Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation.

BACKGROUND: Bioabsorbable implants have restricted indications because of their unique biochemical properties and their inferior biomechanical properties compared with those of conventional metallic implants. The purpose of this prospective study was to assess the efficacy of screws made of polylevolactic acid (PLLA) in the treatment of syndesmotic disruptions associated with ankle fractures and fracture-dislocations. METHODS: Thirty-three consecutive patients with a syndesmotic disruption were managed with standard metallic plate-and-screw fixation of the malleolar fracture and with 4.5-mm polylevolactic acid screws, with purchase in four cortices, for fixation of the syndesmosis. Intraoperative radiographs confirmed reduction of the syndesmosis, and all of the patients were managed with a non-weight-bearing plaster splint or brace for six weeks. Clinical and radiographic assessment and functional evaluation with use of the Olerud-Molander scoring system were performed at the time of follow-up. RESULTS: Ten patients were lost to follow-up prior to the twenty-four-month evaluation, leaving twenty-three patients with an average duration of follow-up of thirty-four months (range, twenty-four to forty-three months). All of the malleolar fractures healed in an anatomical position at an average of three months, and no postoperative displacement of the syndesmosis or widening of the medial clear space was detectable on radiographs. No episodes of osteolysis or late inflammation secondary to the hydrolyzed polylactide occurred. Nineteen patients (83%) had an excellent result, and four patients (17%) had a good result. All twenty-three patients returned to their preinjury level of work and activities of daily living. No patient had malunion, nonunion, loss of reduction, or complications attributable to the biomechanical or biochemical properties of the implants. CONCLUSIONS: Polylevolactic acid screws are effective in stabilizing disruption of the syndesmosis during healing of unstable ankle fractures. In this small series, the bioabsorbable screw was well tolerated, and there was no need for a second operation to remove it.     

Biodegradable screw fixation of the syndesmosis together with metallic osteosynthesis. Preliminary experience of 7 ankles

BACKGROUND AND AIMS: In ankle fractures with separation of the tibiofibular mortise a metallic syndesmosis screw is generally used. As a rule, this transfixing screw is removed by a separate operation 6 to 8 weeks later. Usually the fracture fixation implants are removed by a second operation later on. In order to eliminate separate removal of the transfixing screw, we used a biodegradable syndesmosis screw in a pilot clinical study. PATIENTS AND METHODS: We treated seven consecutive patients with malleolar fractures and separation of the syndesmosis by an ordinary metallic plating and screw fixation of the fractures and biodegradable polyglycolic acid (PGA) screw transfixation of the syndesmosis. RESULTS AND CONCLUSIONS: All the patients ended up with an acceptable result and stable ankle mortise. One of the ankles, which was the only one fixed by two transfixing PGA screws instead of one screw, had transient sinus formation and intraosseal osteolysis. The final result was good also in this case. The ankle mortise can be fixed safely by biodegradable screws in connection with metallic osteosynthesis of malleolar fractures. Thus a separate removal of the transfixing material is possible to eliminate.     

Comparison of a novel FiberWire-button construct versus metallic screw fixation in a syndesmotic injury model

BACKGROUND: There is minimal experience with less rigid syndesmotic fixation devices which may approximate the normal distal tibio-fibular mechanics during healing. This study evaluates the ability of a FiberWire-button implant (Arthrex, Naples, FL) to maintain syndesmotic reduction as compared with a metallic screw. METHODS: Ten matched fresh-frozen cadaveric ankle pairs with intact ligaments were tested (12.5 Nm external rotation force) to establish physiologic syndesmotic diastasis. The same force was applied to the ankles after sectioning of the syndesmotic and deltoid ligaments. Within the pairs, each limb was randomized to receive a FiberWire-button implant or a metallic screw (Synthes, Paoli, PA); the ankles were tested for syndesmotic diastasis with progressive external rotation force, from 2.5 Nm to 25 Nm (or failure). RESULTS: There was no significant difference in diastasis amongst pairs with intact or sectioned syndesmosis (p=0.64 and p=0.80, respectively). There was a significantly greater diastasis in the FiberWire-button group at all external rotation loads (p<0.0001). Nine of the ten pairs failed (all through fracture of the distal fibula). There were no hardware failures. The metallic screw group failed at a lower load (mean 15 Nm) compared to the FiberWire-button group (mean 18 Nm, p=0.0004). The metallic screw group maintained syndesmotic reduction up to 5 Nm of force. CONCLUSIONS: The FiberWire-button was unable to maintain syndesmotic reduction of the ankles at any of the forces applied. The ankles fixed with the FiberWire-button demonstrated significantly greater widening of the syndesmosis compared to the screw, at all loads. CLINICAL RELEVANCE: The FiberWire-button implant may not maintain adequate ankle syndesmotic reduction in the immediate post-operative period relative to a metallic screw.     

