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Spindler FT, Böcker W, Polzer H, Baumbach SF. A 3-Ligament Syndesmotic Injury Is at Higher Risk for Malreduction Than a 2-Ligament Injury: A CT-Based Analysis. Foot Ankle Int 2024:10711007241238227. [PMID: 38817051 DOI: 10.1177/10711007241238227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Syndesmotic malreduction is common and has been associated to an impaired outcome. Various risk factors for DTFJ malreduction have been postulated. The aims of this study were to assess the DTFJ malreduction rate based on (1) the severity of the syndesmotic injury, (2) the anatomy of the tibial incisura, and (3) the fixation device used in patients treated with suture-button systems. METHODS This retrospective, radiographic study included all adult patients who were treated for an acute, unilateral, and unstable syndesmotic injury with a suture-button system and postoperative bilateral CT imaging. Included were isolated syndesmotic injuries and fracture cases. The number of syndesmotic ligaments injured, that is, 2-ligament (AiTFL+IOL) and 3-ligament (AiTFL+IOL+PiTFL), was rated for each patient. The quality of DTFJ reduction, as well as the anatomy of the tibial incisura, was rated based on the postoperative, bilateral CT images and the intraoperative DTFJ reduction was recalculated based on the drilling-tunnel deviation. The possible influence on the DTFJ malreduction rate was assessed. RESULTS A total of 147 patients were included, and 94 and 53 patients had a 2- and 3-ligament syndesmotic injury, respectively. In addition, 113 patients were treated with a single-button system, 26 with a double suture-button system, and 8 with a hybrid fixation (suture-button + screw). Malreduction was significantly higher in 3-ligament compared with 2-ligament injuries, both intraoperatively (51% vs 27%; P = .003) and postoperatively (28% vs 11%; P = .006). The tibial anatomy had no significant influence on the malreduction rates. No significant differences were seen per the different fixation devices used independent of the number of ligaments injured. CONCLUSION This study did not find an influence of the incisura's anatomy on the DTFJ malreduction rate. However, we did find that 3-ligament syndesmotic injuries carried a higher risk of intra- and postoperative malreduction compared with 2-ligament injuries. LEVEL OF EVIDENCE Level III, retrospective radiologic study.
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Affiliation(s)
- Fabian Tobias Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Felix Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
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Penning D, Molendijk J, Halm JA, Schepers T. Measuring External Rotation of the Fibula and Fibular Length in Bilateral Computed Tomography Scans: How Reliable Is This Method? J Orthop Trauma 2024; 38:205-209. [PMID: 38306014 PMCID: PMC10942176 DOI: 10.1097/bot.0000000000002774] [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: 10/24/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVES During ankle fracture surgery, goals include accurate reduction and fixation of the fibula regarding rotation and fibular length. Bilateral postoperative computed tomography (CT) can be performed to assess fibular rotation using the talar dome angle, and fibular length. The aim of this study was to compare side-to-side differences of the fibular rotation and fibular length using bilateral CT scans of uninjured ankles. METHODS DESIGN Retrospective. SETTING Single center, Level I Academic Trauma Center. PATIENT SELECTION CRITERIA Patients with bilateral CT scans of uninjured ankles. OUTCOME MEASURES AND COMPARISONS External rotation using the Nault talar dome method and fibular length using the coronal method of Prior et al. The average, difference, and ratio (injured side/healthy side) and interobserver variability were calculated. RESULTS There were 83 patients included (166 ankles, mean age 47 years, 77.1% male). A random set of 66 ankles (33 CT scans) were used to measure interobserver variability. The mean degrees of external rotation ranged from 6.6 to 7.7, mean difference ranged from 1.4 to 3.4 degrees, mean ratio ranged from 1.1 to 1.5, and interobserver variability ranged from 0.27 to 0.65. For fibular length, the mean ranged from 24.6 to 25.8 mm, mean difference in fibular length ranged from 0.5 to 2.1 mm, mean ratio ranged from 1.0 to 1.1 mm, and interobserver variability ranged from 0.45 to 0.73. CONCLUSIONS Using bilateral ankle CT scans, mean differences in fibular rotation using the Nault talar dome method were 1.4-3.4 degrees. The distal fibular length had a mean difference between both sides of 0.5-2.1 mm. Although the intraclass correlation's were low, the interleg differences between patients were small, making them useful for clinical practice. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Diederick Penning
- Trauma Unit, Department of Surgery, Amsterdam UMC location Meibergdreef, Amsterdam, the Netherlands
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Tansey PJ, Chen J, Panchbhavi VK. Current concepts in ankle fractures. J Clin Orthop Trauma 2023; 45:102260. [PMID: 37872976 PMCID: PMC10589378 DOI: 10.1016/j.jcot.2023.102260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/09/2023] [Indexed: 10/25/2023] Open
Abstract
Ankle fractures are among the most common orthopaedic injuries. Operative management is performed in unstable ankle fracture patterns to restore the stability and native kinematics of the ankle mortise and minimize the risk of post-traumatic degenerative changes. In this study, we review current concepts in ankle fracture management, including posterior malleolus fixation, syndesmosis fixation, deltoid ligament repair, fibular nailing, and early weightbearing, from both a biomechanical and clinical perspective.
