruption. The purpose of this systematic review and meta-analysis is to compare different suture button configurations from the cadaveric literature and to assess their relative effect on the stability of the syndesmotic reduction and functional movement of the ankle. Methods A literature search in the databases MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, and SPORTDiscus via EBSCO were searched through December 2022 to identify studies related to cadaveric modeling of the syndesmosis. Only cadaveric studies with suture button fixation and studies in English were included. The quality of cadaveric studies was assessed using the Quality Assessment for Cadaveric Studies (QUACS) tool. Revman 5.3 software was used to perform the meta-analysis. Results The meta-analysis included 5 studies and 86 limbs. The systematic review included 15 studies. When comparing single and double suture button configurations, no difference was found between groups with regard to fibular rotation (MD =-0.9; 95% CI: -2.09 to 0.27; I2=79%; P=0.13) and both groups had similar rotational stability. The double suture button technique did demonstrate less sagittal fibular translation compared to the single suture button (MD =0.48; 95% CI: 0.02-0.94; I2=66%; P=0.04). When comparing two suture buttons in parallel and divergent configurations, studies did not find any differences with regard to strength or stability. Conclusions There were no significant differences in biomechanical parameters when comparing single and double suture button constructs. While single button suture constructs result in minimal fibular rotation, double suture button constructs minimize fibular translation. This review may serve as a guide for clinicians when approaching these injuries.
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Affiliation(s)
| | - Emily J. Luo
- Duke University School of Medicine, Durham, NC, USA
| | | | - Kevin A. Wu
- Duke University School of Medicine, Durham, NC, USA
| | - Samuel B. Adams
- Duke University Hospital, Department of Orthopaedics, Durham, NC, USA
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30
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Sanchez T, Sankey T, Scheinberg MB, Schick S, Singh S, Cheppalli N, Davis C, Shah A. Factors and Radiographic Findings Influencing Patient-Reported Outcomes Following Maisonneuve Fractures. Cureus 2023; 15:e43536. [PMID: 37719488 PMCID: PMC10501688 DOI: 10.7759/cureus.43536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND This research adds to the literature by providing prognostic information for physicians and patients regarding the outcomes of operative management of Maisonneuve fractures (MFs). To date, this is the only cohort study of patient-reported outcomes measurement information systems (PROMIS) scores following surgical fixation of MF. Patient outcomes were compared focusing on the mean population with an inter-analysis using basic demographic information, radiographic findings, and patient comorbidities and their respective impact on PROMIS scores. METHODS A total of 24 patients between 2012 and 2020 met the inclusion criteria and completed PROMIS surveys at a minimum of 18 months postoperatively. Patient charts were reviewed through the electronic medical record (EMR) for demographic information and comorbidities as well as operative variables. PROMIS scores for physical function (PF), pain interference (PI), and depression were obtained via follow-up visits and phone calls. The impact of categorical variables on complications was compared using Chi-Squared tests. Variables were analyzed with a type 3 SS test to stratify independent risk factors' effect on PROMIS scores and to account for confounding variables. RESULTS PROMIS PF averaged 44.84 and was significantly affected by BMI>30 (p=.033), hypertension (HTN) (p=.026), patients with clinical anxiety or depression (p=.047), and subsequent screw removal (p=.041). PROMIS PI averaged a score of 54.57 and was significantly affected by BMI>30 (p=.0046), coronary artery disease (CAD) (p=.0123), patients with clinical anxiety or depression (p=.0206), and subsequent screw removal (p=.0039). PROMIS depression scores averaged 46.03 and were significantly affected by the presence of CAD (p=.049) and subsequent screw removal (p=.023). CONCLUSION Patient-reported outcomes following MF surgery demonstrated PROMIS scores within +/- 1 standard deviation of the population-based control, and thus many patients can reasonably expect to return to a level of function comparable to the general population. Nonetheless, the significant effects of patient comorbidities and surgical variables ought to be evaluated and utilized as prognostic indicators when managing patient expectations prior to operative treatment of an MF injury.
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Affiliation(s)
- Thomas Sanchez
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Turner Sankey
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Mila B Scheinberg
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Samuel Schick
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Swapnil Singh
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | | | - Chandler Davis
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - Ashish Shah
- Orthopaedic Surgery, University of Alabama at Birmingham, Birmingham, USA
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31
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Ibrahim H, Billings C, Abdalla M, Korra A, Anderson DE. In Vivo Assessment of High-Strength and Corrosion-Controlled Magnesium-Based Bone Implants. Bioengineering (Basel) 2023; 10:877. [PMID: 37508904 PMCID: PMC10376803 DOI: 10.3390/bioengineering10070877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
The biodegradable nature of magnesium in aqueous mediums makes it an attractive material for various biomedical applications when it is not recommended that the material stay permanently in the body. Some of the main challenges that hinder the use of magnesium for bone fracture repair are its limited mechanical strength and fast corrosion rates. To this end, we developed a novel Mg-Zn-Ca-Mn-based alloy and post-fabrication methods that can deliver high-strength and corrosion-controlled implant materials to address these challenges. This study is focused on assessing the in vitro corrosion and in vivo biocompatibility of the developed magnesium-based alloy and post-fabrication processes. The developed heat treatment process resulted in an increase in the microhardness from 71.9 ± 5.4 HV for the as-cast Mg alloy to as high as 98.1 ± 6.5 HV for the heat-treated Mg alloy, and the ceramic coating resulted in a significant reduction in the corrosion rate from 10.37 mm/yr for the uncoated alloy to 0.03 mm/yr after coating. The in vivo assessments showed positive levels of biocompatibility in terms of degradation rates and integration of the implants in a rabbit model. In the rabbit studies, the implants became integrated into the bone defect and showed minimal evidence of an immune response. The results of this study show that it is possible to produce biocompatible Mg-based implants with stronger and more corrosion-controlled properties based on the developed Mg-Zn-Ca-Mn-based alloy and post-fabrication methods.
