Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial)

Functional outcome of routine versus on-demand removal of the syndesmotic screw

Aims

The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS).

Methods

All patients included in the 'ROutine vs on DEmand removal Of the syndesmotic screw' (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups.

Results

The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092).

Conclusion

This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation.

Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair

Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.

The completely patient-reported version of the American Orthopaedic Foot and Ankle Society (AOFAS) score: A valid and reliable measurement for ankle osteoarthritis

BACKGROUND

The American Orthopaedic Foot and Ankle score (AOFAS) is an outcome measure for ankle and hindfoot conditions, which requires scoring from both the patients and the physician. A completely patient-reported version has been developed and used before, but its measurements properties are unknown. Our goal was to determine the measurement properties and the minimally important change (MIC) of a completely patient-reported AOFAS (PR-AOFAS) in patients with ankle osteoarthritis. Additionally, the MIC of both the PR-AOFAS and the AOFAS was estimated, which had not previously been done.

MATERIALS AND METHODS

The PR-AOFAS of 112 patients was evaluated for reliability, construct validity (using the AOFAS, Foot and Ankle Outcome Score, Ankle Osteoarthritis Score, Visual Analogue Scale, and Short Form-36), and responsiveness. The MIC was estimated using the optimal cut-off point of the receiver operating characteristic curve. This was a substudy of a randomized clinical trial on the efficacy of platelet-rich plasma injections for ankle osteoarthritis (OA).

RESULTS

The PR-AOFAS had sufficient construct validity, internal consistency, test-retest reliability, and responsiveness. The smallest detectable change at group level was 2.34. The MIC was 6.5 points (95% confidence interval: 0.6-14.4).

CONCLUSIONS

The measurement properties of the Dutch PR-AOFAS were sufficient in patients with ankle osteoarthritis who are willing to participate in a trial on injection therapy. The minimally important change of the PR-AOFAS is smaller than its smallest detectable change, making it more suitable for use in groups of patients, such as a research setting.

LEVEL OF CLINICAL EVIDENCE

1.

Platelet-Rich Plasma Injections for the Treatment of Ankle Osteoarthritis

BACKGROUND

Ankle osteoarthritis is debilitating and usually affects relatively young people, often as a result of previous ankle traumas, frequently occurring in sports. Platelet-rich plasma (PRP) injections for ankle osteoarthritis have shown no evidence of benefit over the course of 26 weeks. Previous studies on PRP for knee osteoarthritis showed that clinically significant improvements with PRP occurred between 6 to 12 months in the absence of initial benefit. No studies have evaluated the effect of PRP from 6 to 12 months in ankle osteoarthritis.

PURPOSE

To assess the efficacy of PRP injections in ankle osteoarthritis over the course of 52 weeks.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

In this 52-week follow-up trial, 100 patients with ankle osteoarthritis were randomized to a PRP group or placebo (saline) group. Patients received 2 intra-articular talocrural injections: at inclusion and after 6 weeks. Patient-reported outcome measures were used to assess pain, function, quality of life, and indirect costs over 52 weeks.

RESULTS

Two patients (2%) were lost to follow-up. The adjusted between-group difference for the patient-reported American Orthopaedic Foot & Ankle Society score over 52 weeks was -2 points (95% CI, -5 to 2; P = .31) in favor of the placebo group. No significant between-group differences were observed for any of the secondary outcome measures.

CONCLUSION

For patients with ankle osteoarthritis, PRP injections did not improve ankle symptoms and function over 52 weeks compared with placebo injections.

REGISTRATION

NTR7261 (Netherlands Trial Register).

Cost-effectiveness of on-demand removal of syndesmotic screwsx

Purpose

Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw.

Methods

Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs.

Results

Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p < 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness.

Conclusion

The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.

Should Diastatic Syndesmosis be Stabilized in Advanced Pronation-External Rotation Ankle Injuries? A Retrospective Cohort Comparison

OBJECTIVE

With or without screw stabilization for diastatic syndesmosis in advanced pronation-external rotation (PE) ankle injuries has not yet been well-determined. Both techniques were retrospectively compared to investigate the superiority of either of the two.

METHODS

A retrospective cohort study was carried out. From January 1, 2008, to December 31, 2017, 81 consecutive adult patients (average, 42 years; range, 18-78 years; 44 men and 37 women) with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was rechecked by external rotation and hook tests. The necessity of cortical screw insertion to stabilize diastatic syndesmosis was decided by the individual orthopaedic surgeon. Postoperatively, a short leg splint was used for 6 weeks. The syndesmotic screw was removed based on the surgeon's policy. The removal of internal fixation for malleolar fractures was required after 1 year. The outcomes of both approaches were compared clinically, and ankle function was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) score. For statistical comparison, the chi-square test was used for categorical data and the Mann-Whitney U test was used for numerical data.

