Injuries of the distal lower extremity syndesmosis

Immediate Weightbearing After Operative Treatment of Bimalleolar and Trimalleolar Ankle Fractures: Faster Return to Work for Patients with Nonsedentary Occupations

The goal of this study was to compare immediate weightbearing (IWB) and traditional weightbearing (TWB) postoperative protocols in unstable ankle fractures, as this has not been compared in prior works. We hypothesize that an immediate weightbearing protocol after ankle fracture fixation will lead to an earlier return to work. An ankle fracture registry was reviewed for operatively treated unstable bimalleolar and trimalleolar ankle fractures at an ambulatory surgery center and followed up at associated outpatient clinics. All fracture cases reviewed occurred from 2009 to 2015. Immediate weightbearing patients were placed into a controlled ankle motion (CAM) boot and allowed to fully bear weight the day of surgery. Traditional weightbearing patients were placed into a CAM boot with 6 weeks of non-weightbearing. Demographics, fixation technique, and injury characteristics were surveyed. Physical job demand was stratified for 69 patients meeting the inclusion criteria (34 IWB and 35 TWB). The main outcome of this study was measured as the time to return to work. Subgroup analysis of patients with nonsedentary jobs demonstrated a significantly earlier return to work for the IWB group (5.7 versus 10.0 weeks, p = .04). Multivariate regression analysis identified a statistically significant 2.25-week (p = .05) earlier return to work for the IWB group after adjustment for occupational physical demand, demographics, fracture characteristics, and participation in a light work period before full work return. In patients with nonsedentary jobs, an IWB protocol after operative management of bimalleolar and trimalleolar ankle fractures resulted in an earlier return to work compared with traditional protocols.

A novel method of using elastic bionic fixation device for distal tibiofibular syndesmosis injury

PURPOSE

To describe and evaluate the novel method of using elastic bionic fixation device in treating the distal tibiofibular syndesmosis (DTS) injury.

METHODS

From June 2013 to January 2014, 17 subjects with ankle fractures combined with DTS separation were treated by the elastic bionic fixation device. The syndesmotic parameters, healing, functional scores, and possible complications were recorded.

RESULTS

All patients had a mean follow-up of 23.35 ± 4.39 months (range, 15-28 months). Syndesmotic parameters returned to normal after surgery and remained normal throughout the follow-up period. X-ray examinations at 12 months follow-up showed no cable breakage of the elastic bionic fixation device or instrument invalidation compared to that of immediate post-operative X-ray films. Besides, no signs of articular degeneration and arthritis were observed. Furthermore, change in bone density near the fibular fixing button or tibial screw nut was also not detected. Primary wound healing was observed in 16 patients, while the remaining one showed redness and swelling of lateral ankle incision and got wound healing after seven to ten  days of antibiotic therapy and local radio frequency physiotherapy. All obtained excellent and good outcomes according to the AOFAS score at 12 months after surgery.

CONCLUSIONS

The use of elastic bionic fixation device appears to be a promising option in treating DTS injury because it can provide stable and reliable elastic fixation, good functional recovery, and relatively fewer complications.

Distal Tibiofibular Syndesmosis: Anatomy, Biomechanics, Injury and Management

A stable and precise articulation of the distal tibiofibular syndesmosis is essential for normal motion of the ankle joint. Injury to the syndesmosis occurs through rupture or bony avulsion of the syndesmotic ligament complex. External rotation of the talus has been identified as the major mechanism of syndesmotic injury. None of the syndesmotic stress tests was sensitive or specific; therefore the diagnosis of syndesmotic injury should not be made based on the medical history and physical examination alone. With the improvement in ankle arthroscopic technique, it can be used as a diagnostic and therapeutic tool in the management of distal tibiofibular syndesmosis injury.

Effects of inferior tibiofibular syndesmosis injury and screw stabilization on motion of the ankle: a finite element study

PURPOSE

Traditional studies of syndesmosis injury and screw stabilization have been conducted in cadaveric models, which cannot yield sufficient and exact biomechanical data about the interior of the ankle. The purpose of this study was to evaluate the effects of inferior tibiofibular syndesmosis injury (ITSI) and screw stabilization on the motion of the ankle with finite element analysis.

METHODS

Three-dimensional models of the ankle complex were created with CT images of a volunteer's right ankle in three states: normal, post-ITSI, and stabilization with a screw 2.5 cm above (parallel to) the ankle. Simulated loads were applied under three conditions: neutral position with single foot standing, internal rotation, and external rotation of the ankle.

RESULTS

Compared with the normal state, ITSI increased the relative displacement between the lower extremes of the tibia and fibula in the anteroposterior and mediolateral directions and the angular motion of the tibia, fibula, and talus at internal and external rotations (ERs). However, when stabilized with syndesmotic screws, the range of motion (ROM) and all these parameters significantly decreased.

CONCLUSION

ITSI can lead to internal and ER instability of the ankle joint. Screw stabilization is effective in controlling the instability, but may reduce markedly the ROM of the ankle joint. Through this study, it can be proposed that the screws should be removed once the healing is gained in order to restore normal function of the ankle joint as soon as possible.

