三角韧带与下胫腓联合韧带对踝关节稳定的生物力学影响

目的探讨三角韧带与下胫腓联合对踝关节稳定性的生物力学影响。方法采用6例新鲜踝关节标本,常规制成骨-韧带模型(标本可重复利用)。分为:A组:踝关节各韧带均完整;B组:三角韧带离断,下胫腓联合完整;C组:下胫腓联合离断,三角韧带完整;D组:下胫腓联合及三角韧带均离断;E组:锚钉修复三角韧带、螺钉固定下胫腓联合韧带组。对标本施加600 N轴向加载。分别测量三种体位(中立位、背伸10°位、跖屈20°位)在各种状态下胫距关节的接触面积、接触压力、压应力分布等变化。对比分析三角韧带及下胫腓联合韧带修复前后对踝关节稳定的作用。结果在三种体位下均可发现,随着下胫腓联合及三角韧带的离断,胫距关节接触面积逐渐减小,接触压力逐渐增大,与正常A组对比差异有统计学意义(P<0.05),压应力分布逐渐集中并有向外侧移位趋势;三角韧带与下胫腓联合修复前后的胫距关节的接触面积、接触压力等差异有统计学意义(P<0.05);修复后的胫距关节接触面积增大、接触压力减少,与正常组A组对比差异无统计学意义(P>0.05),压应力分布分散。结论三角韧带与下胫腓联合断裂后,距骨发生移位,胫距关节面接触面积、接触压力及压应力分布发生剧烈变化。目前骨锚钉修复三角韧带、螺钉固定下胫腓联合能获得即刻稳定,且其生物力学强度与正常组相似,推荐对三角韧带伴下胫腓联合损伤者行手术治疗以恢复其正常解剖关系。     

The Role of Deltoid Ligament Repair in Ankle Fractures With Syndesmotic Instability: A Systematic Review

Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.     

Clinical Study of Ankle Fracture Combined With Deltoid Ligament Injury: Repair or Not? A Retrospective,Comparative Study

This study retrospectively evaluated patients with ankle fracture to compare the prognosis between patients who had primary repair of the superficial deltoid ligament and those who did not. A total of 71 patients with ankle fracture and fracture-dislocation combined with deltoid ligament injury were divided into 2 groups: repair of superficial layer group (33 cases) and nonrepair group (38 cases). For the repair group, patients first underwent open reduction and internal fixation of the lateral malleolus and received a stress test. If the syndesmosis was widened, it would undergo fixation of the syndesmosis with screws. If instability of the ankle joint was observed, patients might further undergo repair of the superficial deltoid ligament. Ultimately, postoperative functions were evaluated using the Philips and Schwartz scale. All patients achieved bony union without significant pain. In the repair group, plantar and dorsi flexions were 2.5 ± 4.2° (range 0 to 10) and 7 ± 7.1° (range 0 to 20) less than the normal side, respectively. In the nonrepair group, the plantar and dorsi flexions were 2.8 ± 4.6° (range 0 to 10) and 6.6 ± 5.9° (range 0 to 20) less than the normal side. Meanwhile, the Philips and Schwartz scores of the repair and nonrepair groups were 92.5 ± 4.4 (range 80 to 100) and 93.4 ± 3.8 (range 85 to 100), respectively. But the difference of prognosis between the 2 groups was not statistically significant. In conclusion, for ankle joint fracture combined with deltoid ligament injury, routinely exploring or repairing the deltoid ligament was not recommended, but repair of the deltoid ligament increased stability of the ankle joint in the early postoperative stage.     

Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment

BACKGROUND: The purpose of this study was to determine the sensitivity and specificity of MRI in chronic syndesmosis injury by comparing the arthroscopic findings with MRI findings and to suggest therapeutic guidelines of syndesmotic fixation. METHODS: Between January, 2003, and January, 2004, 20 patients were diagnosed with chronic syndesmosis injury according to syndesmosis widening (>2 mm) on arthroscopic examination. The average age of the patients was 32 years. The minimum followup was 22 (22 to 30) months. MRI was obtained in all patients. For evaluating the therapeutic role of syndesmotic fixation, we separated the patients into two groups (with and without transfixation) and compared preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and patient satisfaction. RESULTS: The sensitivity, specificity, and accuracy of MRI were 90.0%, 94.8%, and 93.4%, respectively. In group I with syndesmotic fixation, the AOFAS ankle-hindfoot scale improved from 52 to 87, and in group II without syndesmotic fixation the score improved from 63 to 90 at last followup, which showed no statistically significant difference (p = 0.6453). Also, patient satisfaction showed no difference between the two groups. CONCLUSIONS: MRI showed high sensitivity, specificity, and accuracy under the criteria we proposed, and we recommend it as the main diagnostic tool for diagnosing a chronic syndesmosis injury. These findings might suggest that pain is mainly caused by hypertrophy and impingement of the soft tissue in the distal tibiofibular joint. Arthroscopic debridement alone can be recommended if the distal tibiofibular chronic syndesmosis injury is not combined with medial ankle instability and lateral displacement of the talus.     

三角韧带深层损伤是否影响旋前外旋型踝关节骨折的中期临床疗效

目的了解三角韧带深层损伤对PER型踝关节骨折中期临床疗效的影响。方法回顾性研究2013年1月至2014年12月北京积水潭医院创伤骨科手术治疗的50例PERⅢ度或Ⅳ度骨折患者。其中男37例,女13例;年龄16~68岁,平均30.2岁。根据踝关节内侧损伤类型分为两组:未修复组为内踝三角韧带深层损伤且无内踝骨折患者,未行三角韧带修复手术,共28例;对照组为内踝丘上骨折且三角韧带深层完整患者,行内踝丘上骨折切开复位内固定,共22例。两组患者均行腓骨骨折切开复位内固定和下胫腓螺钉固定。比较两组患者术后6个月以上影像学检查的内踝间隙和下胫腓间隙,以及中期随访的美国足踝外科协会的(AOFAS)的踝-后足评分和疼痛视觉模拟评分(VAS)。结果两组患者的性别、年龄、出现踝关节半脱位或脱位时的表现方式差异有统计学意义(P<0.05)。两组患者在损伤暴力程度、腓骨骨折线高度、是否完全脱位、后踝骨折率、后踝固定率、内固定物取出率、手术时间等差异均无统计学意义(P>0.05)。38例完成术后6个月影像学检查,21例未修复组的内踝间隙为3.7 mm,下胫腓间隙为4.5 mm;17例对照组的内踝间隙为3.4 mm;下胫腓间隙为4.4 mm。术后约3年时随访,未修复组和对照组的平均AOFAS评分分别为98.3分和94.6分,平均VAS评分分别为0.4分和1.5分。术后约5年时随访,未修复组和对照组的平均AOFAS评分分别为97.1分和93.6分,平均VAS评分分别为0.5分和1.2分。对于年龄<45岁的患者,术后约3、5年时随访的AOFAS评分、VAS评分与三角韧带完整与否均无相关性(P>0.05)。年龄与术后5年随访时AOFAS评分(P=0.021)相关。结论对于PER型Ⅲ、Ⅳ度踝关节骨折,在腓骨骨折及下胫腓螺钉固定后,残留三角韧带深层损伤不会影响45岁以内患者的中期疗效。     

Comparison of Open Anterior Syndesmotic Repair Augmented With Suture-Tape and Trans-syndesmotic Screw Fixation: A Biomechanical Study

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.     

Novel Elastic Syndesmosis Hook Plate Fixation Versus Routine Screw Fixation for Syndesmosis Injury

