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Murphy SC, Murphy B, O'Loughlin P. Syndesmotic injury with ankle fracture: A systematic review of screw vs dynamic fixation. Ir J Med Sci 2024; 193:1323-1330. [PMID: 38282112 DOI: 10.1007/s11845-024-03619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 01/30/2024]
Abstract
Cortical screw fixation across the tibiofibular joint is the mainstay of treatment for syndesmotic injury. Dynamic fixation devices have been developed offering similar advantages to screw fixation in terms of reduction and stability of the syndesmosis. Dynamic fixation may also facilitate a more physiological movement between the tibiofibular joint and thus incur less morbidity. Patient's rehabilitation potential is enhanced and reduces the need for hardware removal. Our systematic review aims to analyse the relevant current literature and compare screw fixation to dynamic fixation in the treatment of syndesmotic injury associated with acute ankle fractures. A literature search was performed on Pubmed and Ovid Medline to find scientific papers relating to syndesmotic fixation in acute ankle fractures. Papers were screened and included dependent on predetermined criteria. Risk of bias was assessed after screening full papers by two independent reviewers. Tables and analysis were made using Microsoft excel. A total of 8 papers with 673 patients were included. We found no functional difference between screw fixation or dynamic fixation groups at final follow-up. Three papers showed statistically significant lower rates of reoperation in the dynamic fixation group. Dynamic fixation may offer lower post operative complications and reoperation rates. Therefore, dynamic fixation may be a beneficial alternative treatment compared to traditionally used syndesmotic screws.
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Affiliation(s)
| | - Ben Murphy
- Department of Trauma and Orthopaedic Sugery, Cork University Hospital, Cork, Ireland
| | - Padhraig O'Loughlin
- Department of Trauma and Orthopaedic Sugery, Cork University Hospital, Cork, Ireland
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Rozis M, Sakellariou E, Vasiliadis E, Vlamis J, Pneumaticos SG. The Radiological Anatomy of the Distal Tibiofibular Joint: A Retrospective Computed Tomography Study. Cureus 2024; 16:e53540. [PMID: 38318279 PMCID: PMC10839544 DOI: 10.7759/cureus.53540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 02/07/2024] Open
Abstract
Introduction Distal tibiofibular joint (DTFJ) injuries are commonly encountered in patients with ankle fractures. Achieving optimal fixation is mandatory, but it requires a thorough understanding of the local anatomical relationships. For this reason, we performed a retrospective CT study in healthy ankles to radiologically describe the normal anatomy of the DTFJ and the anatomical relationship of the fibula within the ankle joint. Materials and methods For this study, we retrospectively examined 60 CT scans of healthy, non-injured ankles in a plantigrade position. Patients with prior ankle surgery or systemic diseases with ankle involvement were excluded because we needed to describe the normal anatomy of the joint. The radiological evaluation included the position of the fibula in the fibular notch and the rotational relationship of the fibula with the talus and the medial malleolus. Results Our study included 60 healthy ankles. Thirty-three were right ankles, and 27 were left. The cohort included 36 females and 24 males with a mean age of 48.3 years old. We found that the fibular notch was retroverted on the transverse plane, with the tibiofibular engagement being 0.11 mm (SD=1.57 mm, SE=0.2 mm), at 1 cm proximally to the tibial plafond. Additionally, we observed that the fibula was internally rotated against the lateral talar facet, while the medial and lateral malleolus facets were externally rotated in between. Moreover, we found a strong positive correlation between the incisura retroversion and fibular engagement at 1 cm above the tibial plafond line (Pearson correlation=0.273, p=0.03). Conclusion Our study highlights the importance of gaining a comprehensive understanding of the inherent anatomy of the DTFJ to achieve reduction goals in ankle fractures. According to our results, in ankle fracture treatment, surgeons should aim for anatomical fracture and syndesmotic fixation, with the fibula in internal rotation against the lateral talar facet. Additionally, as normal tibiofibular engagement is borderline, we do not suggest that over-tightening the syndesmotic screws is essential. This study's findings can aid surgeons in reducing the malreduction rates in patients with ankle fractures.
