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

BackgroundTo compare the long-term functional outcomes of patients surgically treated for Weber B ankle fractures with or without syndesmotic fixation.MethodsIn 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.ResultsIn 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).ConclusionsIn multivariable analysis, patients with a syndesmotic fixation had no worse long-term functional outcomes than those without syndesmotic fixation.     

Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review

BackgroundDeltoid ligament injuries are typically caused by supination-external rotation or pronation injury. Numerous ligament reconstruction techniques have been proposed; however, clear indications for operative repair have not yet been well established in the literature.MethodsWe reviewed primary research articles comparing ORIF treatment for ankle fracture with versus without deltoid ligament repair.ResultsFive studies were identified with a total of 281 patients. 137 patients underwent ORIF with deltoid repair, while 144 patients underwent ORIF without deltoid ligament repair. Clinical, radiographic, and functional outcomes, as well as complications were considered. The average follow-up was 31 months (range, 5–120).ConclusionsCurrent literature does not provide clear indication for repair of the deltoid ligament at the time of ankle fracture repair. There may be some advantages of adding deltoid ligament repair for patients with high fibular fractures or in patients with concomitant syndesmotic fixation.Level of clinical evidence: III.     

Evaluation of the syndesmotic screw in low Weber C ankle fractures

OBJECTIVE: To determine the functional and radiographic outcome of low Weber C ankle fractures and to evaluate the contribution of the syndesmotic screw in their outcome. DESIGN: Prospective evaluation of a consecutive series. SETTING: Level I trauma center. PATIENTS: Forty-five patients divided into two groups matched for age, sex, and severity of injury. Twenty-six patients were treated with open reduction, internal fixation, and a supplemental syndesmotic screw, and nineteen patients were treated without a syndesmotic screw. Minimum time to follow-up was three years. METHODS: A subjective, objective, and radiographic ankle scoring system was used. Logistical regression analysis was performed to determine whether the presence or absence of a syndesmotic screw was a predictor of a poor outcome. The likelihood ratio test was used to evaluate the significance of each variable in both univariate and multivariate analyses. RESULTS: There was no statistically significant difference between either group, either using subjective outcome criteria (p = 0.86) or in ankle range of motion (p = 0.94). Logistical regression analysis indicated that fracture dislocation could be used as a predictor of a poor outcome for either group. Inadequate reduction and advancing age were also found to be significant predictors of a poorer outcome regardless of the use of a syndesmotic screw (p = 0.003, p = 0.004). CONCLUSIONS: Judicious fixation of Weber C type injuries within five centimeters of the ankle joint, with or without a syndesmotic screw, gives similar results. Obligatory fixation of these fractures with syndesmotic screws appears to have no benefit and creates the need for an additional procedure.     

Predisposing factors for chronic syndesmotic instability following syndesmotic fixation in ankle fracture: Minimum 5-year follow-up outcomes

BackgroundThis study aimed to identify risk factors for chronic syndesmotic instability following syndesmotic fixation.MethodsWe performed a retrospective review of consecutive patients who had sustained ankle fractures requiring syndesmotic fixation. Patients available for a minimum 5 years of follow-up were classified into 2 groups according to the presence of syndesmotic instability. Statistical binary logistic regression analyses were performed to investigate the significance of various risk factors. Functional outcomes were assessed using the FAOS.ResultsIn total, 166 patients who met the study inclusion criteria underwent analysis. The overall postoperative instability rate was 20.5%, which was significantly affected due to BMI (p = 0.018; OR 6.72), and concomitant posterior malleolar fracture (p = 0.032, OR 2.77). The mean scores in the syndesmotic instability (SI) group were significantly lower than those in the no syndesmotic instability (NSI) group (p = 0.021).ConclusionsObesity and concomitant posterior malleolar fracture were significant risk factors for postoperative syndesmotic instability.     