Unstable external-rotation type ankle fractures with concomitant syndesmosis injury commonly occur. Syndesmosis screw fixation has long been regarded as a reference standard treatment for syndesmosis injury. However, its complications and biomechanical disadvantages have become controversial; thus, we designed a novel elastic syndesmosis hook plate (ESHP) that combines the features of both rigidity and flexibility. The purpose of the present study was to introduce this new method and compare its clinical outcomes with those of routine screw fixation. We randomized 25 patients to the screw fixation group and ESHP group. The average follow-up period was 12 months. The clinical outcomes included malreduction or loss of reduction, overall complications, and function. During the follow-up period, 3 cases (25%) of malreduction were found in screw fixation group on postoperative computed tomography. In the ESHP group, only 1 patient (7.69%) had a narrowed anterior gap between the distal tibia and fibula. However, the difference in the malreduction rate between the 2 groups was not significant statistically (p?=?.32). The overall complication rate in the ESHP group was lower than that in the screw group, although no significant differences were found between the 2 groups. The mean visual analog scale scores in the ESHP and screw groups were 1.46?±?1.33 and 2.42?±?2.07, respectively. The average dorsiflexion range of motion in both groups was satisfactory (14.77° versus 12.83°; p?=?.16). However, a statistically significant difference was found in the plantarflexion range of motion between the 2 groups (p?<?.05). In addition, the ESHP group had an earlier time to return to work (p?<?.05). The ESHP fixation construct can stably fix syndesmosis, retain the physiologic micromotion function of the syndesmosis, and results in fewer complications compared with routine syndesmosis screw fixation for syndesmotic instability. In conclusion, our results have shown ESHP to be a viable method for treatment of syndesmosis instability.     

Deltoid ligament reconstruction with autologous gracilis tendon in chronic medial ankle instability after ankle fracture surgery: A case report

IntroductionThe repair of a deltoid ligament injury, following an ankle fracture with involvement of the syndesmosis, has no univocal consensus. Also the surgical strategies in case of a subsequent chronic instability are still under debate. In this work the result of a double bundle anatomic reconstruction of deltoid ligament with ipsilateral autologous gracilis muscle tendon is presented.Case reportA 50 year old active male patient came to our attention with a catastrophic medial ankle instability, a severe pronation of the hindfoot and disabling ankle pain. He reported a Weber type B fracture of the left ankle with a lesion of the syndesmosis treated with anatomic plate and screws and a transyndesmotic screw 8 months before. The imaging showed a complete deltoid ligament lesion. Due to the impossibility of a direct repair of the ligament, we performed the reconstruction of the medial ligamentous complex with an autologous gracilis tendon graft. 10 months after the medial ligamentous complex reconstruction, the patient showed an excellent recovery of walking ability, disappearance of pain under load and resumed an active lifestyle.DiscussionThe deltoid ligament has a key role in ankle joint stability and its integrity promotes the recovery after ankle fractures. However, its lesion is often left untreated in the acute setting. The result of a chronic untreated deltoid ligament injury could be extremely disabling and the ligament reconstruction, when an optimal native deltoid ligament repair is not achievable, is the choice to restore ankle function and stability.ConclusionIn the delayed treatment of a deltoid ligament rupture the described double bundle anatomic reconstruction with autologous tendon graft can be an effective and suitable option.     

Repair of the Deltoid Ligament Using Posterior Tibial Tendon Autograft:A Novel Technique

Posterior tibial tendon dysfunction (PTTD) is a progressive disorder secondary to advanced degeneration of the posterior tibial tendon, leading to the abduction of the forefoot, valgus rotation of the hindfoot, and collapse of the medial longitudinal arch. Eventually, the disease becomes so advanced that it begins to affect the deltoid ligament over time. This attenuation and eventual tear of the deltoid ligament leads to valgus deformity of the ankle. Surgical correction of PTTD is performed to protect the ankle joint at all costs. Generally, this is performed using osteotomies of the calcaneus and repair or augmentation of the deltoid ligament. Unfortunately, there has been no universal procedure adapted by foot and ankle surgeons for repair or augmentation of the deltoid ligament. Articles have discussed the use of suture and suture anchors, suture tape, nonanatomic allograft repair, nonanatomic autograft repair with plantaris, peroneal and extensor halluces longus tendons to repair and augment the deltoid ligament. There is very little literature, however, in regard to using the posterior tibial tendon to augment the deltoid ligament in accordance with hindfoot fusion for end-stage PTTD deformity. In general, the posterior tibial tendon in triple and medial double arthrodesis is generally removed because it is thought to be a pain generator. This article presents a case study and novel technique using the posterior tibial tendon to augment and repair the laxity of the deltoid ligament in an advanced flatfoot deformity.     