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Affiliation(s)
- Meletis Rozis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, Athens, GRC
| | - Evangelos Sakellariou
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, Athens, GRC
| | - Elias Vasiliadis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, Athens, GRC
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT Trauma Hospital, Athens, GRC
| | - John Vlamis
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, Athens, GRC
| | - Spyros G Pneumaticos
- 3rd Orthopedic Department, National and Kapodistrian University of Athens, KAT General Hospital, Athens, GRC
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Sanda II, Hosin S, Vermesan D, Deleanu B, Pop D, Crisan D, Al-Qatawneh M, Mioc M, Prejbeanu R, Rosca O. Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2048. [PMID: 38138151 PMCID: PMC10744725 DOI: 10.3390/medicina59122048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
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.
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Affiliation(s)
- Isabella-Ionela Sanda
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania;
- Department of Laboratory Medicine, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Samer Hosin
- Doctoral School, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania;
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Dinu Vermesan
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Bogdan Deleanu
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Daniel Pop
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Dan Crisan
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Musab Al-Qatawneh
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Mihai Mioc
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Radu Prejbeanu
- Department of Orthopedics, “Victor Babes” University of Medicine and Pharmacy Timisoara, 300041 Timisoara, Romania; (D.V.); (B.D.); (D.P.); (D.C.); (M.A.-Q.); (M.M.); (R.P.)
| | - Ovidiu Rosca
- Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania;
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Lu H, Zhu J, Deng J, Pan Y, Yang G, Wei S, Zhao Z. Technical note: Intraoperative ultrasound measurement for evaluating the stability of the inferior tibiofibular joint in patients with ankle fractures. Injury 2023; 54:111014. [PMID: 37677857 DOI: 10.1016/j.injury.2023.111014] [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: 06/18/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVES Injury to the tibiofibular syndesmosis is a common complication of ankle fractures. Currently, it is challenging to determine the stability of the tibiofibular joint caused by ankle fractures during surgery. This study aims to establish a standardized method for dynamically evaluating the stability of the inferior tibiofibular joint under intraoperative ultrasound and assess its utility in surgery, thereby assisting in determining the necessity for fixation of the inferior tibiofibular joint after fracture reduction and fixation. METHODS The stability of the inferior tibiofibular joint was assessed using an intraoperative ultrasonic external rotation stress test, with a torque set at 7.2 N·m. The measured parameters included the width of the inferior tibiofibular space in neutral (N) and external rotation (E) positions, stretch ratio (E/N), and injured/healthy side stretch ratio (I/H). Patients with Weber B or C type ankle fractures were selected as participants. RESULTS For the case with Weber C fracture, the N measurement was 4.22 mm after fracture fixation, while E measured 5.77 mm and E/N ratio was 1.37, which were larger than those on the healthy side (N: 4.17, E: 4.50, E/N:1.08), with an I/H ratio of 1.27. Intraoperative X-ray revealed instability of the inferior tibiofibular joint. After inserting a tibiofibular screw, the N measurement was 4.20 mm, while the E measurement recorded 4.32 mm, resulting in an E/N ratio of 1.03 and an I/H ratio of 0.95, indicating improved joint stability. For the Weber B fracture case, the N measurement was 3.55 mm after fracture fixation, while E measured 3.98 mm and the E/N ratio was 1.12, slightly lower than those on the healthy side (N: 3.94, E: 4.47, E/N: 1.13), with an I/H ratio of 0.99. The intraoperative X-ray revealed stability of the inferior tibiofibular joint. Therefore, no further fixation was performed on it. CONCLUSION Standardized intraoperative ultrasound stress test allows for real-time, dynamic assessment of the stability of the inferior tibiofibular joint after ankle fracture reduction and fixation, which can help guide the fixation of the inferior tibiofibular joint, thereby reducing the risk of postoperative traumatic arthritis.
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Affiliation(s)
- Haojie Lu
- School of Clinical Medicine, Tsinghua University, Haidian District, Beijing, China
| | - Jianjin Zhu
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, No.168, Li Tang Road, Changping District, Beijing 102218, China
| | - Jiuzheng Deng
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, No.168, Li Tang Road, Changping District, Beijing 102218, China
| | - Yongwei Pan
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, No.168, Li Tang Road, Changping District, Beijing 102218, China
| | - Guangmin Yang
- School of Clinical Medicine, Tsinghua University, Haidian District, Beijing, China
| | - Shuai Wei
- Department of Nursing, Beijing Tsinghua Changgung Hospital, No.168, Li Tang Road, Changping District, Beijing 102218, China
| | - Zhe Zhao
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, No.168, Li Tang Road, Changping District, Beijing 102218, China.