RESULTS

Seventy-one patients (average, 40 years; range, 18-78 years; 40 men and 31 women) were followed for at least 1 year (87.7%; average, 2 years; range, 1-11 years). Group 1 (with syndesmotic stabilization) had 22 patients and Group 2 (without syndesmotic stabilization), 49 patients. The union rate in Group 1 patients was 100% (22/22), and in Group 2 patients, 91.8% (45/49; p = 0.17). One deep wound infection occurred in Group 1 patients and two in Group 2 patients. Syndesmosis re-diastasis occurred in 13.6% (3/22) of Group 1 patients and 30.6% (15/49) of Group 2 patients (p = 0.13). One syndesmotic screw broke at 6 months. Satisfactory ankle function according to the AOFAS score was noted in 86.4% (19/22) of Group 1 patients and 65.3% (32/49) of Group 2 patients (p = 0.07).

CONCLUSION

Insertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable.

Is routine removal of syndesmotic screw justified? A meta-analysis

BACKGROUND

Syndesmosis injuries are common with rotational ankle injuries, and placement of a positional syndesmotic screw to maintain its reduction is used as the ligaments heal. There is no clear consensus on routine removal or retention of syndesmotic screw. This study aimed to appraise the current evidence both on removal and retention of syndesmotic screw and to conduct a meta-analysis comparing outcomes and rate of complications of syndesmotic screw removal and retention.

METHODS

Following PROSPERO registration, a systematic search using was performed using keywords ('Syndesmosis' OR 'Syndesmotic' OR 'Transsyndesmotic' OR 'distal tibiofibular') AND ('Screw') AND ('Removal' OR 'Retention') AND 'Outcome' in various databases. No language restrictions were applied and the meta-analysis incorporated the PRISMA statement. VAS (Visual analogue scale for pain), AOFAS (American Orthopaedic Foot And Ankle Society) scores expressed as mean ± SD, and both groups' complication rates were compared. Comparisons with a random-effects model were performed, and heterogeneity between the studies was calculated using the I2 statistic. T-test for two independent sample means was used to compare pooled mean and Z-test for two proportions to assess the difference in the proportion of complications.

RESULTS

A total of 7 studies with 522 patients were included in this review for analysis. Pooled analysis showed non-significant difference in AOFAS score (MD = -1.84; 95% CI: -4.33 to 0.66; p = 0.150) as well as for VAS score (MD = -0.48; 95% CI: -1.56 to 0.60; p = 0.390) between the two groups. The value of z and p-value for complication rates was 0.6021 and 0.5485, respectively, which was not significant.

CONCLUSION

There doesn't appear to be a difference in functional outcome, pain scores, and complication rates between patients who had their syndesmotic screws removed and those where screw was retained. The fear of inferior outcomes with retained screws is thus unfounded, and routine removal adds to morbidity and financial burden. In conclusion, present data does not support the routine removal of the intact syndesmosis screw, and a change in practice is needed to abandon routine syndesmotic screw removal.

Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Methods

Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS).

Results

There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007).

Conclusion

ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation.

Cite this article: Bone Joint J 2021;103-B(11):1709–1716.

Removal of Syndesmotic Screw After Fixation in Ankle Fractures: A Systematic Review

Syndesmotic injuries can occur with ankle fractures and can lead to destabilization of the ankle joint. As a result, it usually requires a transyndesmotic screw insertion to stabilize it. Currently, there is no consensus on the type, amount and diameter of screws used, the number of cortices needed to be engaged, the recommended time to weight-bearing, and whether the screw should be removed in these types of injuries. The aim of this study is to evaluate the evidence comparing the removal and non-removal of syndesmotic screws in open and closed ankle fractures that are associated with unstable syndesmosis in terms of functional, clinical, and radiological evidence. The study also looked at the evidence behind broken screw effects. The literature search was conducted on March 16, 2021, using the Ovid Medline and Embase databases. The literature was eligible if it aimed to compare syndesmotic screw removal and retention in ankle fractures. One study found that those with a broken screw had a better clinical outcome than those with an intact screw. The studies were excluded if they were biomechanical studies, case reports, or were relevant but had no adequate English translation. Initially, 53 studies were included but after scanning for eligibility, 11 were identified (including those added from references). Nine were cohort studies, seven of which did not find any difference in functional outcome between routine removal and retention of the syndesmotic screw. Two studies found there were better clinical outcomes in the broken screw group. Another study found that there were slightly worse functional outcomes in patients with intact screws as compared with those with broken, loosened, or removed screws. Two studies were randomized control studies that no significant functional outcomes between removed and intact syndesmotic screws. However, the majority of these studies had a high risk of bias. Overall, the current literature provides no evidence to support routine removal of syndesmotic screws. Keeping in mind the clear complications and financial burden, syndesmotic screw removal should not be performed unless there is a clear indication. Furthermore, removal in the clinic, with the use of prophylactic antibiotics should be considered if indicated in cases with pain or loss of function. Further research in a structured randomized controlled trial (RCT) to examine if there is any difference in short- or long-term outcomes between removed, intact, loose, or broken syndesmotic screws might be beneficial. A multinational protocol for randomized control trials (RODEO-trial) is an example of such a study to determine the usefulness of on-demand and routine removal of screws.

Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review

OBJECTIVES

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

DATA SOURCES

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal."

STUDY SELECTION

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

DATA EXTRACTION

The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

DATA SYNTHESIS

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

CONCLUSIONS

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial)

Background

Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures.

Methods

This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups.

Discussion

If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella.

Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284

Elective removal vs. retaining of hardware after osteosynthesis in asymptomatic patients-a scoping review

BACKGROUND

Osteosynthesis is the internal fixation of fractures or osteotomy by mechanical devices (also called hardware). After bone healing, there are two options: one is to remove the hardware, the other is to leave it in place. The removal of the hardware in patients without medical indication (elective) is controversially discussed. We performed a scoping review to identify evidence on the elective removal of hardware in asymptomatic patients compared to retaining of the hardware to check feasibility of performing a health technology assessment. In addition, we wanted to find out which type of evidence is available.

METHODS

A systematic literature search was performed in PubMed, Embase, EconLit, and CINAHL (November 2019). We included studies comparing asymptomatic patients with an internal fixation in the lower or upper extremities whose internal fixation was electively (without medical indication) removed or retained. We did not restrict inclusion to any effectiveness/safety outcome and considered any comparative study design as eligible. Study selection and data extraction was performed by two reviewers.

RESULTS

We identified 13476 titles/abstracts. Of these, we obtained 115 full-text publications which were assessed in detail against the inclusion criteria. We included 13 studies (1 RCT, 4 cohort studies, 8 before-after studies) and identified two ongoing RCTs. Nine assessed the removal of the internal fixation in the lower extremities (six of these syndesmotic screws in ankle fractures only) and two in the upper extremities. One study analysed the effectiveness of hardware removal in children in all types of extremity fractures. Outcomes reported included various scales measuring functionality, pain and clinical assessments (e.g. range of motion) and health-related quality of life.

CONCLUSIONS

We identified 13 studies that evaluated the effectiveness/safety of hardware removal in the extremities. The follow up times were short, the patient groups small and the ways of measurement differed. In general, clinical heterogeneity was high. Evidence on selected topics, e.g. syndesmotic screw removal is available nevertheless not sufficient to allow a meaningful assessment of effectiveness.

Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial

BACKGROUND

The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes.

METHODS

This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models.

RESULTS

Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar.

CONCLUSIONS

Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Functional outcome 3-6 years after operative treatment of closed Weber B ankle fractures with or without syndesmotic fixation

BACKGROUND

To compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation.

METHODS

In total, 959 adult patients with previous treatment with open reduction and internal fixation (ORIF) for closed ankle fractures were eligible for inclusion in a cross-sectional postal survey 3-6 years after surgery; 645 had Weber B fractures. The survey assessed functional outcomes with three validated ankle questionnaires.

RESULTS

In total 365 (57%) patients responded at a median of 4.2 years after the trauma. After adjusting for age, sex, education, smoking status, body mass index, diabetes, physical status before surgery, fracture classification, and duration of surgery, patients with a syndesmotic fixation had no different OMAS score (p = 0.98), LEFS score (p = 0.61), and SEFAS score (p = 0.98) than those without a syndesmotic fixation. Trimalleolar fracture was associated with worse functional outcomes than unimalleolar on two of the scales, the OMAS (p = 0.028) and LEFS (p = 0.046).

CONCLUSIONS

In multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.

Screw fixation for syndesmotic injury is stronger and provides more contact area of the joint surface than TightRope®: A biomechanical study

BACKGROUND

The rupture of syndesmotic ligaments is treated with a screw fixation as the gold standard. An alternative is the stabilization with a TightRope®. A couple of studies investigated the different clinical outcome and some even looked at the stability in the joint, but none of them examined the occurring pressure after fixation.

