Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures

We studied the late results after bimalleolar and trimalleolar ankle fractures in thirty-four patients after an average follow-up of four years. Twenty-one patients had had open reduction and internal fixation of the medial malleolus only and thirteen, internal fixation of both the medial malleolus and the lateral malleolus. Twenty-four lesions were supination-external rotation fractures; six, pronation-external rotation; and four, supination-adduction fractures. All initial and post-reduction roentgenograms were evaluated, and the patients were re-evaluated two to seven years after fracture. Re-evaluation included physical examination as well as standardized and stress roentgenograms of both ankles. Criteria were developed for measuring the width of the syndesmosis and assessing the late roentgenographic, subjective, and objective results, as well as any late instability of the syndesmosis and osteoarthritis. Significant correlations were found between: (1) the adequacy of the reduction of the syndesmosis and late arthritis, (2) the adequacy of the initial reduction of the syndesmosis and the late stability of the syndesmosis, (3) the late stability of the syndesmosis and the final outcome, and (4) the adequacy of the reduction of the lateral malleolus and that of the syndesmosis. Based on the findings in this small series and on the evidence published in the literature, we concluded that adequate reduction of the syndesmosis is necessary to achieve a stable ankle following supination-external rotation and pronation-external rotation fractures of the ankle, and that the reduction of the syndesmosis will be unsatisfactory if the lateral malleolus is not well reduced.     

踝关节骨折的手术治疗

目的探讨踝关节骨折切开复位内固定方法和治疗效果。方法2001年3月-2006年1月，采用手术治疗踝关节骨折85例。男65例，女20例；年龄17～65岁，平均36．5岁。根据Lauge—Hansen分型，旋前外旋型Ⅱ度12例、Ⅳ度9例，旋后外旋型Ⅱ度34例、Ⅳ度16例，旋后内收型Ⅱ度8例，旋前外展型6例。合并胫腓下联合分离10例。闭合性骨折21例，伤后予以简单手法复位石膏托固定后2h～10d手术；开放性骨折64例，急诊清创同时行骨折复位内固定。结果85例术后切口Ⅰ期愈合。患者均获随访6～36个月，平均10个月。术后未发生骨不连、畸形愈合、胫腓下联合处螺钉断裂等并发症。临床疗效按Baird-Jackson踝关节评分评定，优53例，良23例，可6例，差3例，优良率89．4％。骨折愈合时间平均150d。结论手术治疗踝关节骨折可取得满意的临床疗效，对骨折类型的准确判断及正确选择固定方法对于提高复位质量、改善远期疗效具有重要意义。     

A different approach to the treatment of the lateral malleolar fractures with syndesmosis injury: The ANK nail

This retrospective study was conducted on a total of 139 cases of fractured ankles involving the fibula above the syndesmosis which were treated with open reduction and internal fixation with the intramedullary ANK nail at the Department of Orthopaedic Surgery at Vakif Gureba Teaching Hospital from 1990 to 1997. We were able to review 128 of these patients after a mean follow-up of 3.1 years (range, 1 - 7 years) including 60 with Weber type B and 68 with Weber type C fractures. The results were evaluated using objective, subjective, and roentgenographic criteria described by Cedell. Ninety-three patients (73%) have obtained good objective results, 28 (22%) fair, and seven (5%) have obtained poor objective results. Subjective rating were 94 patients (74%), good; 26 patients (20%), fair; and eight patients (6%), poor. Good radiological results were found in 99 patients (77%), fair radiological results in 21 patients (17%), and poor radiological results were found in eight patients (6%). It is concluded that the ANK nail could be used for the fixation of the lateral malleolar fracture with tear of the syndesmosis ligament.     