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Epstein DJ, Urbanavicius DB, Pang J. How to use X-ray templating to guide minimally invasive screw removal. ANZ J Surg 2023; 93:2499-2501. [PMID: 37095560 DOI: 10.1111/ans.18489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/14/2023] [Accepted: 04/15/2023] [Indexed: 04/26/2023]
Abstract
A How to Do It article describing the use of X-ray templating to guide minimally invasive surgical screw removal. By calibrating X-ray measurements using the screw itself as a template marker, we propose a method to reduce incision size and operative time to minimise the risks associated with screw removal.
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Affiliation(s)
- Daniel Joel Epstein
- Department of Orthopaedic Surgery, Bendigo Health, Bendigo, Victoria, Australia
| | | | - Jack Pang
- Department of Orthopaedic Surgery, Bendigo Health, Bendigo, Victoria, Australia
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Reyes-Valdés A, Martínez-Ledezma M, Fernández-Quezada D, Guzmán-Esquivel J, Cárdenas-Rojas MI. Prevalence and Characteristics of Patients Requiring Surgical Reinterventions for Ankle Fractures. J Clin Med 2023; 12:5843. [PMID: 37762784 PMCID: PMC10532131 DOI: 10.3390/jcm12185843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: Ankle fractures are common injuries that typically require surgical treatment. Complications may arise, leading to reinterventions with poor recovery and reduced quality of life for patients. The aim of this study was to determine the number of patients who underwent surgical reintervention for ankle fractures, characteristics, and associated factors. (2) Methods: A cross-sectional study was conducted to analyze the number of patients requiring surgical intervention for ankle fractures at General Hospital Zone No1 IMSS in Colima over a period of two years. The age, gender, comorbidities, laterality, cause of surgical reintervention, Weber classification, and elapsed time to reintervention were analyzed. (3) Results: A total of 33 patients were included in this study, of whom 63.3% were male, ranging in age from 18 to 51 years old. The predominant Danis-Weber classification for both sexes was suprasyndesmotic fracture (Type C). No established relationship was found between comorbidities and surgical reintervention; however, a significant relationship was observed between home accidents and the need for reintervention. (4) Conclusions: Reintervention in patients previously operated on for ankle fractures is more frequent in male patients and those who sustained the injury at home.
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Affiliation(s)
- Abraham Reyes-Valdés
- Hospital General de Zona No. 1, Instituto Mexicano del Seguro Social, Av. Lapislázuli No. 250 Colonia La Haya, Villa de Álvarez, Colima 28984, Mexico; (A.R.-V.); (M.M.-L.)
| | - Mirna Martínez-Ledezma
- Hospital General de Zona No. 1, Instituto Mexicano del Seguro Social, Av. Lapislázuli No. 250 Colonia La Haya, Villa de Álvarez, Colima 28984, Mexico; (A.R.-V.); (M.M.-L.)
| | - David Fernández-Quezada
- Centro Universitario de Ciencias de la Salud (CUCS), Laboratorio de Microscopía de Alta Resolución, Departamento de Neurociencias, Universidad de Guadalajara, Guadalajara 44340, Mexico;
| | - José Guzmán-Esquivel
- Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Av. Lapislázuli No. 250 Colonia La Haya, Villa de Álvarez, Colima 28984, Mexico;
| | - Martha Irazema Cárdenas-Rojas
- Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Av. Lapislázuli No. 250 Colonia La Haya, Villa de Álvarez, Colima 28984, Mexico;
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7
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Yoon SJ, Yeo ED, Jung KJ, Hong YC, Hong CH, Won SH, Lee KJ, Ji JY, Byeon JY, Lee DW, Kim WJ. Evaluating the Efficacy of Tension Band Wiring Fixation for Chaput Tubercle Fractures. J Clin Med 2023; 12:5490. [PMID: 37685557 PMCID: PMC10488479 DOI: 10.3390/jcm12175490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Chaput tubercle fractures, located at the attachment site of the anterior inferior tibiofibular ligament (AITFL) on the distal tibia, have the potential to destabilize the syndesmosis joint. This study aims to assess the effectiveness of tension band wiring (TBW) as a surgical intervention for managing Chaput fractures and the consequent syndesmosis instability. METHODS A retrospective review of patient charts was undertaken for those who had undergone ankle fracture surgery from April 2019 through May 2022. The surgical procedure involved direct fixation of the Chaput fractures using the TBW method. Radiological assessments were performed using postoperative simple radiographs and computed tomography (CT) scans, while clinical outcomes were evaluated using the Olerud-Molander Ankle Score (OMAS) and the visual analog scale (VAS). RESULTS The study included 21 patients. The average OMAS improved significantly, rising from 5.95 preoperatively to 83.57 postoperatively. Similarly, the average VAS score dropped from 7.95 before the surgery to 0.19 thereafter. Minor wound complications were reported by three patients, and one case of superficial infection was resolved with antibiotic therapy. CONCLUSIONS Our findings suggest that the TBW technique is an effective surgical approach for treating Chaput fractures and associated syndesmosis instability. It provides reliable fixation strength and leads to improved long-term functional outcomes. Further research is needed to compare the TBW technique with alternative methods and optimize the treatment strategies for these complex ankle fractures.
