Augmenting Suture-Button Fixation for Maisonneuve Injuries With Fibular Shortening: Technique Tip

Role of Lateral Ankle Ligaments in Vertical Stability of the Fibula: A Cadaveric Model

BACKGROUND

In unstable ankle fractures, the role of the deltoid and syndesmosis ligaments has been widely studied. However, it is uncertain what the importance of the lateral ankle ligament complex (LALC) is in the vertical stability of the fibula. Given its anatomical position, it should prevent the proximal translation of the fibula. This study aims to evaluate the role of the LALC in stabilizing the fibula in the vertical plane.

METHODS

Eleven below-knee cadaveric specimens were used in this study. Proximal traction of the fibula was performed by applying 50 N in the intact state and after sequential transection of the syndesmotic ligaments, anterior talofibular ligament (ATFL), and the calcaneofibular ligament (CFL). At each stage, the proximal displacement of the fibula was measured. One-way repeated measures analysis of variance with post hoc Bonferroni correction was carried out to determine any significant differences between the groups. A P value <.05 was considered statistically significant.

RESULTS

The vertical displacement of the fibula in the intact state, and after sequential transection of syndesmotic ligaments, ATFL, and CFL was 1.96 ± 1.19 mm, 3.96 ± 1.33 mm, 5.9 ± 1.73 mm, and 10.22 ± 2.76 mm, respectively. There was no significant difference in the proximal displacement of the fibula between the intact and the syndesmotic ligaments groups (P < .05). However, when the syndesmotic ligaments were transected in conjunction with ATFL ± CFL, a significant difference was observed compared to the intact state (P < .001).

CONCLUSION

The complete disruption of syndesmotic ligaments did not significantly increase the proximal displacement of the fibula. However, when the ATFL ± CFL were additionally disrupted, there was a significant increase in the vertical translation of the fibula.

CLINICAL RELEVANCE

To our knowledge, this is the first study describing that LALC plays a paramount role in the vertical stability of the fibula. Concomitant syndesmosis and LALC should be suspected in an axially unstable fibular fracture with a significant proximal displacement.

Compensation of Dynamic Fixation Systems in the Quality of Reduction of Distal Tibiofibular Joint in Acute Syndesmotic Complex Injuries: A CT-Based Analysis

BACKGROUND

There is an ongoing discussion on how to best stabilize syndesmotic injuries. Previous studies have indicated a better quality of reduction of the distal tibiofibular joint (DTFJ) for the suture button systems compared to syndesmotic screw fixation. Still, the reason for this superiority remains unclear. The aims of this retrospective study were to (1) analyze the deviation of the tibial and fibular drilling tunnels of the suture button system and (2) to compare these to the quality of reduction of the DTFJ assessed on bilateral postoperative CT images.

METHODS

Included were all adult patients who underwent syndesmotic stabilization for an acute injury using a suture button system, with postoperative, bilateral CT imaging over a 10-year period. A total of 147 patients were eligible. Based on individually reconstructed axial CT slices, the postoperative quality of reduction of the DTFJs was rated on bilateral CT images. Furthermore, the rotation and translation of the suture button drilling tunnels were analyzed. Based on these measurements, the intraoperative reduction of the DTFJ was recalculated and again rated. Using these values, the correction potential of suture button systems on the reduction of the DTFJ was analyzed.

RESULTS

(1) The drilling tunnel deviated considerably for both rotation |2.3±2.1 degrees| (range: |0.0-13.1 degrees|) and translation |0.9±0.8 mm| (range: |0-4.3 mm|). Based on the deviation of the drilling tunnels in fibula and tibia, the calculated intraoperative reduction of the DTFJ was classified as malreduced in 35.4%. (2) The DTFJ was postoperatively identified as malreduced in 17% of patients. Overall, the suture button system tended to compensate toward a more anatomical reduction both in the axial and sagittal plane.

CONCLUSION

A suture button system postoperatively deviates and apparently has the capacity to compensate for intraoperative malreduction. Analysis of the drilling tunnels revealed that the use of a rigid fixation system would have doubled the postoperative malreduction rate.

Maisonneuve Fractures of the Ankle: A Critical Analysis Review

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Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures.

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The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT).

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The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN.

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Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome.

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Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.

Indications and Surgical Treatment of Acute and Chronic Tibiofibular Syndesmotic Injuries with and Without Associated Fractures

Syndesmosis injury may occur in a wide variety of clinical scenarios. Accurate diagnosis and anatomic reconstruction are necessary for optimizing clinical outcomes. The management considerations of syndesmotic injuries with associated proximal fibula fractures are reviewed. Methods to improve the accuracy of syndesmotic reduction are outlined. The management of fractures of the posterior malleolus, Chaput tubercle, and Wagstaffe tubercle is discussed with an emphasis on their contributions to syndesmotic stability. The evolving role of flexible fixation for syndesmosis injuries is discussed. Causes and strategies for dealing with loss of reduction and malreduced syndesmotic injuries are presented.