锚钉固定缝合治疗三角韧带陈旧性损伤

 目的 探讨锚钉固定重叠缝合治疗三角韧带陈旧性损伤的疗效。方法 回顾性分析2007年1月至2011年12月,治疗17例三角韧带陈旧性损伤患者资料,男11例,女6例;年龄18～58岁,平均32.1岁;均有踝关节扭伤史,病程为7～25个月,平均14.2个月。患者术前均行踝关节负重正、侧位X线片、双足正、斜位X线片、MRI及B超检查。确诊为内侧三角韧带损伤后,患肢行踝关节镜检查再次明确诊断并清理关节内增生的滑膜及合并损伤的关节软骨。切开踝关节内侧间隙,清理韧带残端瘢痕组织,其中2例同时清理陈旧性内踝尖撕脱骨折片。将三角韧带深层断端缝合于内踝尖,三角韧带浅层重叠缝合于内踝骨膜,使用锚钉固定。采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)踝与后足评分评价手术前后踝关节。结果 17例患者均获得随访,随访时间12～34个月,平均20.1个月。影像学与术中检查均发现三角韧带损伤且已瘢痕化。距骨-第一跖骨角及Saltzman位后足力线角分别从术前5.4°±1.8°和8.2°±2.6°降至术后4.0°±0.9°和5.3°±1.3°。AOFAS踝与后足评分,术前为平均(76.8±7.0)分 ,末次随访时为平均(94.1±3.3)分;其中优10例,良6例,可1例,优良率为94.1%(16/17)。17例患者疼痛均有效缓解。末次随访时,无一例患者出现三角韧带再损伤。结论 锚钉固定缝合治疗三角韧带陈旧性损伤可以获得良好的效果。     

后外侧联合内侧入路急诊内固定治疗三踝骨折

目的 探讨后外侧联合内侧入路急诊内固定治疗三踝骨折的疗效.方法 对23例三踝骨折患者急诊采用后外侧入路行后踝骨折复位空心螺钉或支撑钢板内固定、外踝骨折复位钢板内固定,内侧入路行内踝骨折复位空心螺钉内固定.末次随访时采用AOFAS踝-后足功能评分标准评价疗效.结果 患者均获得随访,时间10～32个月.切口均一期愈合.骨折...     

一种特殊类型的Maisonneuve损伤的诊断和治疗

目的报道一种特殊类型的Maisonneuve损伤的诊断和治疗效果。方法回顾性分析首都医科大学附属北京朝阳医院骨科自2015年1月至2019年7月收治的4例Maisonneuve损伤患者资料。男3例,女1例;年龄34~61岁,平均45.3岁;患者均为闭合性损伤。所有患者初始X线片表现为踝关节后脱位,手法复位后复查X线及CT显示复位良好无合并踝关节骨折,故急诊漏诊,门诊复查后显示下胫腓联合分离。所有患者均采用恢复腓骨长度、固定下胫腓联合及修复三角韧带的方法治疗。术后12个月采用美国足踝外科协会(AOFAS)的踝-后足评分评价患者术后功能。结果41例患者术后获12~14个月(平均12.7个月)随访。术后骨折愈合时间为110~185 d,平均149.3 d。术后未出现相关并发症,术后12个月AOFAS的踝-后足评分为82~96分(平均90.5分);其中优3例,良1例。结论临床表现为踝关节后脱位且不伴有明显踝关节骨折的Maisonneuve损伤临床上易漏诊,对单纯踝关节后脱位的患者复位后结合体格检查需要拍摄胫腓骨全长X线片明确诊断。一旦确诊,需行手术治疗。通过修复踝关节三角韧带及稳定下胫腓联合的方法可以达到满意的疗效。     

Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: A prospective and comparative study