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Affiliation(s)
- Sung-Joon Yoon
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Eui-Dong Yeo
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul 05368, Republic of Korea;
| | - Ki-Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Yong-Cheol Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Chang-Hwa Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
| | - Sung-Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea;
| | - Kyung-Jin Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170, Jomaru-ro, Bucheon-si 14584, Republic of Korea;
| | - Jae-Young Ji
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Je-Yeon Byeon
- Department of Plastic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea;
| | - Dhong-Won Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, 120-1, Neungdong-ro, Gwangjin-gu, Seoul 05030, Republic of Korea;
| | - Woo-Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongam-gu, Cheonan 31151, Republic of Korea; (S.-J.Y.); (K.-J.J.); (Y.-C.H.); (C.-H.H.)
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Cho D, Kukadia S, Drakos M. Common Football Foot and Ankle Injuries: Non-Surgical and Surgical Management. HSS J 2023; 19:322-329. [PMID: 37435125 PMCID: PMC10331273 DOI: 10.1177/15563316231160458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/13/2022] [Indexed: 07/13/2023]
Affiliation(s)
- David Cho
- Hospital for Special Surgery, New York, NY, USA
| | | | - Mark Drakos
- Hospital for Special Surgery, New York, NY, USA
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Koh D, Mehta K. Anterior Displacement of a Posterior Malleolar Fragment Through the Syndesmosis: A Case Report. Cureus 2023; 15:e42451. [PMID: 37637621 PMCID: PMC10449562 DOI: 10.7759/cureus.42451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Ankles are the most common site of injury in lower limb fractures. Despite this, the classification of the Maisonneuve fracture is still highly controversial, perhaps due to its low incidence. Typically described as a proximal fibular fracture with associated injury to the syndesmosis and medial structures secondary to an external rotation mechanism, the injury often necessitates surgical intervention to restore joint stability for good functional outcomes. A 32-year-old lady sustained a pronation external rotation injury resulting in a proximal fibula fracture with disruption of the distal tibiofibular syndesmosis as well as an associated posterior malleolar fracture with displacement of the fragment anteriorly through the syndesmosis to the ventral aspect of the ankle joint. The patient underwent surgical fixation of the posterior malleolar fracture as well as repair of the syndesmosis with a screw. This report aims to highlight the details of a Maisonneuve fracture with the rarer associated posterior malleolar fracture, and its anterior displacement through the syndesmosis, as well as provide a narrative review of the current literature.