Untreated small posterior fragment of ankle fracture with early removal of syndesmotic screw is associated with recurrent syndesmotic instability

IntroductionThis retrospective study aimed to report outcomes of fixation of bi-malleolar or tri-malleolar fractures combined with syndesmotic injury with or without posterior malleolar fracture (PMF), and to ascertain whether syndesmotic screw removal at 6 to 8 weeks or 3 months postoperatively is more beneficial.MethodsWe retrospectively reviewed patients who received open reduction and internal fixation for bi-malleolar (without PMF) or tri-malleolar ankle fracture (with PMF) with syndesmotic injury between January 2013 and December 2017 with at least 24 months of postoperative follow-up. All patients suffered syndesmotic instabilities and were treated using a syndesmotic screw without PMF fixation. Patients with bi-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks postoperatively were included in Group I, tri-malleolar fracture with syndesmotic screw removal at 6 to 8 weeks in Group II, and tri-malleolar fracture with syndesmotic screw removal at 3 months in Group III. Demographic data, clinical and radiographic outcomes were analyzed.ResultsA total of 113 patients were included (Group I, n=47; Group II, n=43; Group III, n=23). Average size of PMF was 14% in patients with tri-malleolar fractures (Groups II and III). No significant difference in ankle functional outcome among groups was observed. The recurrence rate of syndesmotic instability was 10.6% in Group I, 20.9% in Group II, and 8.7% in Group III. Although the difference in recurrence rates of syndesmotic instability among three groups was not statistically significant (P=0.264), Group II showed more interval change in tibiofibular clear space between initial postoperative radiographs and last follow-up radiographs (P=0.028) compared to the other two groups. Fracture union was achieved in all patients without screw breakage.ConclusionWe suggest that the better timing for syndesmotic screw removal is 3 months, instead of 6 to 8 weeks postoperatively, to reduce the risk of recurrence of syndesmotic instability for tri-malleolar fracture without posterior fragment fixation.Level of EvidenceLevel III- Case-control study.     

Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures

OBJECTIVE: Given the continued debate regarding syndesmotic screw fixation, we reviewed our institution's series of ankle syndesmotic screw insertions: 1) to examine technical aspects of syndesmotic screw fixation; and 2) to identify predictors of function and quality of life utilizing validated instruments. DESIGN: Retrospective observational study (level IV). SETTING: Three university hospitals. PATIENTS AND METHODS: All patients with ankle injuries who received syndesmotic screw fixation at 3 university-affiliated hospitals from 1998 to 2001. A combined hospital database for all 3 university affiliated hospitals was searched to identify all ankle fractures. Potentially eligible patients' charts were hand searched to determine the use of syndesmotic screw fixation. Radiographs from each patient were assessed for final eligibility for study inclusion. Baseline demographic information, fracture type (Lauge-Hansen, AO Weber), radiographic measurements of syndesmotic reduction, type of implants (number of screws, number of cortices, screw size), and screw removal at follow-up were determined. All radiographs were standardized for magnification. Patients also reported return to work, a visual analogue ankle pain score, and completed 2 functional outcomes instruments (Short Musculoskeletal Functional Assessment Index, Olerud and Molander Scale). MAIN OUTCOMES: Return to work, a visual analogue ankle pain score, and 3 functional outcomes instruments (Short Musculoskeletal Functional Assessment Index, Olerud and Molander Scale). RESULTS: Of 425 ankle fractures treated, 51 fractures had syndesmotic screw fixation. Patients were often males (67%), mean age 40.0 +/- 18.0 years, with sedentary occupations (88%), and twisting injuries (80%). Seventy percent of injuries were pronation external rotation injuries, and 30% were supination external rotation injuries. The ankle was dislocated in 45% of cases. The most common constructs for fixation included lateral plates with syndesmotic screws (45%). The majority of constructs included a single 3.5-mm cortical screw through 3 cortices of bone. Based upon postoperative x-rays, 16% of syndesmoses were not reduced. Additionally, 8 patients were deemed have inappropriate/lack of indications for syndesmotic screw insertion. At final follow-up (N = 39 patients, mean 18.1 months), patients achieved good function and quality of life (mean scores: Short Musculoskeletal Functional Assessment functional index = 11.4 +/- 10.6, Short Musculoskeletal Functional Assessment bother index = 13.5 +/- 13.1, Olerud and Molander = 74.1 +/- 23.4, visual analogue pain scale = 1.7 +/- 1.9). The only significant predictor of functional outcome was reduction of the syndesmosis (P = 0.04). This variable alone accounted for 18% of the variation in Short Musculoskeletal Functional Assessment Index physical function scores and 15% of the variance in the Olerud and Molander (running subscale) outcome measure. CONCLUSIONS/SIGNIFICANCE: Our findings suggest: 1) technical aspects of syndesmotic screw fixation vary between surgeons; 2) 16% of syndesmotic screws may have been unnecessary; and 3) despite variability in technique and indications, anatomic reduction of syndesmosis was significantly associated with improved Short Musculoskeletal Functional Assessment Index functional outcome. Larger, prospective studies are needed to further explore our findings.     