PurposeSyndesmosis injury is common in external-rotation type ankle fractures (ERAF). Trans-syndesmosis screw fixation, the gold-standard treatment, is currently controversial for its complications and biomechanical disadvantages. The purpose of this study was to introduce a new method of anatomically repairing the anterior-inferior tibiofibular ligament (AITFL) and augmentation with anchor rope system to treat the syndesmotic instability in ERAF with posterior malleolus involvement and to compare its clinical outcomes with that of trans-syndesmosis screw fixation.Methods53 ERAFs with posterior malleolus involvement received surgery, and the syndesmosis was still unstable after fracture fixation. They were randomised into screw fixation group and AITFL anatomical repair with augmentation group. Reduction quality, syndesmosis diastasis recurrence, pain (VAS score), time back to work, Olerud–Molander ankle score and range of motion (ROM) of ankle were investigated.ResultsOlerud–Molander score in AITFL repair group and screw group was 90.4 and 85.8 at 12-month follow-up (P > 0.05). Plantar flexion was 31.2° and 34.3° in repair and screw groups (P = 0.04). Mal-reduction happened in 5 cases (19.2%) in screw group while 2 cases (7.4%) in repair group. Postoperative syndesmosis re-diastasis occurred in 3 cases in screw group while zero in repair group (P > 0.05). Pain score was similar between the two groups (P > 0.05). Overall complication rate and back to work time were 26.9% and 3.7% (P = 0.04), 7.15 months and 5.26 months (P = 0.02) in screw group and repair group, respectively.ConclusionsFor syndesmotic instability in ERAF with posterior malleolus involvement, the method of AITFL anatomical repair and augmentation with anchor rope system had an equivalent functional outcome and reduction, earlier rehabilitation and less complication compared with screw fixation. It can be selected as an alternative.     

踝部骨折伴三角韧带损伤的手术治疗

[目的]比较不同手术方式对踝部骨折伴三角韧带损伤的治疗效果.[方法]回顾性分析2018年1月～2019年6月接受手术治疗的合并下胫腓分离和三角韧带损伤的踝关节骨折患者82例,依据术前医患沟通结果,将患者分两组.其中,41例开放复位骨折内固定同时行三角韧带修复(修复组),另外41例仅行开放复位骨折内固定,未修复三角韧带(...     

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.     

Is There a Relation between AOFAS Ankle-Hindfoot Score and SF-36 in Evaluation of Achilles Ruptures Treated by Percutaneous Technique?

The percutaneous technique of Achilles tendon repair seems to offer satisfactory clinical and functional results, although these results have been evaluated mainly using objective rating scales. Recently, some “subjective” rating scales have been combined to evaluate the results of various surgical treatments. The purpose of the present study was to compare the results of a percutaneous Achilles tendon repair evaluated objectively using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and subjectively using the Medical Outcomes Study, short-form, 36-item questionnaire (SF-36) questionnaire. A total of 17 consecutive patients were treated for acute Achilles tendon rupture using the modified percutaneous Ma and Griffith technique. We reviewed all patients with a follow-up of 24 to 64 months (mean 45.5). At the final follow-up visit, the AOFAS ankle-hindfoot score of each patient was compared with each 1 of the 8 domains of the SF-36 questionnaire, using the parametric Pearson correlation coefficient and the equivalent nonparametric Spearman rho correlation coefficient. The relation between the objective (AOFAS) and subjective (SF-36) results showed a significant correlation (Pearson's correlation coefficient) between the physical functioning (r = 0.597, p = .011) and bodily pain (r = 0.663, p = .004) SF-36 domains, and a nonstatistically significant correlation with the other SF-36 domains. Very similar results were found using the nonparametric Spearman rho correlation coefficient. These results suggest that regarding pain and function, the AOFAS ankle-hindfoot score and SF-36 provide complementary information; therefore, we believe that the SF-36 questionnaire should be used with the AOFAS ankle-hindfoot score for a more complete evaluation of the outcome.     