旋前旋后外旋型三踝骨折的手术治疗

目的：探讨旋前、旋后外旋型（IV度）三踝骨折的手术方法和临床疗效。方法：2000年3月至2006年7月,对42例旋前、旋后外旋型（IV度）三踝骨折行切开复位内固定术,男31例,女11例;年龄19～76岁,平均40.5岁。开放性损伤4例,闭和性损伤38例。根据Lauge-Hansen分类,旋前外旋型IV度三踝骨折18例,旋后外旋型IV度三踝骨折24例。受伤距手术时间2h～27d。内、外踝均采用标准内、外侧切口。如需行后踝骨折处理,则将内踝切口延长,同时显露内、外及后踝。整复固定的顺序是后踝、内踝、外踝和下胫腓联合。骨折复位固定完成后,行踝部正侧位及踝穴（Mortise）位X线检查。结果：全部患者均获得随访,时间6～24个月,平均13.5个月。骨折愈合时间12～16周,疗效根据梁军等改良Baird-Jackson的主客观及X线评价标准进行评定,包括疼痛、踝关节的稳定性、行走能力、跑步能力、踝关节活动范围、踝关节X线测量等。本组优20例,良16例,可4例,差2例,优良率85.7%。术后未发生感染、骨不连、骨折畸形愈合等并发症,但发生1例下胫腓骨三皮质固定螺钉断裂。结论：手术治疗的关键在于恢复并稳定踝关节的解剖关系,最大限度恢复踝关节功能。     

微创经皮内固定治疗复杂踝部骨折53例

目的：探讨微创内固定治疗复杂踝部骨折的手术方法和临床疗效。方法：自2007年1月至2011年12月,采用微创经皮内固定治疗53例复杂踝部骨折患者,男31例,女22例;年龄18-65岁,平均38．2岁。按Lauge-Hansen分型：旋后外旋型Ⅳ度32例,旋前外旋型Ⅲ、Ⅳ度13例,旋前外展型Ⅲ度5例,因腓骨骨折严重粉碎无法分类3例。Denis—Weber分类：A型4例,B型34例,C型15例。受伤至手术时间2h-14d,平均5d。骨折复位固定顺序为后踝、内踝、外踝和下胫腓联合。后踝骨折采用踝前切口间接复位固定,内外踝骨折采用经皮螺钉、接骨板或张力带固定,必要时螺钉固定下胫腓联合。术后采用Baird-Jackson评价系统进行疗效评价。结果：48例获随访,时间10-36个月,平均13个月。骨折全部愈合,愈合时间10-18周,平均12周。根据Baird-Jackson评价系统进行疗效评定,术后踝关节功能平均（94．7±4．2）分,其中优28例,良15例,可3例,差2例。1例发生皮肤浅表性感染,经换药治愈;2例发生下胫腓联合固定螺钉断裂。结论：采用微创经皮内固定治疗复杂踝部骨折可保证踝关节获得解剖复位,保护骨折端血运及软组织覆盖,最大限度地恢复踝关节功能,获得满意的临床疗效。     

A reliable method for intraoperative detection of lateral malleolar malrotation using conventional fluoroscopy

ObjectiveTo introduce a new method for intraoperative detection of rotational malreduction of the lateral malleolus using conventional fluoroscopy.Material and methodsFrom January 2014 to December 2017, 56 Weber type C unstable lateral malleolar fractures with syndesmosis injury were identified. The fibular fracture patterns were simple oblique or transverse in 20, comminuted in 25, and Maisonneuve injury with fibular neck fractures in 11 cases. 47 cases were operated with ORIF, and 9 cases of Maisonneuve fractures were operated with CRIF. The mortise view of the contralateral uninjured ankle was used for intraoperative comparison. Two indexes were applied for fluoroscopic detection of distal fibula malrotation, i.e. the contour profile change in lateral malleolar shape, and the intrinsic structure appearance of lateral malleolar fossa cortex. Postoperative talofibular joint congruency was measured on axial CT scan to confirm the reduction quality.ResultsUsing the two radiographic parameters for intraoperative fluoroscopic evaluation, we finally achieved satisfying reduction and fixation of the lateral malleolus in all 56 cases. A more spoon-shaped fibula profile and disappearance of the lateral fossa cortex shadow indicates an internal rotation, while a more pointed blade-shaped fibula profile and disappearance of lateral fossa cortex shadow indicates an external rotation. Postoperative CT scanning identified distal fibular no rotation in 44 cases (78.6%), mild rotation less than 5° in 12 cases (21.4%), with 7 cases internal rotation (mean 3.1°) and 5 cases external rotation (mean 2.8°).ConclusionUsing conventional intraoperative fluoroscopy on mortise view, new radiographic parameters can provide reliable method to detect rotational malreduction of the lateral malleolus.     