Cost analysis of ankle syndesmosis internal fixation

BackgroundUnstable ankle syndesmosis injuries are common, and the optimal surgical fixation is controversial. The two main options for stabilization of syndesmotic injuries are suture button fixation and screw fixation. Suture button fixation has a higher initial cost, but may have a lower hardware removal rate. The purpose of this study was to compare the costs of syndesmotic fixation.MethodsA cost analysis was performed at a single university-affiliated hospital. Variables included the number of suture buttons, the number and type of syndesmosis screws used, and the frequency of hardware removal and operative time required for hardware removal. There were four clinical scenarios evaluated: (A) one suture button versus one cortical screw; (B) two suture buttons versus two cortical screws; (C) one suture button versus one locking screw; (D) two suture buttons versus two locking screws. Suture button removal rate was assumed to be 0% in the analysis.ResultsCost equivalence was achieved at an 18 to 53% syndesmotic screw removal rate depending on the fixation construct used and the amount of time required for hardware removal. When the syndesmosis screws were removed 100% of the time, suture button fixation was more economical by $85,000–$194,656 per 100 ankles. When hardware was never removed, suture button fixation was more expensive by $169,844–$295,500 per 100 ankles.ConclusionThis study demonstrates that the costs associated with syndesmosis fixation are more dependent on the rate of hardware removal than the type of hardware utilized. Routine removal of syndesmosis screws is clearly less economical than suture button fixation.     

Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures

OBJECTIVE: This study was designed to compare intraoperative fluoroscopic stress testing, static radiographs, and biomechanical criteria for the diagnosis of distal tibiofibular syndesmotic instability associated with external rotation type ankle fractures. DESIGN: Prospective, consecutive series. SETTING: Academic level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight skeletally mature patients with unstable unilateral external rotation ankle fractures were prospectively recruited. INTERVENTION: Before surgery, the treating surgeon detailed the operative treatment plan, including need for syndesmotic fixation. In pronation-external rotation injuries, biomechanical criteria were applied to predict syndesmotic instability. Ankles were examined using intraoperative fluoroscopic external rotation stress tests. The contralateral uninjured limb was used as a control. A 7.2-Nm force was applied for the external rotation stress examination. Stress testing was performed after lateral malleolar fixation and repeated after medial and syndesmotic fixation. MAIN OUTCOME MEASURES: The incidence of syndesmotic instability was determined based on radiographic clear space measurements and compared with previously published criteria. RESULTS: Intraoperative fluoroscopy detected unpredicted syndesmotic instability in 37% of ankles. In supination-external rotation (OTA 44B) injuries, unpredicted syndesmosis instability was found in 10 of 30 patients (33%). In pronation-external rotation injuries (OTA 44C), 4 of 7 patients (57%) were associated with syndesmosis disruption not predicted by biomechanical criteria. In bimalleolar fractures, syndesmosis fixation improved stability compared with rigid bimalleolar fixation alone (P < 0.01). CONCLUSIONS: Preoperative radiographs and biomechanical criteria are unable to routinely predict the presence or absence of syndesmosis instability. Rigid bimalleolar fixation was frequently not sufficient to stabilize syndesmotic disruption. Intraoperative stress fluoroscopy is a valuable tool for detection of unstable syndesmotic injuries.     

Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature

Syndesmotic rupture is present in 10 % of ankle fractures and must be recognized and treated to prevent late complications. The method of fixation is classically rigid fixation with one or two screws. Knowledge of the biomechanics of the syndesmosis has led to the development of new dynamic implants to restore physiologic motion during walking. One of these implants is the suture-button system. The purpose of this paper is to review the orthopaedic trauma literature, both biomechanical and clinical, to present the current state of knowledge on the suture-button fixation and to put emphasis on the advantages and disadvantages of this technique. Two investigators searched the databases of Pubmed/Medline, Cochrane Clinical Trial Register and Embase independently. The search interval was from January 1980 to March 2011. The search keys comprised terms to identify articles on biomechanical and clinical issues of flexible fixation of syndesmotic ruptures. Ninety-nine publications met the search criteria. After filtering using the exclusion criteria, 11 articles (five biomechanical and six clinical) were available for review. The biomechanical studies involved 90 cadaveric ankles. The suture-button demonstrated good resistance to axial and rotational loads (equivalent to screws) and resistance to failure. Physiologic motion of the syndesmosis was restored in all directions. The clinical studies (149 ankles) demonstrated good functional results using the AOFAS score, indicating faster rehabilitation with flexible fixation than with screws. There were few complications. Preliminary results from the current literature support the use of suture-button fixation for syndesmotic ruptures. This method seems secure and safe. As there is no strong evidence for its use, prospective randomized controlled trials to compare the suture-button to the screw fixation for ankle syndesmotic ruptures are required.     

Overtightening of the ankle syndesmosis: is it really possible?

BACKGROUND: Many surgeons and orthopaedic references recommend that fixation of a disrupted distal tibiofibular syndesmosis be performed with the ankle in dorsiflexion to avoid overtightening and subsequent restriction of ankle dorsiflexion. This recommendation is based in large part on one cadaveric study without clinical correlation. The purpose of the present study was to examine whether overtightening of the syndesmosis limits maximal ankle dorsiflexion. METHODS: Nineteen cadaveric ankles were used for the study. Each ankle was tested for the initial range of motion after release of the Achilles tendon proximal to the ankle joint. All capsular and ligamentous structures remained intact. Kirschner wires were placed in the tibia and talus. The angle between the wires with the ankle maximally dorsiflexed was measured before and after syndesmotic compression. Syndesmotic compression was achieved with a 4.5-mm lag screw with the ankle in plantar flexion. RESULTS: There was no difference between the values for maximal dorsiflexion before and after syndesmotic compression. CONCLUSIONS: Syndesmotic compression in and of itself does not diminish ankle dorsiflexion in a cadaveric model. Clinical Relevance: Maximal dorsiflexion of the ankle during syndesmotic fixation is not required in order to avoid loss of dorsiflexion. It is likely that the most important aspect of syndesmotic fixation is anatomic reduction of the syndesmosis and that the degree of ankle dorsiflexion during fixation is not important.     

Rupturen der tibiofibularen Syndesmose

The standard treatment of distal ruptures of the tibiofibular syndesmosis is an anatomical reduction of the fibula and fixation with one or two tibiofibular syndesmosis screws. The incidence of isolated distal rupture of the tibiofibular syndesmosis is rare. On the other hand 1 in 10 fractures of the ankle is associated with a relevant syndesmotic instability. The classification of Lauge Hansen is based on the analysis of the pathomechanism. A correct reduction and positioning of the screws is mandatory for a good clinical result. Injuries of the ankle combined with syndesmotic instability lead to worse outcome than those without, even after surgical treatment. This can be explained by many reasons, especially by the severity of the injuries but also by the quality of reduction and fixation. The syndesmosis screw fixation method is presented as a standard fixation and additionally the Ankle TightRope? is described as a valid treatment alternative.     