Incidence and severity of malreduction of the tibiofibular syndesmosis following surgical treatement of displaced ankle fractures and impact on the function –Clinical study and MRI evaluation

PurposeTo compare tibiofibular reduction quality in different types of operatively treated ankle fractures and the impact on clinical and functional outcome at mid-term follow-up.Patients and methodsOne hundred patients with an acute ankle fracture who had undergone open reduction and internal fixation were included. Eighty-eight patients who suffered from ligamentous ankle injury with neither fracture nor syndesmotic lesions served as a control group. Tibiofibular alignment was measured on MR images in all 188 patients. In case of tibiofibular malreduction tibiotalar positioning was determined as well. Clinical and functional outcome was assessed using the AOFAS hindfoot score as well as the SF-36.ResultsNo tibiofibular malreduction was found in type Weber B fractures, irrespective of syndesmotic instability followed by syndesmotic screw placement, as compared to the control group. A significant tibiofibular malreduction was detected in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic screw, in comparison to the control group. Tibiotalar displacement could not be detected. Clinical and functional outcome analysis revealed no significant differences between the treatment groups.ConclusionThree-dimensional imaging may improve tibiofibular malreduction visualization in bimalleolar/trimalleolar/dislocated type Weber B fractures and in isolated type Weber C fractures with syndesmotic transfixation. The clinical impact of improving tibiofibular positioning remains highly questionable since there was no correlation between tibiofibular alignment and the clinical outcome at mid-term follow-up.     

Clinical outcomes of an olive wire and external fixator versus a metallic screw in the treatment of inferior tibiofibular syndesmosis injuries in ankle fractures

BackgroundMetal screws are the most widely used in treating syndesmotic injuries, but failure and the rigidity of the screws can threaten the success of the treatment and increase the cost of care. We have provided an alternative with an olive wire and external fixator(OWEF) used for syndesmotic fixation.MethodsA retrospective longitudinal follow-up study was conducted. From February 2011 to January 2018, 58 of 72 patients with ankle fractures and associated syndesmotic disruption were treated with either screw or OWEF fixation. The costs, complications, and clinical outcomes using Olerud-Molander score and Visual Analog score in screw and OWEF fixation group were compared.ResultsWe found the severity of the injury, BMI of the patients and the different fixation methods were determinants of the complications and clinical outcomes. But if no malreduction of the syndesmosis was present, no difference in clinical result was detected.ConclusionThe OWEF method appeared to be at least equally functional and effective to screw fixation while maintaining possible lower complication rate.Levels of clinical evidenceLevel 3     

Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores

PurposeChronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores.MethodIt is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50–77 years) followed by over 35.6 months (Range 22–48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits.ResultsAll the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22–48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.30⁰+ 4.9⁰ and 12.5⁰ + 4.7⁰ respectively. Three patients had minor wound complications. All the patients returned to activities of daily living.ConclusionFHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.     

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

BackgroundSyndesmosis 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.MethodsFollowing 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.ResultsA 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.ConclusionThere 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.     

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

ObjectiveWith 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.MethodsA 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.ResultsSeventy‐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).ConclusionInsertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable.     