Biomechanical Analysis of a Novel Syndesmotic Plate Compared With Traditional Screw and Suture Button Fixation

Many lateral malleolus fractures have been found to have syndesmosis injuries after anatomic reduction. The main methods for the treatment of syndesmosis injuries are screw fixation and suture-button flexible fixations. In pursuit of innovation, we have designed a novel syndesmotic plate (NSP) for simultaneous fixation of lateral malleolus fractures and distal tibiofibular syndesmosis injuries. The purpose of this study is to compare the biomechanical characteristics of the NSP to syndesmotic screw and suture-button fixations. Twelve adult cadaveric specimens were used in this experiment. Axial loading as well as rotation torque were applied in 3 different ankle positions: neutral, dorsiflexion, and plantarflexion. After the initial specimens were tested, they were made into a pronation-abduction III fracture model as described by Lauge-Hansen. Subsequently, the specimens were fixed sequentially using a distal fibular anatomic locking plate (DFALP) combined with syndesmotic screws, DFALP combined with suture button, and NSP. Then the above tests were repeated. The syndesmotic displacement and the strain of the tibia and fibula were recorded during the experiment. In most cases, the displacements and strains of the NSP group and the screw group were smaller than the suture button groups and the native (SBGAN) (p < .05), and the displacements and strains of the NSP group were also slightly smaller than the screw group in most cases, and there was no significant difference between the 2 groups. The NSP we developed has a fixed strength no less than the traditional syndesmotic screw fixation. This provides us a new idea for the treatment of distal tibiofibular syndesmosis injuries.     

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.     

External torsion fractures of the tibia combined with ankle joint fractures]

The aim of this retrospective study is to emphasize on combined fractures of the tibia with lesions of the ankle joint. The report bases on 820 fractures of the lower leg. 123 cases showed external rotation fractures of the tibia, which were combined with lesions of the ankle joint in 88 cases. 25 patients were operated on the ankle joint. Because of the combination of external rotation fractures with lesions of the ankle joint, which accounted to 65% of the posterior tibial margin, to 17% of the lateral malleolus and to 3% of the syndesmosis, it is important to investigate the ankle joint radiologically and clinically.     

Proceedings of the Finnish Orthopaedic Association: Helsinki,Finland, November 11, 1978

In a prospective study of 41 patients, severe ankle fractures of Lauge-Hansen types SE III–IV, PA III, and PE III–IV were treated by open reduction and internal fixation using biodegradable self-reinforced polglycolide cylinder-shaped rods. Disruption of the distal tibiofibular syndesmosis and/or fracture of the posterior tibial margin requiring reduction and fixation were the inclusion criteria for the study. The mean follow-up time after operation was 16(12-32) months. Two failures of fixation necessitated reoperation. A secondary displacement of 1-2 mm of the lateral malleolus occurred in 3 cases. Transient accumulation of soluble polyglycolide mass complicated the course in 3 cases, but did not influence the radiographic or the functional result. Function became good in 30 patients. The advantage of the biodegradable implants is that they do not need to be removed at secondary operations.     

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.     

Fracture fixation with biodegradable rods. Forty-one cases of severe ankle fractures

In a prospective study of 41 patients, severe ankle fractures of Lauge-Hansen types SE III-IV, PA III, and PE III-IV were treated by open reduction and internal fixation using biodegradable self-reinforced polyglycolide cylinder-shaped rods. Disruption of the distal tibiofibular syndesmosis and/or fracture of the posterior tibial margin requiring reduction and fixation were the inclusion criteria for the study. The mean follow-up time after operation was 16 (12-32) months. Two failures of fixation necessitated reoperation. A secondary displacement of 1-2 mm of the lateral malleolus occurred in 3 cases. Transient accumulation of soluble polyglycolide mass complicated the course in 3 cases, but did not influence the radiographic or the functional result. Function became good in 30 patients. The advantage of the biodegradable implants is that they do not need to be removed at secondary operations.     