The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction

Tibiofibular injury repair of ankle fractures may result in over-compression when performed via a partially threaded screw depending on its placed level. We aimed to examine the relationship between the screw level relative to the tibiotalar joint and syndesmosis malreduction in postoperative radiographs of ankle fractures treated with partially threaded screws. We retrospectively analyzed 129 patients who underwent surgery due to lateral malleolar fractures between 2011 and 2019. We measured the distance between the screw and the tibiotalar joint and stratified the patients per their screw level as either trans-syndesmotic or suprasyndesmotic. According to Lauge-Hansen, 83 cases were supination-external rotation type (64.3%), and the remaining were pronation-external rotation type (35.7%) injuries. We found postoperative syndesmosis malreduction in 20 cases (15.5%). Eight (6.2%) cases had medial clear space mismatch. As the distance of the screw to the joint increased, postoperative medial clear space values increased (rho: 0.190, p = .031). The relationship between postoperative syndesmosis mismatch and the level of the syndesmotic screw was statistically significant (p = .044). In syndesmosis repair with a partially threaded screw, as the distance of the screw from the joint increases, the over-compression caused by the screw may cause an increase in postoperative syndesmotic malreduction rates.     

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.     

Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation

We assessed syndesmotic set screw strength and fixation capacity during cyclical testing in a cadaver model simulating protected weight bearing. Sixteen fresh frozen legs with artificial syndesmotic injuries and a syndesmotic set screw made of stainless steel or titanium, inserted through three or four cortices, were axially loaded with 800 N for 225,000 cycles in a materials testing machine. The 225,000 cycles equals the number of paces taken by a person walking in a below knee plaster during 9 weeks. Syndesmotic fixation failure was defined as: bone fracture, screw fatigue failure, screw pullout, and/or excessive syndesmotic widening. None of the 14 out of 16 successfully tested legs or screws failed. No difference was found in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Mean lateral displacement found after testing was 1.05 mm (S.D. = 0.42). This increase in tibiofibular width exceeds values described in literature for the intact syndesmosis loaded with body weight. Based on this laboratory study it is concluded that the syndesmotic set screw cannot prevent excessive syndesmotic widening when loaded with a load comparable with body weight. Therefore, we advise that patients with a syndesmotic set screw in situ should not bear weight.     

Ruptured tibio-fibular syndesmosis: comparison study of metallic to bioabsorbable fixation

The patients of this study come from a series of 43 consecutive ankle fracture patients with syndesmotic rupture operated on at our department. Of these patients, 18 were treated with bioabsorbable self-reinforced poly-L-lactide screw and 12 treated with metallic screw. All agreed to participate in this study. They were examined after a minimum follow-up period of 12 months. The patients were examined for measurements from ankle radiographic and computed tomography films, loaded dorsal range of movement of the ankle, and duration of sick leave. Subjective results were obtained by a constructed questionnaire. There were no significant differences between the patient groups in any of the parameters measured. We conclude that the fixation of a syndesmotic rupture can be done with a bioabsorbable self-reinforced poly-L-lactide screw.     

The distal tibiofibular syndesmosis during passive foot flexion. RSA-based study on intact, ligament injured and screw fixed cadaver specimens

Introduction: The aim of the study was to investigate the kinematics of the distal tibiofibular syndesmosis in intact and ligament injured ankles and to assess how effective is the syndesmotic screw in restraining mortise width variations during passive foot flexion. Materials and methods: The trials were carried out on seven fresh frozen cadaver specimens. The distal tibiofibular syndesmosis widening was investigated using Roentgen stereophotogrammetric analysis, in intact and ligament injured ankles and after the fixation of the syndesmotic screw. The AO-ASIF recommendations were followed for screw implant. Results: Injury to the syndesmotic and deltoid ligaments of the ankle did not result in a significant variation of the syndesmosis behavior during passive foot flexion. The 4.5-mm diameter cortical screw used in this study proved effective in restraining mortise width variation during foot flexion. The recorded mortise widening in the flexion arc extending from the neutral to the maximally dorsiflexed position was negligible in intact and ligament injured joints. Conclusion: The result does not endorse the recommendation of placing the foot in full dorsal flexion during screw implantation. The choice of screw fixation as a treatment for ankle syndesmosis disruption should be carefully evaluated.     