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Affiliation(s)
- Hamdy Ibrahim
- Department of Mechanical Engineering, University of Tennessee, Chattanooga, TN 37403, USA
| | - Caroline Billings
- College of Veterinary Medicine, University of Tennessee, Knoxville, TN 37996, USA
| | - Moataz Abdalla
- Department of Mechanical Engineering, University of Tennessee, Chattanooga, TN 37403, USA
| | - Ahmed Korra
- Department of Mechanical Engineering, University of Tennessee, Chattanooga, TN 37403, USA
| | - David Edger Anderson
- College of Veterinary Medicine, University of Tennessee, Knoxville, TN 37996, USA
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Wongcharoenwatana J, Hoellwarth JS, Greenstein MD, Reif TJ, Fragomen AT, Rozbruch SR. Comparative fixation devices for preventing migration of the proximal tibiofibular joint during tibial lengthening: a tether versus screw fixation. J Orthop Surg Res 2023; 18:298. [PMID: 37452380 PMCID: PMC10349522 DOI: 10.1186/s13018-023-03771-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/01/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND When lengthening the tibia segment using motorized internal lengthening nails (MILN), undesired distal migration of the proximal fibula segment is prevented by tibiofibular stabilization, traditionally using a screw. A tightened cortical suspensory fixation rope (tether) is an alternative option, but its appropriateness has never been studied. The primary outcome was comparing the amount of proximal fibular migration between patients who were stabilized with either a tether or a screw. The secondary outcome was to evaluate the effect of fibular migration on the clinical outcome between both groups. METHODS A retrospective study was conducted on patients who underwent tibial lengthening with MILN between April 2016 and June 2022. Two cohorts were compared: 18 limbs with tether fixation versus 29 limbs with screw fixation. Data on the patient's age, sex, etiologies, and clinical outcomes were collected. Radiographic measurements included the lengthening distance and the amount of proximal fibular migration. RESULTS In total, 47 limbs from 41 patients, with average age 35.01 ± 13.72 years old. There were 28 males (68.29%) and 13 females (31.71%). The tether group demonstrated a statistically significant greater distance of migration than the screw group (p < 0.001), with an average migration distance of 8.39 ± 5.09 mm and 2.59 ± 3.06 mm, respectively. No correlation was found between the amount of tibial lengthening and the distance of proximal fibular migration in both the tether group (p = 0.96) and the screw group (p = 0.32). There was no significant difference in the change of knee extension between both groups (p = 0.3), and no patients reported knee pain or tightness. CONCLUSION A screw provides better resistance to proximal tibiofibular joint migration during MILN lengthening, but the difference appears clinically inconsequential. Either option appears suitable.
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Affiliation(s)
- Jidapa Wongcharoenwatana
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA.
- Department of Orthopaedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Jason S Hoellwarth
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - Michael D Greenstein
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - Taylor J Reif
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, New York, NY, USA
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Koh D, Mehta K. Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report. Cureus 2023; 15:e42451. [PMID: 37637621 PMCID: PMC10449562 DOI: 10.7759/cureus.42451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.
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Affiliation(s)
- Don Koh
- Orthopaedics, Changi General Hospital, Singapore, SGP
| | - Kinjal Mehta
- Orthopaedics, Changi General Hospital, Singapore, SGP
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Zhu N, Zhong Q, Zhan J, Zhang S, Liu W, Yao Y, Jing J. A new type of elastic fixation, using an encircling and binding technique, for tibiofibular syndesmosis stabilization: comparison to traditional cortical screw fixation. J Orthop Surg Res 2023; 18:269. [PMID: 37009903 PMCID: PMC10069037 DOI: 10.1186/s13018-023-03579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/03/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND The distal tibiofibular syndesmosis (DTS) is a complex fibrous joint that contributes to the stability and weight-bearing function of the ankle. As such, repair of DTS injury is required, providing fixation strength while maintaining ankle range of motion. The aim of this study was to compare a new elastic fixation technique, using an encircling and binding technique, for DTS stabilization, compared to the traditional cortical bone screw fixation. METHODS This was a retrospective analysis of 67 patients treated for a DTS injury at our hospital, between June 2019 and June 2021. Of them, 33 were treated with encircling and binding (EB group) and 34 using a cortical screw (CS group). The following outcomes were compared between groups: time to inferior tibiofibular fixation; length of hospital stay; time to partial weight bearing; time to complete weight bearing; complications; imaging data; and functional scores. RESULTS Successful stabilization was achieved in all cases, with a mean follow-up period of 15.78 ± 2.97 months. Time to fixation and time to partial and complete weight bearing were shorter for the EB than that for the CS group. The length of hospital was not different between groups. With regard to complications, a superficial infection developed in one patient in each group, with wound healing achieved after active treatment. Screw fracture occurred in two patients in the CS group. At 3 months post-surgery, the American Foot Surgery Association Ankle-Hindfoot score (AOFAS) was higher and the pain score lower for the EB than that for the CS group, but with no between-group difference at the final follow-up. On imaging, the tibiofibular clear space and tibiofibular overlap were not different between groups. CONCLUSIONS DTS fixation using encircling and binding yielded better clinical and functional outcomes than did cortical screw fixation at 3 months post-surgery, with no difference at the final follow-up. This novel fixation technique provides firm fixation, combined with earlier return to postoperative exercise and recovery of ankle function.