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

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

Deltoid ligament repair versus trans-syndesmotic fixation for bimalleolar equivalent ankle fractures

IntroductionThe role of deltoid ligament repair is controversial in the treatment of bimalleolar equivalent ankle injuries. Our purpose was to compare midterm functional outcomes and reoperation rates of unstable distal fibula fractures treated with open reduction internal fixation (ORIF) of the fibula and either deltoid ligament repair, trans-syndesmotic fixation, or combined fixation.MethodsSkeletally mature subjects were retrospectively identified after fixation of isolated unstable distal fibula fractures treated at a single academic level 1 hospital from January 2005 to May 2019. The AAOS Foot and Ankle Module outcomes questionnaire (AAOS-FAM) was obtained at a mean time from surgery of 4.6 +/- 3.1 years. Subjects underwent one of three methods of fixation including distal fibula ORIF and one of the following: trans-syndesmotic fixation (N = 66), deltoid ligament repair (N = 16), or combined trans-syndesmotic fixation and deltoid ligament repair (N = 26). Outcomes scores and Charlson Comorbidity Index scores were compared between groups by Kruskal-Wallis testing for non-normally distributed data. Rates of reoperation were compared by Fisher's exact test. Statistical significance was set to P < 0.05 for all comparisons.ResultsThere was no significant difference in AAOS-FAM scores between the three groups (P = 0.18). No subjects in the deltoid ligament repair group underwent reoperation compared to 17 (26%) in the trans-syndesmotic fixation group and six (23%) in the combined fixation group. The most common reason for reoperation was removal of hardware, which was performed in 12 (18%) subjects in the trans-syndesmotic fixation group and three (12%) subjects in the combined fixation group.ConclusionsDirect deltoid ligament repair yields similar functional scores and fewer reoperations compared to trans-syndesmotic fixation at midterm follow up. Deltoid ligament repair may be a favorable treatment strategy when considering trans-syndesmotic fixation in the surgical treatment of unstable distal fibula fractures.     

经外踝钢板双螺钉交接棒技术内固定治疗下胫腓联合损伤

目的探讨经外踝钢板双螺钉交接棒技术内固定治疗下胫腓联合损伤的临床效果。方法自2009-01—2012-06对33例下胫腓损伤采用经外踝钢板双螺钉交接棒技术内固定治疗。疗效采用美国足踝外科协会踝与后足功能评分（AOFAS）评定。结果 33例术后均获得平均23.6（12~38）个月随访。术后摄X线片检查示平均13（9~15）周骨折愈合。2例开放性损伤患者伤口均一期缝合,无感染发生。随访过程中未出现内固定断裂及复位丢失,无骨不连、畸形愈合及踝关节不稳。末次随访时采用AOFAS踝与后足功能评分评定疗效：平均84.7（43~95）分;优12例,良18例,可2例,差1例,优良率90.9%。结论经外踝钢板双螺钉交接棒技术可以结合2种螺钉的固定优势,具有创伤小、操作简便、固定可靠有效的优点,是治疗下胫腓联合损伤的较好方法。     

Biomechanical evaluation of open suture anchor fixation versus interference screw for biceps tenodesis

Biceps tenodesis provides reliable pain relief for patients with biceps tendon abnormality. Previous cadaver studies have shown that, for biceps tenodesis, an interference screw provides biomechanical strength to failure superior to that of suture anchors. This finding has led some providers to conclude that screw fixation for biceps tenodesis is superior to suture anchor fixation. The purpose of the current study was to test the hypothesis that the strength of a 2-suture-anchor technique with closing of the transverse ligament is equal to that of interference screw fixation for biceps tenodesis.In 6 paired, fresh-frozen cadaveric shoulder specimens, we excised the soft tissue except for the biceps tendon and the transverse ligament. We used 2 different methods for biceps tenodesis: (1) suture anchor repair with closing of the transverse ligament over the repair, and (2) interference screw fixation of the biceps tendon in the bicipital groove. Each specimen was preloaded with 5 N and then stretched to failure at 5 mm/sec on a materials testing machine. The load-to-failure forces of each method of fixation were recorded and compared. Mean loads to failure for the suture anchor and interference screw repairs were 263.2 N (95% confidence interval [CI], 221.7-304.6) and 159.4 N (95% CI, 118.4-200.5), respectively. Biceps tenodesis using suture anchors and closure of the transverse ligament provided superior load to failure than did interference screw fixation. This study shows that mini-open techniques using 2 anchors is a biomechanically comparable method to interference fixation for biceps tendon tenodesis.