Dynamics of Tibiofibular Syndesmosis in Correlation with the Level of the Syndesmotic Scress in Maisonneuvre Fractures of the Ankle - a Cadaver Study

Background: The objective of this study was to determine the level of the syndesmotic screw, the number of screws needed, and whether one or both cortices of tibia should be engaged to closely reproduce the physiological stability and elastic of the ankle mortise in syndesmotic rupture after Maisonneuve fractures. Material and Methods: Twelve fresh frozen cadaveric pairs of lower extremities were used for this study. The knee was exarticulated and soft tisue removed leaving the lateral and medial ankle ligaments intact. The tibiofibular syndesmosis was then sharply sectioned. All specimens were mounted in an Instron 2000 material testing machine. An axial loading of 500 N was applied. Syndesmotic diastasis was measured by a linear transducer system. The specimens were divided into three groups. In group I, the specimens were instrumented with one syndesmotic screw 2.5 cm above tibia plafond. In group II, the same procedure was performed as in group I with the syndesmotic screw positioned 4 cm above tibia plafond. In group III, the syndesmosis was fixed in each pair with two screws 2.5 and 4 cm above tibia plafond. In all groups, the screws were positioned randomly through three cortices on the one side and through four cortices on the contralateral side. Results: Significant difference was observed between the application of one or two screws through three or four cortical shells on one side and the level of the screw on the other. Conclusions: According to the results of this study, we recommend to use one screw through four cortices 2.5 cm above the tibia plafond.     

Syndesmosis Fixation in Unstable Ankle Fractures Using a Partially Threaded 5.0-mm Cannulated Screw

The present study evaluated the radiographic outcomes of syndesmosis injuries treated with a partially threaded 5.0-mm cannulated screw. The present study included 58 consecutive patients with syndesmosis injuries concurrent with ankle fractures who had undergone operative fixation with a partially threaded 5.0-mm cannulated screw to repair the syndesmosis injury. Radiographic indexes, including the medial clear space, tibiofibular overlap, tibiofibular clear space, and fibular position on the lateral radiograph, were measured on the preoperative, immediate postoperative, and final follow-up radiographs. The measurements were compared between the injured and intact ankles. All preoperative radiographic indexes, including the medial clear space (p?<?.001), tibiofibular overlap (p?<?.001), tibiofibular clear space (p?<?.001), and fibular position on the lateral radiograph (p?=?.026), were significantly different between the injured and intact ankles. The medial clear space of the injured ankle was significantly wider than that of the intact ankle preoperatively (p?<?.001) and had become significantly narrower immediately postoperatively (p?<?.001). Finally, the medial clear space was not significantly different between the injured and intact ankles at the final follow-up examination (p?=?.522). No screw breakage or repeat fractures were observed. A 5.0-mm partially threaded cannulated screw effectively restored and maintained the normal relationship between the tibia and fibula within the ankle mortise with a low risk of complications. This appears to be an effective alternative technique to treat syndesmosis injuries concurrent with ankle fractures.     

Syndesmotic Internal Brace~(TM) for anatomic distal tibiofibular ligament augmentation

Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the Tight Rope~?system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 Tight Ropes~?. Therefore, we developed a new syndesmotic Internal Brace~(TM) technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The Internal Brace~(TM) technique was developed by Gordon Mackay from Scotland in 2012 using Swive Locks~? for knotless aperture fixation of a Fiber Tape~? at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern,patients can either be treated by the new syndesmotic Internal Brace~(TM) technique alone as a single anterior stabilization, or in combination with one posteriorly directed Tight Rope~? as a double stabilization, or in combination with one Tight Rope~? and a posterolateral malleolar screw fixation as a triple stabilization. Moreover,the syndesmotic Internal Brace~(TM) technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an Internal Brace~(TM) after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic Internal Brace~(TM) technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.     

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.     

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.     