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Affiliation(s)
- Nan Zhu
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Qigang Zhong
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Junfeng Zhan
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Shuo Zhang
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Liu
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yunfeng Yao
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Juehua Jing
- Department of Orthopedics, Second Affiliated Hospital of Anhui Medical University, Hefei, China.
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Mutschler M, Naendrup JH, Pfeiffer TR, Jaecker V, Arbab D, Shafizadeh S, Buchhorn T. Current status of the management of isolated syndesmotic injuries in Germany. Arch Orthop Trauma Surg 2023; 143:2019-2026. [PMID: 35403865 PMCID: PMC10030432 DOI: 10.1007/s00402-022-04423-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 03/10/2022] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Manuel Mutschler
- Witten/Herdecke University, Witten/Herdecke, Germany, Alfred-Herrhausen-Straße 50, 58448.
- Department of Foot Surgery, Waldkrankenhaus Bonn, Johanniter GmbH, Bonn, Germany, Waldstraße 73, 53177.
| | - Jan-Hendrik Naendrup
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
- Department of Oncology, HaematologyInfectiology and Internistic Critical Care Medicine, University of Cologne, Cologne, Germany
| | - Thomas R Pfeiffer
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
| | - Vera Jaecker
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Witten/Herdecke University, Cologne Merheim Medical Centre, Cologne, Germany
| | - Dariusch Arbab
- Witten/Herdecke University, Witten/Herdecke, Germany, Alfred-Herrhausen-Straße 50, 58448
- Department of Orthopaedic Surgery, Klinikum Dortmund, Dortmund, Germany
| | - Sven Shafizadeh
- Witten/Herdecke University, Witten/Herdecke, Germany, Alfred-Herrhausen-Straße 50, 58448
- Department of Trauma Surgery, Orthopaedic Surgery and Sports Traumatology, Sana Medical Centre Cologne, Cologne, Germany
| | - Tomas Buchhorn
- Foot and Ankle Department, Sporthopaedicum Straubing-Regensburg, Straubing, Germany
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Comparison of a Novel Modified All-Suture Construct versus Suspensory Suture-button Fixation in a Syndesmotic Injury Model. J Orthop Trauma 2023; 37:e104-e110. [PMID: 36219777 DOI: 10.1097/bot.0000000000002503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To biomechanically investigate a novel modified all-suture construct compared with commercially available suspensory button fixation for stabilization of the syndesmosis. METHODS Eight matched pairs of cadaver lower limbs were obtained. We used a material testing machine and Optotrak optoelectronic 3D motion measurement system for testing. Syndesmotic injuries were simulated, and specimens were fixed with either a suspensory suture button or modified all-suture construct. Repaired specimens were then cyclically loaded for 500 cycles. Spatial relationship of the tibia and fibula were continuously monitored for the intact, destabilized, and repaired states. The results were analyzed using independent samples t test. RESULTS There was no significant difference in sagittal or coronal plane translation between intact and either repair. Compared with the intact state, both repair techniques demonstrated significantly more external rotation of the fibula relative to the tibia and decreased construct stiffness. Cycling of the specimens did not significantly increase coronal or sagittal plane translation; however, external rotation of the fibula relative to the tibia increased and stiffness decreased with cycling for both repair techniques. CONCLUSIONS Our data suggest that sagittal and coronal plane translation is no different from the intact state for both fixation techniques. However, rotation of the fibula relative to the tibia was increased, and construct stiffness was decreased compared with the intact state for both fixation techniques. These findings suggest that an all-suture construct could offer syndesmotic fixation comparable with proprietary suspensory button fixation in a cadaver model.
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What is the best treatment for syndesmosis fixation? Suture-button or syndesmotic screw ? Bilateral CT-based early postoperative analysis. Foot Ankle Surg 2023; 29:128-135. [PMID: 36535844 DOI: 10.1016/j.fas.2022.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/22/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to compare the effectiveness of syndesmotic screw (SS) and suture button (SB) on the reduction and fixation of syndesmosis via early postoperative bilateral computed tomography (CT). METHODS This single-center retrospective study included 76 patients aged ≥ 18 years with a unilateral syndesmosis injury. SS was applied to 40 patients and SB to 36 patients. The differences between the sides stabilized using SB or SS and the intact sides were analyzed using the parameters of tibio-fibular clear space (∆CS) and anterior or posterior sagittal translation (∆ST) depending on the orientation of the fibula. The cases in which the fibula was translocated to the posterior of the tibia after the change of ∆ST and ∆CS> 2 mm were evaluated as malreduction. Axial CT images taken from the level of syndesmosis fixation were divided into 4 zones according to the orientation angle of the implant sent from the fibula to the tibia. RESULTS No significant difference was found in the analyses performed between total patient group with malreduction and fixation groups in terms of ∆CS and ∆ST values (p = 0.708, p = 0.289). It was observed that the fixation material was in zone 3 in 54 patients and in zone 2 in 22 patients. No significant difference was found in the analyses performed between the SS and SB groups according to the implant zone (p = 0.191). In the SS group sent from Zone 2, the malreduction rate according to the ∆ST value of syndesmosis was found to be significantly higher than in the SB group (p = 0.008, p = 0.003). CONCLUSION When the implant is applied with the correct technique, there is no difference between SS and SB in terms of early postoperative reduction. When the SS is advanced at an inappropriate angle, it negatively affects the reduction of the fibula, while SB can better tolerate angle errors up to certain degrees due to its flexible structure. Therefore, it can be presumed that the suture button system is a more convenient method in the reduction and fixation of syndesmosis than the syndesmotic screw. LEVEL OF EVIDENCE Level IV.