Operative Management of AO Type 44 Ankle Fractures: Determinants of Outcome

The consequences of inadequate treatment of ankle fractures can be disastrous. We assessed the radiologic and functional outcomes, postoperative quality of life (QOL), and its determinants for patients treated operatively for AO type 44 ankle fractures. Evidence is lacking concerning the management of posterior malleolus fractures and syndesmotic injuries. Our retrospective adult cohort study included 432 AO/OTA type 44 ankle fractures (431 patients). The median follow-up period was 52 months. Outcomes were assessed from the medical records, radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle scale (functional outcome), and EuroQol EQ-5D questionnaires. The median AOFAS scale score was 88; 27.9% of patients reported restricted mobility and 40.4% pain or discomfort. In 8.8%, radiographic failure was observed. The presence of posterior malleolus fractures was significantly associated with poor functional outcomes, and a postoperative step-off correlated with radiologic failure, poor functional outcome, and poor postoperative QOL. Late syndesmotic screw removal was associated with worse EQ-5D time trade-off QOL scores. A substantial number of patients experienced functional impairment, discomfort, and pain. Syndesmotic injury was associated with ankle joint failure and poor functional outcomes. Our data indicate that all displaced posterior malleolus fracture fragments affecting the posterior articular tibial surface in patients aged ≤65 years require anatomic reduction.     

Aftercare Following Syndesmotic Screw Placement: A Systematic Review

For ankle fractures, in general, several studies have been published on immobilization (e.g., cast or boot) versus early motion after surgical treatment. However, no studies have been performed to determine the best aftercare strategy for surgically treated patients with ankle fractures with concomitant acute distal tibiofibular syndesmotic injuries. The aim of the present review was to compare the functional outcomes of ankle fractures with syndesmotic injury treated with a cast or boot versus early motion. We performed a systematic review using the electronic databases from January 1, 2000 to September 1, 2012 of the Cochrane Library, PubMed MEDLINE^®, EMbase, and Google Scholar. The included studies were those in which ankle fractures with acute distal tibiofibular syndesmotic injuries had been treated with 1 or more syndesmotic screws, with a mean follow-up period of at least 12 months and at least 25 patients included. The functional outcomes, measured using the American Orthopaedic Foot Ankle Society Hindfoot scale, Olerud-Molander Ankle Scale, and Short Musculoskeletal Function Assessment, were compared. A total of 9 studies were identified with a total of 531 patients. The number of included patients ranged from 28 to 93. The mean follow-up period was 12 to 101 months. Of the 9 studies, 3 used an early motion protocol (195 patients) and 6 (336 patients) a protocol of immobilization for at least 6 weeks. For the American Orthopaedic Foot Ankle Society Hindfoot scale, the mean scores for immobilization were 86 to 91 points and for early motion, 84 to 89. For the Olerud-Molander Ankle Scale, the scores for immobilization were 47 to 90 and for early motion, 46 to 82 points. The Short Musculoskeletal Function Assessment score for immobilization was 11 and for early motion ranged from 12 to 27 points. No apparent differences could be detected in the published data considering the functional outcomes between immobilization versus an early motion protocol in ankle fractures with acute distal tibiofibular syndesmotic injuries treated with a syndesmotic screw. However, level 1 and 2 studies on this subject are lacking.     

Biomechanical comparison of suture-button,bioabsorbable screw,and metal screw for ankle syndesmotic repair: A meta-analysis

BackgroundTo compare biomechanically metal screw fixation to suture-button or bioabsorbable screw fixation for ankle syndesmotic injuries.MethodsA literature search of the comparison studies in Pubmed and Google Scholar was conducted. The biomechanical outcomes of interest were syndesmotic stability in the coronal, sagittal, and axial planes as well as torque and rotation at failure.ResultsA total of 11 cadaveric studies were included. In the suture-button group, coronal displacement (MD 1.72 mm, p = 0.02) and sagittal displacement (MD 2.65 mm, p = 0.0003) were increased relative to the metal screw group. In contrast, no difference was found with axial rotation (MD 0.35 degrees, p = 0.57). Bioabsorbable screws exhibited equivalent failure torque (MD ?3.04 Nm, p = 0.53) and rotation at failure (MD 3.77 degrees, p = 0.48) in comparison to metal screws.ConclusionsSuture-button provide less rigidity when compared to metal screw fixation. They afford flexible syndesmotic micromotion which may more closely resemble a physiological state and be helpful for ligament healing. Bioabsorbable screws demonstrate similar mechanical strength properties to metal screws.     

Ankle fractures: High implant cost is not associated with better patient reported outcomes

IntroductionAnkle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries.Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture.MethodsAll ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost.ResultsThere was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [−411.8, −54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [−74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48).ConclusionsThe utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.     

Management of acute injuries of the tibiofibular syndesmosis

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11–20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.     