下胫腓联合螺钉治疗下胫腓韧带联合损伤的临床观察

目的：探讨踝关节周围骨折合并下胫腓韧带联合损伤的手术方法。方法：对2005年9月至2007年12月用下胫腓联合螺钉固定治疗的20例（21踝）下胫腓韧带联合损伤患者进行回顾性研究,其中男11例（12踝）,女9例（9踝）;年龄27～52岁,平均36岁。所有患者结合病史、查体及影像学检查进行诊断,按照Lauge-Hansen分型进行手术治疗。X线测量：①胫骨前结节与腓骨的重叠阴影;②下胫腓联合间隙;③内踝关节面与距骨关节面的间隙。临床疗效采用改良Baird-Jackson评分标准进行评价。结果：20例（21踝）均获得随访,时间1～2.2年,平均1.3年。术前正侧位下胫腓联合重叠影为（0.46±3.56）mm,下胫腓联合间隙为（5.69±0.88）mm,胫距关节内间隙为（5.67±1.23）mm,踝穴位下胫腓联合重叠影为（-0.87±0.96）mm;术后下胫腓联合重叠影为（7.14±0.62）mm,下胫腓联合间隙为（3.28±0.39）mm,胫距关节内间隙为（3.12±0.33）mm,踝穴位下胫腓联合重叠影为（2.91±0.30）mm,与术前比较差异均有统计学意义（P〈0.01）。术后CT复查显示：下胫腓联合仍存在一定程度分离的有4例,均为轻度。术后Baird-Jackson评分为（86.24±13.26）分（62～98分）,在各项评定内容中,13踝（61.90%）获得无痛踝关节,16踝（76.19%）无踝关节不稳征象,11踝（52.38%）恢复正常行走能力,8踝（38.10%）恢复正常奔跑能力,11踝（52.38%）恢复正常的工作能力。踝关节背伸活动度（21.05±5.00）°,跖屈活动度（33.57±5.76）°,内翻活动度（19.48±4.57）°,外翻活动度（24.05±4.86）°。踝关节发生创伤性骨性关节炎表现的患者3例,无一例发生断钉;临床疗效优12踝,良2踝,可4踝,差3踝。结论：下胫腓联合3层皮质螺钉固定是治疗下胫腓韧带联合损伤的有效方法之一,精细的手术操作技术和下胫腓联合解剖关系的恢复是患者获得良好踝关节功能的重要因素,术后常规?     

Operative treatment for separation of distal tibiofibular syndesmosis

Objective: To study the influence of separation of distal tibiofibular syndesmosis on ankle joint and to compare various operative methods so as to find suitable stabilization for separated distal tibiofibular syndesmosis. Methods: From July 1997 to July 2002, we treated 87 patients (64 males and 23 females, aged 18-54 years) with separation of distal tibiofibular syndesmosis, among whom, 79 were combined with fracture of malleolus. Manipulative reduction, internal fixation with cancellous screws and external fixation with plaster support were performed on 37 patients, fixation with plate and screws for fibular fracture and fixation with cancellous screws for distal tibiofibular syndesmosis on 34 patients, and repair of the distal tibiofibular ligaments with tendon of peroneus longus, reduction of the separated distal tibiofibular syndesmosis, and fixation with cancellous screws on 16 patients. The ankle joint had been dorsiflexed for 30°when the distal tibiofibular syndesmosis was fixed with cancellous screws. And the cancellous screws were taken out at 8-10 weeks after operation. Results: These patients were followed up for at least two years. The curative effects were assessed according to the complaints of the patients and the contour, function and radiogram of the ankle joint: excellent in 55 patients (63%), good in 18 patients (21%) , and fair in 14 patients (16%). Separation of distal tibiofibular syndesmosis recurred in 2 patients, who underwent a reoperation for repairing the distal tibiofibular ligaments with tendon of peroneus longus and recovered. One cancellous screw was broken off. No necrosis developed in the anterior skin of the ankle mortise. Conclusions:Separation of distal tibiofibular syndesmosis can be treated with various reasonable operations. Repair with tendon of the peroneus longus can get excellent outcomes for complete separation of the distal tibiofibular syndesmosis.