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Does a Reduced Secondary Operation Rate Offset Higher Implant Charges when Utilizing Suture Button Fixation for Syndesmotic Injuries? J Orthop Trauma 2023; 37:77-82. [PMID: 36001894 DOI: 10.1097/bot.0000000000002476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether a reduced secondary operation rate offsets higher implant charges when using suture button fixation for syndesmotic injuries. DESIGN Retrospective cohort study. SETTING Single, urban, Level 1 trauma center. PARTICIPANTS Three-hundred twenty-seven (N = 327) skeletally mature patients with rotational ankle fractures (OTA/AO type 44) necessitating concurrent syndesmotic fixation. INTERVENTION Suture button or solid 3.5-mm screw syndesmotic fixation. MAIN OUTCOME MEASUREMENTS To compare implant charges with secondary operation charges based on differential implant removal rates between screws and suture buttons. RESULTS Patients undergoing screw fixation were older (48.8 vs. 39.6 years, P < 0.01), had more ground-level fall mechanisms (59.3% vs. 51.1%, P = 0.026), and sustained fewer 44C type injuries (34.7% vs. 56.8%, P = 0.01). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs. 5.7%, P = 0.005). Binomial logistic regression identified nonsmoker status (B = 1.03, P = 0.04) and implant type (B = 1.41, P = 0.008) as factors associated with implant removal. Adjusting for age, the NNT with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backward calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% cost savings for suture buttons when considering reduced secondary operation rates. CONCLUSIONS A reduced secondary operation rate may offset increased implant charges for suture button syndesmotic fixation when considering institutional implant removal rates for operations occurring in tertiary care settings. Given these offsetting charges, surgeons should use the syndesmotic fixation strategy they deem most appropriate in their practice setting. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Zhong Q, Zhan J, Yang H, Zhu N, Feng R, Yao Y. A New Method of Nice Knot Elastic Fixation for Distal Tibiofibular Syndesmosis Injury. Orthop Surg 2023; 15:785-792. [PMID: 36710316 PMCID: PMC9977588 DOI: 10.1111/os.13635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE The distal tibiofibular syndesmosis (DTS) is a fretting joint and it is still a hot issue how to satisfy strong internal fixation while allowing fretting. This study described and evaluated a new method for elastic fixation of DTS injury with Nice Knot. METHODS The study was designed as a retrospective study. Between June 2020 and June 2021, 31 patients who were diagnosed with ankle fracture and DTS injury without additional orthopedic injuries were enrolled in this case series. The study included 22 males and nine females, with an average age of 34.71 ± 14.66 years. All patients were treated with Nice Knot binding for DTS. Surgical time, length of stay, time of DTS fixation, total weight-bearing time, complications, imaging parameters, and functional scores at follow-up were recorded. Paired sample t-tests or single factor analyses of variance were used at intra-group comparison. RESULTS All patients completed surgery with normal syndesmotic parameters. The recovery of DTS injury was verified by Hook and lateral malleolus rotation tests. The average follow-up time was 15.97 ± 3.30 months. Only one case showed superficial infection after surgery, and the wound healed after symptomatic treatment. In terms of imaging, there were no significant differences in tibiofibular clear space (TFCS), tibiofibular overlap distance (TFOS), medial clear space (MCS), and superior clear space (SCS) immediately and at different follow-up points after surgery. All obtained excellent and good outcomes according to the AOFAS score at least follow-up after surgery. CONCLUSIONS Nice Knot elastic fixation of DTS injury is firm and stable while maintaining the physiological micromotion of the ankle joint.