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Affiliation(s)
- Don Koh
- Orthopaedics, Changi General Hospital, Singapore, SGP
| | - Kinjal Mehta
- Orthopaedics, Changi General Hospital, Singapore, SGP
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10
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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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11
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Saad BN, Rampertaap Y, Menken LG, Whitlock KG, Crook BS, Baker RL, Keller DM, Liporace FA, Gage MJ, Yoon RS. Direct versus indirect posterior malleolar fixation in the treatment of trimalleolar ankle fractures: Is there a difference in outcomes? OTA Int 2022; 5:e219. [PMID: 36569113 PMCID: PMC9782365 DOI: 10.1097/oi9.0000000000000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 07/07/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE The purpose of this study was to examine the differences in functional outcomes between direct and indirect surgical fixation methods of the posterior malleolus in the setting of trimalleolar fractures and identify any variables affecting patient outcomes. METHODS Primary outcomes were evaluated by PROMIS scores for short-term outcomes regarding total pain (TP) and total function (TF) comparing 40 patients with direct fixation with 77 with indirect fixation. Continuous variables were analyzed using t tests for parametric variables and the Mann-Whitney U test for nonparametric variables. Categorical variables were analyzed using a χ2 test. Univariate and multivariate linear regression models were performed to analyze factors that affect outcomes of TP and TF. RESULTS There was no difference in TP or TF between groups (P = 0.65 vs. P = 0.19). On univariate linear regression for TP, BMI, incidence of complication, tobacco use, and open injury showed significance in increasing pain levels with open injuries providing the greatest effect (coef = 11.8). On multivariate analysis, BMI, incidence of complication, open injury, and tourniquet time all significantly increased pain. For TF, univariate analysis showed age, BMI, incidence of complication, and diabetes to decrease function, and use of external fixator and tourniquet time increased function. In the multivariate model, increased BMI, open injuries, and increasing tourniquet time all decreased TF while use of an external fixator increased TF. CONCLUSION This study showed no difference in TP and TF using the PROMIS outcome scores when comparing direct fixation versus indirect fixation under univariate and multivariate models. LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Bishoy N. Saad
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Yajesh Rampertaap
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Luke G. Menken
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Keith G. Whitlock
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Bryan S. Crook
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Rafael L. Baker
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David M. Keller
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Frank A. Liporace
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
| | - Mark J. Gage
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Richard S. Yoon
- Division of Orthopaedic Trauma & Adult Reconstruction, Department of Orthopaedic Surgery, Jersey City Medical Center—RWJBarnabas Health, Jersey City, NJ and
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12
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Altmeppen JN, Colcuc C, Balser C, Gramlich Y, Klug A, Neun O, Manegold S, Hoffmann R, Fischer S. A 10-Year Follow-Up of Ankle Syndesmotic Injuries: Prospective Comparison of Knotless Suture-Button Fixation and Syndesmotic Screw Fixation. J Clin Med 2022; 11:jcm11092524. [PMID: 35566650 PMCID: PMC9105986 DOI: 10.3390/jcm11092524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 04/24/2022] [Accepted: 04/28/2022] [Indexed: 12/16/2022] Open
Abstract
Background: Acute syndesmosis injury (ASI) is an indication for surgical stabilization if instability is confirmed. In recent years, fixation using the knotless suture-button (SB) device has become increasingly established as an alternative to set screw fixation (SF). This study directly compared the clinical long-term results after prospective randomized inclusion. Materials and Methods: Between 2011 and 2012, 62 patients with ASI were enrolled in a prospective, randomized, and monocentric study. Forty-one patients were available for a 10-year follow-up ((31 males and 10 females), including 21 treated with SB (mean age 44.4 years), and 20 with SF (mean age 47.2 years)). In addition to comparing the demographic data and syndesmosis injury etiology, follow-up assessed the Olerud−Molander Ankle Score (OMAS) and FADI-Score (Foot and Ankle Disability Index Score) with subscales for activities of daily living (ADL) and sports activity. Results: The mean OMAS was 95.98 points (SB: 98.81, SF: 93.00), the mean FADI ADL was 97.58 points (SB: 99.22, SF: 95.86), and the mean FADI Sport was 94.14 points (SB: 97.03, SF: 91.10). None of the measurements differed significantly between the groups (p > 0.05). No clinical suspicion of chronic instability remained in any of the patients, regardless of treatment. Conclusions: The short-term results showed that athletes in particular benefit from SB fixation due to their significantly faster return to sports activities. However, the available long-term results confirm a very good outcome in the clinical scores for both approaches. Chronic syndesmotic insufficiency was not suspected in any of the patients. Level of evidence: I, randomized controlled trial.
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Affiliation(s)
- Jan Niklas Altmeppen
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Christian Colcuc
- Department of Trauma and Orthopaedic Surgery, Evangelical Hospital Bethel Bielefeld, 33611 Bielefeld, Germany;
| | - Christian Balser
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Yves Gramlich
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Alexander Klug
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Oliver Neun
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
| | - Sebastian Manegold
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
| | - Reinhard Hoffmann
- Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (J.N.A.); (C.B.); (Y.G.); (A.K.); (R.H.)
| | - Sebastian Fischer
- Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany; (O.N.); (S.M.)
- Correspondence: ; Tel.: +49-(0)-69-475-0
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