Cerclage Wire and Lag Screw Fixation of the Lateral Malleolus in Supination and External Rotation Fractures of the Ankle

Wound dehiscence and exposed lateral hardware can occur after open reduction internal fixation of lateral malleolus. The bulk of a lateral plate and the minimum soft tissue over the lateral malleolus may contribute to this situation. The objective of this study was to evaluate a series of patients with lateral malleolar fractures treated with operative reduction using minimal hardware. We wanted to observe whether there was any loss of reduction and whether there were any incidences of soft tissue disruption. Fifty-two patients with long spiral fracture of the lateral malleolus in a supination-external rotation injury were treated with two or three 3.5-mm lag screws inserted 1 cm apart and 1 or 2 circlage wires. Less rigid fixation was supplemented with a below-the-knee plaster cast. All patients were followed up until clinical and radiological evidence of fracture healing at 6, 10, and 14 weeks postoperatively. By 10 weeks, all patients were full weight bearing, although most patients still limped. At 14 weeks' follow-up, there were no infections or wound dehiscences. All patients were able to return to their activities of daily living. All the fractures had united without loss of original position. Two fractures of the posterior bone spikes seen during surgery united uneventfully. Long spiral fractures of the lateral malleolus of the ankle can be treated successfully with 2 or 3 lag screws and circlage wires without compromising the outcome of the fracture healing.     

不同类型踝关节骨折的手术治疗

目的 探讨不同类型踝关节骨折的手术方法和疗效。方法 采用切开复位内固定术治疗踝关节骨折87例。结果 82例获随访,时间1-3年。优57例,良15例,可6例,差4例,优良率达87.8%。结论 外踝骨折和下胫腓联合损伤的复位及固定是治疗踝关节骨折的关节。     

踝关节骨折伴下胫腓联合分离的手术治疗及临床意义

目的探讨治疗踝关节骨折伴下胫腓联合分离的手术方法及临床意义。方法自2002年1月～2005年12月对112例伴踝关节骨折下胫腓联合分离行腓骨内固定或不固定,内踝内固定,三角韧带探查修复术。未固定下胫腓联合。术后随访6～36个月,平均20.8个月。结果用Mazur评分系统评估手术疗效:优98例,良14例。未见骨折不愈合、关节不稳及创伤性关节炎等并发症。结论对伴下胫腓联合分离的踝关节骨折行手术治疗时,除了固定内、外踝,还要修复三角韧带损伤。恢复了内、外侧所有结构的完整性后才能真正恢复下胫腓联合及踝关节的正常生物力学环境和稳定性,这时即使不固定下胫腓联合,也可以获得下胫腓联合的稳定。固定内、外踝和下胫腓联合,而三角韧带的损伤不修复,虽然下胫腓韧带可以获得愈合,但三角韧带会愈合不佳、韧带松弛及功能不良,最终仍会导致创伤性关节炎。     

The use of T-LCP (locking compression plate) for the treatment of the lateral malleolar fractures

Background

The authors evaluated results and hardware-related complications after the fixation of Danis-Weber (D-W) types A and B lateral malleolus fractures using a 3.5-mm T-shaped locking compression plate (T-LCP) for distal radius.

Methods

Twenty-six patients with Danis-Weber type A or B lateral malleolar fractures treated between January 2001 and February 2008 were included in this study. Mean age of the patients was 52.6 (28–77) years. All patients were treated using a 3.5-mm T-shaped locking plate for distal radius fractures. The distal fragment was fixed with at least 2 locking screws more. Ankle motion was allowed early after surgery. The authors evaluated serial radiographs, range of motion, skin irritation, and AOFAS scores at final follow-ups.

Results

All fractures united during follow-up. Eight cases were of D-W type A, and 18 were of D-W type B. A mean number of three screws were placed at the distal fragment (2–4). There were 6 cases (23.1%) of implant irritation over the operative site, but no other complications were encountered. At final follow-ups, the AOFAS score of affected ankles was 97.1 ± 4.4.