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Affiliation(s)
- Qigang Zhong
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Junfeng Zhan
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Hu Yang
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Nan Zhu
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Ru Feng
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Yunfeng Yao
- Second Affiliated Hospital of Anhui Medical UniversityHefeiChina
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Xu B, Wang S, Tan J, Chen W, Tang KL. Comparison of Suture Button and Syndesmotic Screw for Ankle Syndesmotic Injuries: A Meta-analysis of Randomized Controlled Trials. Orthop J Sports Med 2023; 11:23259671221127665. [PMID: 36636033 PMCID: PMC9830096 DOI: 10.1177/23259671221127665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/02/2022] [Indexed: 01/07/2023] Open
Abstract
Background The syndesmotic screw (SS) and suture button (SB) fixation methods are both widely used for the reduction of ankle syndesmotic injury, with varying outcomes. Purpose To review recently published randomized controlled trials (RCTs) to assess the outcomes between SS and SB fixation for ankle syndesmotic injury. Study Design Systematic review; Level of evidence, 1. Methods The PubMed, Embase, ClinicalTrials.gov, and Cochrane databases were searched for relevant RCTs published between 1966 and 2021 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies were RCTs comparing SS and SB fixation for ankle syndesmotic injury. The risk of bias was evaluated using the Cochrane Risk of Bias tool. Primary outcomes included complications, malreduction, and unplanned reoperation, and secondary outcomes were the American Orthopaedic Foot & Ankle Society (AOFAS) score, Olerud-Molander ankle score (OMAS), and EuroQol-5 Domain (EQ-5D) score. The mean difference (MD) and risk ratio (RR) were calculated for continuous and dichotomous outcomes, respectively. Random- or fixed-effects model was applied according to heterogeneity. Results Of 389 studies, 8 RCTs involving 512 patients were included. Overall, 257 patients received SS fixation and 255 patients received SB fixation. The 2 groups did not differ significantly in malreduction (RR, -0.06; 95% CI, -0.18 to 0.07) or EQ-5D (MD, 0.01; 95% CI, -0.01 to 0.03). However, the SB group showed significant advantages over the SS group in complications (RR, 0.42; 95% CI, 0.26 to 0.66), unplanned reoperation (RR, 0.62; 95% CI, 0.43 to 0.89), AOFAS score (MD, 3.04; 95% CI, 1.77 to 4.31), and OMAS (MD, 4.51; 95% CI, 1.54 to 7.48). The risk of bias of the included studies was acceptable. Conclusion The results showed that there were no significant differences between the SS and SB groups in malreduction and EQ-5D scores. However, the SB group had significantly better local irritation rates, unplanned reoperation rates, AOFAS scores, and OMASs.
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Affiliation(s)
- Baoyun Xu
- Sports Medicine Center, Southwest Hospital of Army Medical
University, Chongqing, China
| | - Shanshan Wang
- Department of Pain and Rehabilitation, Xinqiao Hospital of Army
Medical University, Chongqing, China
| | - Jindong Tan
- Sports Medicine Center, Southwest Hospital of Army Medical
University, Chongqing, China
| | - Wan Chen
- Sports Medicine Center, Southwest Hospital of Army Medical
University, Chongqing, China.,Kang-lai Tang, MD, or Wan Chen, MD, Southwest Hospital of Army
Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing,
China ( or
)
| | - Kang-lai Tang
- Sports Medicine Center, Southwest Hospital of Army Medical
University, Chongqing, China.,Kang-lai Tang, MD, or Wan Chen, MD, Southwest Hospital of Army
Medical University, No. 30 Gaotanyan Street, Shapingba District, Chongqing,
China ( or
)
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Klepacki K, Kowal I, Konieczny G, Tomczyk Ł, Miękisiak G, Morasiewicz P. Radiographic Assessment of Tibiofibular Syndesmosis Injury with Different Durations and Types of Fixation. J Clin Med 2022; 11:jcm11216331. [PMID: 36362557 PMCID: PMC9657914 DOI: 10.3390/jcm11216331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction: There is no consensus among orthopedic surgeons on the number of cortical layers (tricortical or quadricortical fixation) involved or the duration of syndesmotic fixation after a tibiofibular syndesmosis (TFSD)-injury treatment. The purpose of this study was to assess radiographic parameters following the treatment of TFSD injuries, with various time-windows of syndesmotic screw removal and numbers of cortical layers involved. Materials and Methods: Fifty-five patients, aged from 25 to 75 years, were included in the study. The follow-up period ranged from 2 years to 4 years and 2 months. The patients were subdivided into groups based on the duration of the syndesmotic fixation (8–15 weeks—19 patients or 16–22 weeks—36 patients) and the number of cortices involved (tricortical—17 patients or quadricortical fixation—38 patients). Results: The quadricortical fixation group showed a significant development of ankle joint arthritis and subtalar joint arthritis at the final follow-up. The mean medial clear space was 2.84 mm in the tricortical fixation group and 3.5 mm in the quadricortical fixation group (p = 0.005). Both groups, with different screw removal times showed significant development of posttraumatic arthritis. A comparison of the two groups (with different time-windows of the screw removal) revealed a significant difference only in terms of the postoperative tibiofibular (TF) overlap and the observed rates of talonavicular arthritis at the final follow-up. Discussion: We found that the duration of the screw fixation had no effect on most of the evaluated radiographic parameters. Only the postoperative TF overlap was lower in the 8–15-week fixation group, and the proportion of patients with talonavicular joint arthritis at the final follow-up was higher in the 16–22-week fixation group. In addition, the number of cortices involved in the screw fixation had no effect on the radiographic outcomes in our patients, apart from the differences in one parameter—the medial clear space—at the final follow-up. Conclusion: We achieved similar radiographic results irrespective of the duration of the screw fixation and the number of cortices involved. All study subgroups showed the development of adjacent-joint arthritis following treatment. Considering the results of our study, the economic and medical aspects of treatment, and the possibility of a faster recovery, the most optimal solution seems to be the use of a tricortical fixation, with the screws being removed after 8–15 weeks.
