Treatment of a high-energy transsyndesmotic ankle fracture: A case report of "logsplitter injury"

High-Energy Transsyndesmotic Ankle Fracture Dislocation-Injury Characteristics, Radiographic Outcomes, and Factors Affecting the Rate of Posttraumatic Arthritis in Logsplitter Injuries

OBJECTIVES

To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing posttraumatic arthritis in high-energy transsyndesmotic ankle fracture dislocations or "logsplitter" injuries.

DESIGN

Retrospective cohort study.

SETTING

Academic level one trauma center.

PATIENTS/PARTICIPANTS

Twenty-seven adult patients with logsplitter injuries.

INTERVENTION

All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair.

MAIN OUTCOME MEASUREMENTS

The rate of posttraumatic arthritis at one year along with rate and reasons for reoperation.

RESULTS

Twenty-seven patients were included with a mean follow-up of 14.5 ± 12.5 months. At one-year postoperative, 14 of the 20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. The reoperation rate was 51.9%. There was no significant difference in the arthritis rate with the number of syndesmosis screws used, quality of reduction, or addition of deltoid repair.

CONCLUSIONS

The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.