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Affiliation(s)
- Patrick J. Tansey
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Jie Chen
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
| | - Vinod K. Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Route 0165, Galveston, TX, 77555-0165, USA
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Dong QY, Wu Y, Wang CH, Park YW. A Novel Flexible Fixation Method for Syndesmotic Injury. Foot Ankle Int 2023; 44:854-861. [PMID: 37329236 DOI: 10.1177/10711007231177044] [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: 06/18/2023]
Abstract
BACKGROUND This study aims to evaluate the results and the safety of a novel fixation method we developed for syndesmosis injuries that we call the "embrace" technique. METHODS Between March 2018 and October 2020, a total of 67 patients with ankle fractures and syndesmotic injuries underwent syndesmosis fixation with the embrace technique at our institute. Plain radiographs and computed tomographic (CT) scans were obtained preoperatively. Postoperative radiographic assessment included anteroposterior (AP) and lateral radiographs and CT scans of both ankles. Additionally, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Olerud-Molander Ankle Score, and visual analog scale (VAS) score were used for postoperative assessment. RESULTS The mean age was 27.6 ± 10.9 (range, 14-56) years. The mean follow-up time was 30.3 ± 6.2 (range, 24-48) months. There were no malreductions indicated by any CT parameter except fibular rotation in a postoperative comparison between 2 sides. We found significant preoperative-postoperative changes in anterior difference, posterior difference, and fibular rotation but no significant preoperative-postoperative difference in fibular translation. There was no significant postoperative difference between the affected-side and normal-side measurements of any parameter. Complications included delayed wound healing, lateral pain because of wire knot irritation (11.9%), and medial fiber wire irritation (7.5%). The mean AOFAS, Olerud-Molander, and VAS scores at the last follow-up were 94.4 ± 6.8 (range, 84-100), 95.4 ± 6.1 (range, 80-100), and 0.68 ± 1.0 (range, 0-3) points, respectively. CONCLUSION In our cohort, this novel technique proved to be an effective method for syndesmosis fixation in patients with ankle fractures associated with very good radiologic and patient-reported outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Quan Yu Dong
- Department of Hand, Foot and Microsurgery, the Affiliated Hospital of Qingdao University, Qingdao City, Shandong Province, China
| | - Yong Wu
- Department Foot and Ankle Surgery, Yueyang People's Hospital of Hunan Province, Yue Yang, China
| | - Chen Han Wang
- Department of Hand, Foot and Microsurgery, the Affiliated Hospital of Qingdao University, Qingdao City, Shandong Province, China
| | - Yong Wook Park
- Department of Hand, Foot and Microsurgery, the Affiliated Hospital of Qingdao University, Qingdao City, Shandong Province, China
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Lenz CG, Urbanschitz L, Shepherd DW. Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace. Foot (Edinb) 2023; 56:102026. [PMID: 37001344 DOI: 10.1016/j.foot.2023.102026] [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: 10/31/2021] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program. MATERIALS AND METHODS Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardised postoperative rehabilitation protocol was established. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively. RESULTS The average follow-up was 13 months. The total FAAM score for ADL was 95 ± 4.9 % (range, 83 - 100 %) and for sport activities 87 ± 13.6 % (range, 50 - 100 %). The rating of mean postoperative function for ADL was 94 ± 5.5 % (range, 80 - 100 %) and 90 ± 13 % (range, 35 - 100 %) for sportv. The difference between acute and chronic injuries was statistically higher (p < 0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p = 0.9296 and p = 0.1615, respectively). Twenty-seven patients (90 %) rated their overall current level of function as normal or nearly normal. CONCLUSION This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries.
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Affiliation(s)
| | - Lukas Urbanschitz
- Department of Orthopaedic Surgery, Schulthess Klinik, Zurich, CH, Switzerland.
| | - David W Shepherd
- Western Health Victoria, Melbourne Orthopaedic Group, Victoria, Australia.