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Affiliation(s)
- Krzysztof Klepacki
- Orthopedic Surgery Department, Provincial Specialist Hospital in Legnica, Iwaszkiewicza 5, 59-220 Legnica, Poland
| | - Igor Kowal
- Orthopedic Surgery Department, Provincial Specialist Hospital in Legnica, Iwaszkiewicza 5, 59-220 Legnica, Poland
| | - Grzegorz Konieczny
- Faculty of Health Sciences and Physical Education, The Witelon State University of Applied Sciences in Legnica, 59-220 Legnica, Poland
| | - Łukasz Tomczyk
- Department of Management of Food Quality and Safety, Poznan University of Life Sciences, 60-637 Poznań, Poland
| | - Grzegorz Miękisiak
- Institute of Medical Sciences, University of Opole, ul. Oleska 48, 45-052 Opole, Poland
| | - Piotr Morasiewicz
- Department of Orthopaedic and Trauma Surgery, Institute of Medical Sciences, University of Opole, al. Witosa 26, 45-401 Opole, Poland
- Correspondence:
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“Flexible nature of fixation” in syndesmotic stabilization of the inferior tibiofibular joint affects the radiological reduction outcome. INTERNATIONAL ORTHOPAEDICS 2022; 46:2649-2657. [PMID: 35982324 PMCID: PMC9556355 DOI: 10.1007/s00264-022-05550-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/11/2022] [Indexed: 11/01/2022]
Abstract
Abstract
Purpose
Fibular mobility after suture button stabilization (SBS) of inferior tibiofibular joint (syndesmosis) injuries has been described. This effect is called the “flexible nature of fixation (FNF).” In this study, we aimed to quantify FNF in syndesmotic stabilization.
Methods
Postoperative bilateral computed tomography (CT) of ankle fractures with syndesmosis stabilization by SBS or syndesmotic screw (SYS) was retrospectively analyzed. The transverse offset (TO) and vertical offset (VO) were defined by evaluating the drill channels. The reduction outcome was evaluated by the side-to-side difference between the clear space and the anterior tibiofibular distance (antTFD). The calculated anterior tibiofibular distance (cal-antTFD) was calculated by subtracting the TO from the validated antTFD. Subsequently, a reevaluation of the reduction outcomes after SYS or SBS stabilization was performed using cal-antTFD.
Results
Sixty patients (44 with SBS and 16 with SYS stabilization) were analyzed. The intra-rater and inter-rater reliabilities for TO and VO were excellent (α > 0.92). SYS stabilization showed lower mean TO (− 0.02 mm; SD 0.14) and VO (0.11 mm; SD, 0.29 mm) than SBS stabilization (TO 1.16 mm, SD 1.4 mm; VO 0.2 mm, SD 0.8 mm; p = 0.001). The rate of malreduction according to cal-antTFD was higher than that of antFTD (p = 0.033).
Conclusion
The presented method, which evaluates the position of the tibial to the fibular drill channel, allowed the quantification of the “FNF.” The often described difference in the dynamic stabilization of SBS compared to the rigid stabilization by SYS could be objectified. Considering cal-antTFD illustrates that FNF potentially reduces the rate of malreduction in SBS stabilization.
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Cao MM, Zhang YW, Hu SY, Rui YF. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg 2022; 9:965814. [PMID: 36017521 PMCID: PMC9398172 DOI: 10.3389/fsurg.2022.965814] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ankle fracture-dislocations are one of the most severe types of ankle injuries. Compared to the simple ankle fractures, ankle fracture-dislocations are usually more severely traumatized and can cause worse functional outcomes. The purpose of this study was to review the previous literatures to understand the anatomy, mechanisms, treatment, and functional outcomes associated with ankle fracture-dislocations. METHODS The available literatures from January 1985 to December 2021 in three main medical databases were searched and analyzed. The detailed information was extracted for each article, such as researchers, age, gender, groups, type of study, type of center research, level of evidence, significant findings, study aim, cause of injury, time from injury to surgery, type of fracture, direction of dislocation, follow-up, postoperative complications and functional evaluation scores. RESULTS A total of 15 studies (1,089 patients) met the inclusion criteria. Only one study was a prospective randomized trial. The top-ranked cause of injury was high-energy injury (21.3%). Moreover, the most frequent type of fracture in ankle dislocations was supination-external rotation (SER) ankle fracture (43.8%), while the most common directions of dislocation were lateral (50%) and posterior (38.9%). CONCLUSIONS Collectively, most ankle fracture-dislocations are caused by high-energy injuries and usually have poor functional outcomes. The mechanism of injury can be dissected by the ankle anatomy and Lauge-Hansen's classification. The treatment of ankle fracture-dislocations still requires more detailed and rational solutions due to the urgency of occurrence, the severity of injury, and the postoperative complications.