Evaluation of a modified Broström–Gould procedure for treatment of chronic lateral ankle instability: A retrospective study with critical analysis of outcome scoring

BackgroundChronic lateral ankle instability accounts for 20% of the ankle injuries. This study evaluates functional outcome of the modified Broström–Gould technique using suture anchors, with 4 different clinical scores.MethodsA consecutive series of 41 patients were included with a minimum follow-up of one year. The function was assessed using 4 clinical scores including: the AOFAS for hind foot; the FAAM; the CAIT and the CAIS.ResultsOut of 41 patients; 27 patients were very satisfied, 11 satisfied and 3 were not satisfied. Ankle mobility returned to normal in 93% of patients. At follow-up the AOFAS was 89/100 (37–100), the FAAM 85/100% (35–100%), the CAIT 20/30 (5–30), and the CAIS 74/100% (27–100%).ConclusionOutcome of modified Broström–Gould procedure is good with high satisfaction rate in terms of ankle mobility. The disparity in outcome of scores, signals towards the need of a standard evaluation system.     

Comparing Different Surgical Techniques for Addressing the Posterior Malleolus in Supination External Rotation Ankle Fractures and the Need for Syndesmotic Screw Fixation

Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.     

Surgical outcome in chronic syndesmotic injury: A systematic literature review

BackgroundChronic injuries of the distal tibio-fibular syndesmosis often present with non-specific clinical and radiographic findings. If chronic instability to the distal tibio-fibular syndesmosis is verified, various reconstruction options are available. The purpose of this article is to give a systematic review of current surgical treatment options in patients with chronic syndesmotic injury.MethodsThree major medical databases were searched from inception through December 12, 2017: PubMed, ScienceDirect, and SpringerLink. Studies were included if they were original research studies which assessed the outcome of patients treated surgically for chronic syndesmotic instability. Only studies written in English were considered. The following data were extracted from each study: number of patients and ankles included, average patients’ age, gender, study design, preoperative examination, time between the initial injury and the operation, postoperative follow-up time, operative technique, complication rates, and clinical outcome. The modified Coleman Score was used to assess the methodologic quality of the included studies.ResultsSeventeen (17) studies were included. All studies were retrospective or prospective case series. Each study was performed at a single center. In general, good functional outcomes and low complication rates were reported. The American Orthopaedic Foot and Ankle (AOFAS) score was most frequently used outcome tool to measure postoperative outcomes. The quality of the included studies was overall satisfactory.ConclusionsA few studies have reported on the operative outcomes after treating chronic syndesmotic instability. Several different techniques were used to treat this problem. The quality of current studies is overall satisfactory but could be improved with larger patient numbers and prospective analysis. Recognition of this clinical entity as an identifiable and treatable cause of ankle pain requires vigilant clinical investigation.Level of evidenceLevel IV; Systematic Review of Level IV Studies.     

Syndesmotic screw fixation in Weber C ankle injuries--should the screw be removed before weight bearing?

OBJECTIVE: To compare the outcomes of Weber C ankle fractures treated with syndesmotic screw fixation where the screw was removed prior to weight bearing against those where the screw was left in situ indefinitely. DESIGN: Retrospective observational analysis of a consecutive series. SETTING: Acute tertiary hospital. PATIENTS: Thirty-three patients with ankle fractures and syndesmotic disruption were treated with open reduction, internal fixation, and syndesmotic stabilisation with a syndesmotic screw. Three patients defaulted follow-up after 1-3 months. In the remaining 30, the syndesmotic screw was removed prior to weight bearing in 23 patients and was left in situ in 7 patients. Mean follow-up was 15 months. METHODS: Assessment with subjective, objective, and radiographic criteria was used. Statistical analysis was performed with independent groups t-test and chi-square test. RESULTS: There was no statistically significant difference between ankle scores, functional outcome or range of motion between the two groups. However, there was a significantly higher incidence of syndesmotic screw breakage and osteolysis in the group where screws were retained. CONCLUSIONS: Judicious fixation of Weber C type injuries with syndesmotic screw fixation allows for good functional outcome. Retaining of the syndesmotic screw on commencement of weight bearing seems to increase the risk of subsequent screw breakage. Removal of the screw prior to weight bearing should be performed to avoid such an eventuality.