Randomized trial comparing suture button with single 3.5 mm syndesmotic screw for ankle syndesmosis injury: similar results at 2 years

Background and purpose - Better outcomes are reported for suture button (SB) compared with syndesmotic screws (SS) in patients treated for an acute ankle syndesmotic injury. One reason could be that screws are more rigid than an SB. A single tricortical 3.5 mm syndesmotic screw (TS) is the most dynamic screw option. Our hypothesis is that 1 SB and 1 TS provide similar results. Therefore, in randomized controlled trial, we compared the results between SB and TS for syndesmotic stabilization in patients with acute syndesmosis injury. Patients and methods - 113 patients with acute syndesmotic injury were randomized to SB (n = 55) or TS (n = 58). The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was the primary outcome measure. Secondary outcome measures included Manchester Oxford Foot Questionnaire (MOXFQ), Olerud-Molander Ankle score (OMA), visual analogue scale (VAS), EuroQol- 5D (EQ-5D), radiologic results, range of motion, complications, and reoperations (no implants were routinely removed). CT scans of both ankles were obtained after surgery, and after 1 and 2 years. Results - The 2-year follow-up rate was 84%. At 2 years, median AOFAS score was 97 in both groups (IQR SB 87-100, IQR TS 90-100, p = 0.7), median MOXFQ index was 5 in the SB group and 3 in the TS group (IQR 0-18 vs. 0-8, p = 0.2), and median OMA score was 90 in the SB group and 100 in the TS group (IQR 75-100 vs. 83-100, p = 0.2). The syndesmotic reduction was similar 2 years after surgery; 19/55 patients in the SB group and 13/58 in the TS group had a difference in anterior syndesmotic width ≥ 2 mm (p = 0.3). 0 patients in the SB group and 5 patients in the TS group had complete tibiofibular synostosis (p = 0.03). At 2 years, 10 TS were broken. Complications and reoperations were similar between the groups. Interpretation - We found no clinically relevant differences regarding outcome scores between the groups. TS is an inexpensive alternative to SB.

Strategies to Avoid Syndesmosis Malreduction in Ankle Fractures

Nearly half of surgically treated ankle fractures may have associated syndesmotic disruption, and the quality of reduction has been shown to affect functional outcomes. Malreduction ranges from 15% to 50% in the literature, and achieving anatomic reduction remains a significant challenge, even for experienced surgeons. Keys to success include having a stepwise plan and an understanding of reliable fluoroscopic parameters to help achieve reduction in both the coronal and sagittal planes. This article summarizes the literature on syndesmotic reduction and provides the authors' preferred technique using fluoroscopy.

Syndesmotic Fixation Utilizing a Novel Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes

Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants.Level of Evidence: Level IV: Retrospective case series.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

Getting the Starting Point Right: Prevention of Skiving and Fibular Cortical Breach During Suture Button Placement for Syndesmotic Ankle Injuries

The use of suture button (SB) devices in the treatment of syndesmotic ankle injuries is increasing. These constructs have demonstrated better syndesmotic reduction, improved clinical outcomes, and lower rates of hardware removal compared with screw fixation. However, placing a SB device without a fibular plate can be technically challenging. In this technique tip, we use an illustrative case to demonstrate a technique tip that minimizes the risk of anterior or posterior cortical breach of the fibula and helps facilitate more accurate placement of a SB device.Levels of Evidence: Level V: Expert opinion.

[Comparison of bioabsorbable screw and metallic screw for Maisonneuve fracture]

Objective

To compare the clinical and radiographic outcomes of bioabsorbable screw and metallic screw for Maisonneuve fracture.

Methods

The clinical data of 68 patients of Maisonneuve fracture treated with open reduction and internal fixation between October 2012 and October 2016 were retrospectively analyzed. Metallic screw fixation was used in 37 cases (group A) and absorbable screw fixation was used in 31 cases (group B). There was no significant difference in age, gender, weight, operated side, cause of injury, time from injury to operation, and complications between the two groups ( P>0.05). At last follow-up, the tibiafibular clear space (TFCS), tibiafibular overlap (TFO), medial clear space (MCS), and syndesmotic malreduction rate were recorded. And the dorsiflexion and plantar-flexion range of motion, pain visual analogue scale (VAS) score, ankle and hind foot score of American Orthopaedic Foot and Ankle Society (AOFAS), and Olerud-Molander (OM) score were recorded.

Results

All patients were followed up 25-43 months, with an average of 32.3 months. There was no significant difference in the operation time between the two groups ( t=1.229, P=0.282). All the fractures healed, and there was no significant difference in fracture healing time between the two groups ( t=1.367, P=0.413). At last follow-up, the syndesmotic malreduction rate of group A was 16.2% (6/37), showing no significant difference when compared with group B [6.2% (2/31)] ( χ ²=1.549, P=0.213). There were 3 complications in group A, 1 was superficial wound infection, 1 was local heterotopic ossification due to failure to remove the screws in time, 1 was local heterotopic ossification of the screws; and there were 2 complications in group B, 1 was rejection and 1 was local heterotopic ossification of the screws. There was no significant difference in the incidence of complications between the two groups ( χ ²=0.068, P=0.794). There was no significant difference in TFCS, MCS, TFO, ankle dorsiflexion and plantar-flexion range of motion, AOFAS score, OM score, and VAS score between the two groups at last follow-up ( P>0.05).

Conclusion

Compared with metallic screw, absorbable screws provide adequate fixation and functional recovery with avoiding screw removal and lower syndesmotic malreduction.