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Affiliation(s)
- Mu-Min Cao
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yuan-Wei Zhang
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Sheng-Ye Hu
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yun-Feng Rui
- Department of Orthopaedics, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, China
- Trauma Center, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Aitor IG, Galvez-Sirvent E, Martinez-Diez JM, Pallares-Sanmartín J, Kalbakdij-Sanchez C, Mills S, Rubio-Suarez JC, Gil-Garay E, Rodriguez-Merchan EC. Comparative CT Study on Syndesmosis Mobility after Static or Dynamic Fixation for Ankle Fractures with Syndesmotic Rupture: A Pilot Study. THE ARCHIVES OF BONE AND JOINT SURGERY 2022; 10:702-711. [PMID: 36258740 PMCID: PMC9569140 DOI: 10.22038/abjs.2022.61845.3020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/15/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The objective of this prospective randomized pilot study is to compare, by computed tomography (CT), the mobility of syndesmosis after static fixation (SF) or dynamic fixation (DF) in ankle fractures with syndesmotic rupture (AFSR) in adults, and to compare this mobility with that of healthy ankles. METHODS Forty-two patients with an AFSR were randomized to 2 groups: SF (N=21) or DF (N=21). Seven patients were lost to follow-up. Ultimately, 35 patients (SF, N=20; DF, N=15) were analyzed. The clinical results were assessed with the American Orthopedic Foot and Ankle Society scale. To assess syndesmosis mobility, CT in 30° of plantar flexion (PFlex) and 20° of dorsal flexion (DFlex) was performed on both ankles one year after the fracture. Four parameters were measured: anterior tibiofibular distance, posterior tibiofibular posterior distance, angle of fibular rotation (AFR), and anteroposterior fibular translation. RESULTS The AFR between DFlex and PFlex was more similar to the non-affected side in the DF group. The other three parameters showed no statistical differences between types of fixation. The mean loss of AFR compared with the non-affected side was 1.2° in the SF group and 0.1° in the DF group. No clinical differences between the SF group and the DF group were found. No correlation between clinical and radiological results was observed. CONCLUSION The AFR was more similar to the non-affected side in the DF group. However, this finding did not correlate with a better clinical result.
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Affiliation(s)
- Ibarzabal-Gil Aitor
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
| | - Elena Galvez-Sirvent
- Department of Orthopedic Surgery, Infanta Elena University Hospital, Valdemoro, Madrid, Spain
| | | | | | | | - Sarah Mills
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
| | - Juan C. Rubio-Suarez
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
| | - Enrique Gil-Garay
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
| | - E. Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital-IdiPaz, Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research, IdiPAZ (La Paz University Hospital, Autonomous University of Madrid), Madrid, Spain
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Hookway S, Lambers A, Page R, Bedi H. The Australian ankle syndesmosis injury survey. Injury 2022; 53:2304-2310. [PMID: 35219537 DOI: 10.1016/j.injury.2022.02.024] [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: 11/11/2021] [Revised: 01/29/2022] [Accepted: 02/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND & OBJECTIVE The ankle syndesmosis is frequently disrupted in ankle injuries, with higher incidence in concomitant ankle fractures. There is debate regarding the most appropriate surgical management of these injuries, with the development of suture-button devices challenging the conventional approach of surgical stabilisation with syndesmotic screws. The primary aim of this study was to assess current practice variation at a national level, enabling a comparison with reported practice around the world. The secondary aims were to assess practice variation between operative indications and inconsistencies between surgeon device usage and personal preference should they be injured themselves. METHODS A 20-item survey detailing surgical experience, diagnosis, surgical management preference and a series of case studies was conducted. The survey was endorsed and promoted by the Australian Orthopaedic Association (AOA). RESULTS 125 responses were received during the three-month study period. The most commonly used method to stabilise a syndesmotic injury by Australian orthopaedic surgeons was two 3.5 mm screws (26.4%), closely followed by one suture-button (23.2%). Overall, 44% of surgeons employ a dynamic stabilisation method and 54.4% a static stabilisation method. Half of surgeons recommend routine removal of syndesmosis screws, and surgeons tend to use two devices for high Weber C fractures. One third of surgeons who most commonly use screws in their practice would actually prefer a suture-button for management of their own syndesmosis injury. CONCLUSION Significant variability remains in the management of syndesmosis injuries. This survey of Australian orthopaedic surgeons reveals higher suture-button device use when compared to other countries.
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Affiliation(s)
- Sam Hookway
- Barwon Health, Geelong, Victoria, Australia.
| | | | - Richard Page
- Barwon Health, Geelong, Victoria, Australia; St John of God Hospital, Geelong, Victoria, Australia; Barwon Centre for Orthopaedic Research and Education, IMPACT, School of Medicine, Deakin University, Geelong, Victoria, Australia
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Kang L, Helms E, Broadhead M. Bilateral ankle syndesmosis injury: a rare case report. Orthop Rev (Pavia) 2022. [DOI: 10.52965/001c.35494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This report describes a case of bilateral acute ankle syndesmosis injuries in a 15-year-old male basketball player. The patient had a background of previous inversion injuries but no symptoms of chronic pain or instability. The case report illustrates the importance of clinical suspicion when evaluating acute syndesmosis injuries in conjunction with radiographic assessments in primary care. This is the first reported case of such injury in bilateral limbs.
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Kang L, Helms E, Broadhead M. Bilateral ankle syndesmosis injury: a rare case report. Orthop Rev (Pavia) 2022; 14:35494. [PMID: 35769662 PMCID: PMC9235416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 05/03/2022] [Indexed: 06/15/2023] Open
Abstract
This report describes a case of bilateral acute ankle syndesmosis injuries in a 15-year-old male basketball player. The patient had a background of previous inversion injuries but no symptoms of chronic pain or instability. The case report illustrates the importance of clinical suspicion when evaluating acute syndesmosis injuries in conjunction with radiographic assessments in primary care. This is the first reported case of such injury in bilateral limbs.