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Vohra R, Singh A, Thorat B, Patel D. Instability of the distal tibiofibular syndesmosis. J Orthop Surg (Hong Kong) 2023; 31:10225536231182349. [PMID: 37449812 DOI: 10.1177/10225536231182349] [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: 07/18/2023] Open
Abstract
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
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Affiliation(s)
- Rajeev Vohra
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Avtar Singh
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Babaji Thorat
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
| | - Dharmesh Patel
- Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India
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Spindler FT, Gaube FP, Böcker W, Polzer H, Baumbach SF. Value of Intraoperative 3D Imaging on the Quality of Reduction of the Distal Tibiofibular Joint When Using a Suture-Button System. Foot Ankle Int 2023; 44:54-61. [PMID: 36537750 PMCID: PMC9834319 DOI: 10.1177/10711007221138775] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The quality of reduction of the distal tibiofibular joint (DTFJ) has a major impact on the outcome. Novel suture-button systems as well as intraoperative 3D imaging can be applied to increase the quality of DTFJ reduction intraoperatively. The individual effect of either remains unknown. The aim of this study was to investigate the value of intraoperative 3D imaging on the quality of reduction of the DTFJ when using a suture-button system. METHODS Retrospective, radiographic study including adult patients who underwent surgical stabilization of the syndesmosis with a suture-button system for acute, unilateral, unstable syndesmotic injuries with postoperative bilateral CT imaging. The use of an intraoperative 3D scan was the individual surgeon's choice. Assessed was whether the intraoperative 3D imaging had an influence on the postoperative quality of DTFJ reduction and revision rates. These findings were put in perspective to the correction potential of the suture-button system. RESULTS A total of 147 patients were included; 76 of these received an intraoperative 3D imaging. Neither the rate of formal malreduction (17% vs 17%) nor the postoperative revision rate (4% vs 3%) differed significantly between patients with or without intraoperative 3D imaging. Intraoperative 3D imaging revealed a false-negative rate of 14%. The intrinsic correction potential of the suture-button system reduced the number of formally malreduced DTFJs in both groups by 51%. CONCLUSION The additional value of intraoperative 3D imaging to assess the quality of DTFJ reduction in our series did not improve syndesmotic reduction when using a flexible suture-button system. LEVEL OF EVIDENCE Level III, retrospective comparative cohort study.
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Affiliation(s)
- Fabian T. Spindler
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Federico P. Gaube
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Hans Polzer
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Sebastian F. Baumbach
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
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Safe drilling zones for anteriorly, central, and posteriorly angulated syndesmotic stabilization devices. Knee Surg Sports Traumatol Arthrosc 2022; 31:2199-2207. [PMID: 36547696 PMCID: PMC10183421 DOI: 10.1007/s00167-022-07291-x] [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: 08/29/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE The purposes of the study were to (1) analyze the shape of the distal fibula at the location of syndesmotic stabilization and to (2) define safe zones at the distal-lateral fibula for three different drilling tunnel orientations: anteriorly-, posteriorly angulated and center-center. METHODS Postoperative, bilateral CT images of adult patients that underwent syndesmotic stabilization (suture-button system) for an acute, unilateral ankle injury were analyzed. Manual axial CT reconstructions of the uninjured side were generated. First, the axial shape of the distal fibula was classified. The aspect ratio between the anterio-lateral and the posterior-lateral surfaces of the fibula was calculated to assess symmetry. Second, the same axial planes were used to define the safe zones. Each drilling-tunnel orientation (anterior, central, posterior) comprised a fixed medial tibial anchor point and a safe zone on the lateral fibula. For each of the three orientations, the most anteriorly and posteriorly drilling tunnel location was simulated. Next to a cumulative visual analysis, a quantitative analysis of the most anterior and posterior point on the anterio- and posterior-lateral surfaces was calculated. RESULTS A total of 96 CT datasets were analyzed. (1) 81% of fibulae revealed a triangular convex-, 10% an irregular-, and 8% a quadrilateral shape. The lateral surface ratio was 1.0 ± 0.2 (range: 0.7-1.5), not differing between the fibula types (n.s.). (2) The safe corridor on the lateral surface of the fibula for an anteriorly angulated drilling tunnel was - 8% to - 41%, for a posteriorly angulated drilling tunnel was 0% to 46%, and for a center-center alignment - 7 ± 11% (range: - 28 to 18%). CONCLUSION The meta-diaphyseal region of the distal fibula revealed a homogeneous crosssectional shape. The lateral apex of the fibula can serve as a landmark defining safe zones to place the drilling tunnels correctly. Applying these safe zones in clinical practice could help to avoid the misplacement of the syndesmotic fixation device. LEVEL OF EVIDENCE Level III, retrospective radiographic study.
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