OBJECTIVE

Is there a difference in pressure inside the distal tibiofibular joint between a screw fixation and a TightRope®? Does the contact area differ in these two treatment options?

METHODS

This biomechanical study aimed to investigate the differences in fixation of the injured syndesmotic ligaments by using a fixation with one quadricortical screw versus singular TightRope® both implanted 1 cm above the joint. By using 12 adult lower leg cadaveric specimens and pressure recording sensor, we recorded the pressure across the distal tibiofibular joint. Additionally we measured the contact surface area across the joint.

RESULTS

The mean of the pressure across the distal tibiofibular joint from the start of the insertion of the fixation device to the complete fixation was 0.05 Pascal for the TightRope® and 0.1 for the screw (P= 0.016). The mean of the maximum pressure across the joint (after completion of fixation and releasing the reduction clamp) was 1.750 mega Pascal with the screw fixation and 0.540 mega Pascal with TightRope® (P= 0.008). The mean of the measured contact area of the distal tibiofibular joint after fixation was 250 mm2 in the TightRope® group and of 355 mm2 in the screw fixation (P= 0.123).

CONCLUSIONS

The screw fixation is stronger and provides a larger surface contact area, which leads us to the conclusion that it provides a better stability in the joint. While previous clinical studies did not show significant clinical difference between the two methods of fixation, the biomechanical construct varied. Long term clinical studies are required to establish whether this biomechanical distinction will contribute to various clinical outcomes.

A Systematic Review and Meta-Analysis on Treatment of Ankle Fractures With Syndesmotic Rupture: Suture-Button Fixation Versus Cortical Screw Fixation

Ankle fractures accompanied by syndesmotic rupture are a complex challenge for orthopedic surgeons. Sufficient reduction and stabilization of the syndesmosis are important to prevent early degeneration of the ankle joint and to optimize clinical outcomes. The purpose of the study was to systematically review the literature comparing the suture-button fixation method with the cortical screw fixation method when treating syndesmotic rupture. For this, a systematic review of the literature was performed that included Cochrane, PubMed, and Embase. The following search terms were used: ankle fractures, syndesmosis rupture, tibiofibular syndesmosis injury, ankle joint, tightrope, and suture button. Inclusion criteria were comparison studies, acute ankle fractures with syndesmotic rupture, adult patients, and Coleman score >60. Cadaveric studies, chronic instability, open fractures, polytrauma, and arthropathies were exclusion criteria. Two investigators independently reviewed titles and relevant abstracts. Reoperation and malreduction rates were compared in a meta-analysis. Six studies with 275 patients were included: 2 randomized controlled trials and 2 prospective and 2 retrospective cohort studies. All studies used similar surgical techniques. Functional outcomes (American Orthopedic Foot and Ankle Society scale and the Olerud-Molander score) were not quantitatively comparable. No significantly less number of malreduction events were detected in the suture-button group (risk ratio = 0.19, 95% confidence interval 0.03 to 1.04, p = .06). Significantly lower reoperation rate was detected in the suture-button group (risk ratio = 0.21, 95% confidence interval 0.06 to 0.69, p = .01). We conclude that the suture-button technique showed a significantly lower reoperation rate and tendency toward less malreduction and better American Orthopedic Foot and Ankle Society scale scores. This finding is clinically relevant; however, this conclusion is primarily based on 2 studies, and therefore the interest for further research increases.

Ankle Fractures: An Expert Survey of Orthopaedic Trauma Association Members and Evidence-Based Treatment Recommendations

OBJECTIVES

To describe current practice patterns of orthopaedic trauma experts regarding the management of ankle fractures, to review the current literature, and to provide recommendations for care based on a standardized grading system.

DESIGN

Web-based survey.

PARTICIPANTS

Orthopaedic Trauma Association (OTA) members.

METHODS

A 27-item web-based questionnaire was advertised to members of the OTA. Using a cross-sectional survey study design, we evaluated the preferences in diagnosis and treatment of ankle fractures.

RESULTS

One hundred sixty-six of 1967 OTA members (8.4%) completed the survey (16% of active members). There is considerable variability in the preferred method of diagnosis and treatment of ankle fractures among the members surveyed. Most responses are in keeping with best evidence available.

CONCLUSIONS

Current controversy remains in the management of ankle fractures. This is reflected in the treatment preferences of the OTA members who responded to this survey.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for authors for a complete description of levels of evidence.