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Application of an arched, Ni-Ti shape-memory connector in repairing distal tibiofibular syndesmosis ligament injury. BMC Musculoskelet Disord 2022; 23:476. [PMID: 35590289 PMCID: PMC9118800 DOI: 10.1186/s12891-022-05449-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the clinical effect of internal fixation of a Ni–Ti arched shape-memory connector in the treatment of distal tibiofibular syndesmosis ligament injury. Methods From January 2013 to January 2016, 108 cases of ankle fracture with distal tibiofibular syndesmosis ligament injury in our hospital were selected, and all of them were fixed with ASCs or screw fixation. The functional evaluation and efficacy evaluation were performed according to the Olerud Molander Ankle Score (Omas) and SF-36. At the same time, follow-ups recorded the incidence of postoperative complications: osteoarthritis, superficial infection, symptomatic hard and soft tissue irritation, early removal and poor reduction of internal fixation, and later loss of reduction. Results In the ASC(Ni–Ti Arched shape-memory Connector) group, the incidence of symptomatic hardware, soft tissue or superficial infection decreased to 2.77%(from 13.8% or 11.1% in SCREW group). The early removal rate(2.77%) of internal fixation was also lower than that of the screw group. While the incidence of osteoarthritis is 13.8% in SCREW group, the incidence of osteoarthritis in the later follow-up was also as low as 1.38% in ASC group. Loss of fracture reduction due to removal of the fixation device for the distal tibiofibular syndesmosis ligament was not observed in the ASC group. With two postoperative scoring systems (OMAS and SF-36), patients in the ASC group significantly get higher score than that in SCREW group. Conclusion The design of the Ni–Ti arched shape-memory connector can be adapted to the irregular anatomical structure of the malleolus and the ability to continue to contract by body temperature. The use of ASCs in fixation of articular ligaments can preserve a slight range of motion, and the results suggest that ASCs can effectively reduce the incidence of fixation looseness, fracture, infection and other complications.
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Gadomski BC, Labus KM, Stewart HL, Bisazza KT, Nelson BB, Puttlitz CM, McGilvray KC, Regan DP, Easley JT. A Large Animal Model for Orthopedic Foot and Ankle Research. Front Vet Sci 2022; 9:816529. [PMID: 35187145 PMCID: PMC8850350 DOI: 10.3389/fvets.2022.816529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
Trauma to the soft tissues of the ankle joint distal syndesmosis often leads to syndesmotic instability, resulting in undesired movement of the talus, abnormal pressure distributions, and ultimately arthritis if deterioration progresses without treatment. Historically, syndesmotic injuries have been repaired by placing a screw across the distal syndesmosis to provide rigid fixation to facilitate ligament repair. While rigid syndesmotic screw fixation immobilizes the ligamentous injury between the tibia and fibula to promote healing, the same screws inhibit normal physiologic movement and dorsiflexion. It has been shown that intact screw removal can be beneficial for long-term patient success; however, the exact timing remains an unanswered question that necessitates further investigation, perhaps using animal models. Because of the sparsity of relevant preclinical models, the purpose of this study was to develop a new, more translatable, large animal model that can be used for the investigation of clinical foot and ankle implants. Eight (8) skeletally mature sheep underwent stabilization of the left and right distal carpal bones following transection of the dorsal and interosseous ligaments while the remaining two animals served as un-instrumented controls. Four of the surgically stabilized animals were sacrificed 6 weeks after surgery while the remaining four animals were sacrificed 10 weeks after surgery. Ligamentous healing was evaluated using radiography, histology, histomorphometry, and histopathology. Overall, animals demonstrated a high tolerance to the surgical procedure with minimal complications. Animals sacrificed at 10 weeks post-surgery had a slight trend toward mildly decreased inflammation, decreased necrotic debris, and a slight increase in the healing of the transected ligaments. The overall degree of soft tissue fibrosis/fibrous expansion, including along the dorsal periosteal surfaces/joint capsule of the carpal bones was very similar between both timepoints and often exhibited signs of healing. The findings of this study indicate that the carpometacarpal joint may serve as a viable location for the investigation of human foot and ankle orthopedic devices. Future work may include the investigation of orthopedic foot and ankle medical devices, biologic treatments, and repair techniques in a large animal model capable of providing translational results for human treatment.
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Affiliation(s)
- Benjamin C. Gadomski
- Orthopedic Bioengineering Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, CO, United States
- *Correspondence: Benjamin C. Gadomski
| | - Kevin M. Labus
- Orthopedic Bioengineering Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, CO, United States
| | - Holly L. Stewart
- Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Katie T. Bisazza
- Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Brad B. Nelson
- Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Christian M. Puttlitz
- Orthopedic Bioengineering Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, CO, United States
| | - Kirk C. McGilvray
- Orthopedic Bioengineering Research Laboratory, Department of Mechanical Engineering and School of Biomedical Engineering, Colorado State University, Fort Collins, CO, United States
| | - Daniel P. Regan
- Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO, United States
| | - Jeremiah T. Easley
- Preclinical Surgical Research Laboratory, Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
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Gilbertson JA, Sweet MC, Weistroffer JK, Jastifer JR. Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation. Foot Ankle Int 2022; 43:186-192. [PMID: 34493113 DOI: 10.1177/10711007211041325] [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] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey A Gilbertson
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Matthew C Sweet
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
| | - Joseph K Weistroffer
- Department of Orthopaedic Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA
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