Conclusion

T-LCP use for type A or B lateral malleolar fractures resulted in low hardware-related complications and produced good results at follow-up.     

内踝后丘部骨折的诊断及手术治疗

目的总结内踝后丘部骨折的诊断及手术治疗经验。方法 2008年3月-2010年11月,采用切开复位内固定治疗14例外踝和/或后踝骨折合并内踝后丘部骨折患者。男5例,女9例;年龄27～60岁,平均44.5岁。致伤原因:扭伤9例,交通事故伤3例,高处坠落伤2例。病程3～9 d,平均6.5 d。外踝骨折14例,后踝骨折10例。内踝后丘部骨折根据Lauge-Hansen分型标准分型:旋前外旋型8例,旋前外展型3例,旋后外旋型3例。结果术后切口均Ⅰ期愈合,无相关并发症发生。患者均获随访,随访时间12～24个月,平均16.8个月。X线片检查示骨折均愈合,愈合时间为2～4个月,平均2.9个月。术后14周采用下肢活动范围测量法测量患侧跖屈、背伸活动范围分别为(38.40±3.50)°及(16.30±2.41)°,与健侧(40.50±3.48)°及(17.90±2.28)°比较,差异均无统计学意义(P>0.05)。根据Olerud和Molander踝关节骨折评分标准评定踝关节功能,获优7例,良6例,一般1例。结论螺旋CT检查可显示内踝后丘部骨折,骨折后应积极手术复位坚强固定。     

Examination of the pathologic anatomy of ankle fractures.

A prospective study of the translational and rotational displacement of the lateral malleolus in ankle fractures was carried out utilizing roentgenographic techniques. Twenty-six ankle fractures in 25 patients were studied using both routine plain films and CT scanning with two- and three-dimensional multiplanar reconstruction. Eighty-one percent were Lauge-Hansen supination-external rotation type injuries. Overall, 21 fractures did not involve the medial malleolus. Initial talar shift was less than or equal to 2 mm in 15 fractures. Although all patients exhibited external rotation deformities of the lateral malleolus on plain films, only one fracture was found to possess any degree of external rotation relative to the talus. The proximal fibula was seen on CT scans to have increased internal rotation with respect to the tibia in 19 cases. One patient had a slightly externally rotated proximal fibula; the remainder appeared normally aligned. The displacements measured by the CT scans at the talofibular articulation were compared with the standard plain film measurements. The displacements at the distal lateral malleolus were consistently overestimated by the plain roentgenograms, presumably because the capsular and ligamentous attachments to the distal fibula limit malleolar displacement. The talocrural angle, determined on both plain films and CT scans, was also not found to be a sensitive measure of fibular shortening nor of the severity of the fracture. The results of this study suggest that, in an isolated lateral malleolar ankle fracture, the apparent external rotation of the fracture fragment is relative only to the proximal fibula and is not associated with derangement of the talofibular articulation. Based on these mechanical considerations, surgical intervention for such fractures may not be necessary. This hypothesis is consistent with previous long-term clinical studies.     

Reconstruction of malunited fractures of the lateral malleolus

The cases of twenty-six patients who had a reconstructive surgical procedure for treatment of a malunion of a displaced fracture of the fibula were evaluated. In these patients, who had pain, swelling of the ankle, and stiffness at an average of six years after the injury, the malunions were classified radiographically as either occult (eighteen patients) or overt (eight patients). An occult malunion was one in which the talus remained in its normal position, but the lateral malleolus showed residual displacement, characterized by external rotation and shortening. In an overt malunion, there were similar changes in the lateral malleolus, but the talus was displaced. All of the patients were treated by osteotomy of the lateral malleolus to correct the external rotation and shortening, to reduce the lateral subluxation of the anterior aspect of the tibiofibular joint, and to restore the stability of the talus. At an average follow-up of seven years (range, six months to eleven years), twenty of the twenty-six patients were able to resume the preinjury level of activity; three had improvement in the ability to walk and in the level of functional activity, although they still had intermittent pain; and three had not benefited from the procedure.     

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury

Background:

With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

Materials and Methods:

12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

Results:

At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

Conclusion:

We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.