Can We Tell if the Syndesmosis Is Reduced Using Fluoroscopy?

OBJECTIVE

To evaluate the ability of surgeons to determine whether the fibula is reduced in the sagittal plane in relation to the tibia based on the fluoroscopic images by comparison with the known normal for both the ipsilateral and contralateral ankles.

METHODS

Perfect lateral radiographs of both ankles were obtained in 7 cadaveric specimens. The fibula was translated 2.5 and 5 mm in the anterior and posterior directions. Four orthopaedic trauma-trained surgeons were presented with a fictitious case consisting of a "normal" image, followed by 10 randomly selected images from both ankles, and were asked to determine whether the fibula was reduced, or displaced anteriorly or posteriorly. The ability of the surgeons to identify displacement and interobserver reliability was assessed.

RESULTS

The surgeons were better able to identify malreduction than reduction (negative predictive value (NPV) 95% ipsilateral, 85% contralateral). The overall sensitivity for reduction was 94% for the ipsilateral ankle, but only 68% for the contralateral ankle. Anterior displacement and greater magnitudes of displacement were most easily diagnosed. All reviewers had the most difficulty with 2.5 mm of posterior displacement. The intraobserver agreement was excellent for anterior displacement and 5 mm of displacement in either direction (kappa = 0.71/0.75). Surgeons who routinely used the contralateral lateral radiograph were more accurate.

CONCLUSIONS

Although it is unknown how much translational displacement of the syndesmosis is acceptable, it seems that the experienced surgeon will be able to reduce the joint within 2.5 mm and that fluoroscopic comparisons to the normal ankle are helpful in determining malreduction.

Prognosis of ankle syndesmosis injury

PURPOSE

Ankle syndesmosis injury has been associated with persistent pain and prolonged recovery; however, no predictors of prolonged recovery have been identified. The aims of this study were to establish prognosis for ankle syndesmosis injury compared with a lateral ankle sprain and to explore factors associated with prolonged recovery.

METHODS

Participants (n = 63) age 21 ± 3.2 yr, with acute ankle ligament injuries (diagnosed through magnetic resonance imaging), were recruited from 10 sport clubs and sports medicine and physiotherapy clinics in two Australian cities. Follow-up was until full recovery and with preinjury activity level. Time to return to play was compared between injury types using Kaplan-Meier survival curves. Secondary analysis investigated putative factors that increased risk of prolonged recovery. For this analysis, participants unrecovered at 2 wk completed the following: Fear Avoidance Beliefs Questionnaire (FABQ); Star Excursion Balance Test, weight-bearing lunge, and vertical jump (VJ). These variables were correlated with time to recovery using bivariate Pearson's r correlation coefficient.

RESULTS

The median recovery time for conservatively treated ankle syndesmosis injury was 62 and 15 d for lateral sprain. The sport-specific subscale scores of the FABQ were significantly higher (P = 0.017) for the ankle syndesmosis group, whereas vertical jump height was lower for this group, (P = 0.052). No baseline variables were strong predictors (r ≥ 0.6) of recovery. Moderate correlations were found for VJ (r = -0.471, P = 0.004) and the sport-specific subscale of the FABQ (r = 0.463, P = 0.004).

CONCLUSIONS

Conservatively treated ankle syndesmosis injuries took four times longer to recover than lateral ankle sprain. Tests such as VJ and FABQ may identify individuals at risk of prolonged recovery and allow health professionals to determine realistic and appropriate time to recovery.

Analysis of the stress and displacement distribution of inferior tibiofibular syndesmosis injuries repaired with screw fixation: a finite element study

BACKGROUND

Studies of syndesmosis injuries have concentrated on cadaver models. However, they are unable to obtain exact data regarding the stress and displacement distribution of various tissues, and it is difficult to compare models. We investigated the biomechanical effects of inferior tibiofibular syndesmosis injuries (ITSIs) and screw fixation on the ankle using the finite element (FE) method.

METHODOLOGY/PRINCIPAL FINDINGS

A three-dimensional model of a healthy ankle complex was developed using computed tomography (CT) images. We established models of an ITSI and of screw fixation at the plane 2.5 cm above and parallel to the tibiotalar joint surface of the injured syndesmosis. Simulated loads were applied under three conditions: neutral position with single-foot standing and internal and external rotation of the ankle. ITSI reduced contact forces between the talus and fibula, helped periarticular ankle ligaments withstand more load-resisting movement, and increased the magnitude of displacement at the lower extreme of the tibia and fibula. ITSI fixation with a syndesmotic screw reduced contact forces in all joints, decreased the magnitude of displacement at the lower extreme of the tibia and fibula, and increased crural interosseous membrane stress.

CONCLUSIONS/SIGNIFICANCE

Severe syndesmosis injuries cause stress and displacement distribution of the ankle to change multidirectional ankle instability and should be treated by internal fixation. Though the transverse syndesmotic screw effectively stabilizes syndesmotic diastasis, it also changes stress distribution around the ankle and decreases the joint's range of motion (ROM). Therefore, fixation should not be performed for a long period of time because it is not physiologically suitable for the ankle joint.