Effect of Posterior Malleolar Fixation on Syndesmotic Stability.

BACKGROUND: Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs. PURPOSE: To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system. RESULTS: With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs. CONCLUSION: Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially. CLINICAL RELEVANCE: Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%.

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue.

BACKGROUND: Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively. METHODS: A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated. RESULTS: Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure. CONCLUSIONS: After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication. LEVEL OF EVIDENCE: Level IV: Case series without control.

Anterior Inferior Tibiofibular Ligament Suture Tape Augmentation for Isolated Syndesmotic Injuries.

BACKGROUND: The best operative construct and technique for treatment of isolated syndesmotic injuries is highly debated. The purpose of this study was to determine whether the addition of anterior inferior tibiofibular ligament (AITFL) suture repair or suture tape (ST) augmentation provides any biomechanical advantage to the operative repair of an isolated syndesmotic injury. METHODS: Twelve lower leg specimens underwent biomechanical testing in 6 states: (1) intact, (2) AITFL suture repair, (3) AITFL suture repair + transsyndesmotic suture button (SB), (4) AITFL suture repair + ST augmentation + SB, (5) AITFL suture repair + ST augmentation, and (6) complete syndesmotic injury. The ankle joint was subjected to 6 cycles of 5 Nm internal and external rotation torque under a constant axial load. The spatial relationship between the tibia, fibula, and talus was continuously recorded with a 5-camera motion capture system. RESULTS: AITFL suture repair and AITFL suture repair + ST augmentation showed no statistically significant change in fibula kinematics compared to the intact state. Compared to native, AITFL suture repair + SB showed increased fibular external rotation (+2.32 degrees, P < .001), and decreased tibiofibular gap (overtightening) (-0.72 mm, P = .007). AITFL suture repair + ST augmentation + SB also showed increased fibular external rotation (+1.46 degrees, P = .013). Sagittal plane motion of the fibula was not significantly different between any states. None of the repairs restored intact state talus rotation; however, the repairs that used ST augmentation reduced the talus external rotation laxity compared to the complete syndesmotic injury. CONCLUSION: AITFL suture repair and AITFL ST augmentation best restored the rotational kinematics and stability of the fibula and ankle joint in an isolated syndesmotic injury model. CLINICAL RELEVANCE: AITFL suture repair with or without ST augmentation may be a good operative addition or alternative to SB fixation for isolated syndesmotic disruptions.

Chronic Syndesmotic Injury: Revision and Fixation With a Suture Button and a Quadricortical Screw.

Background. Chronic syndesmotic injury may cause long-term pain and reduced ankle function. Today, there is no consensus about the best surgical treatment of these injuries. We present the technique and results of revision and fixation with a suture button and a quadricortical screw. Methods. Eleven patients treated for chronic syndesmotic injury were included. The patients completed questionnaires regarding ankle function, and computed tomography scans were obtained to evaluate tibiofibular distance and osteoarthritis. Complications were registered. Results. At mean 45 months follow-up, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 87 points. There were 5 complications, including 3 hardware-related pain. The tibiofibular distance was significantly reduced with surgery. Seven patients had progression of osteoarthritis. Conclusions. Even though the majority of the patients had progression of radiological signs of osteoarthritis, the functional outcome after revision and fixation with a suture button and a quadricortical screw in chronic syndesmotic ruptures is good and comparable to the results presented in other studies.Levels of Evidence: Level IV: Case series without control, technical note.

Randomized trial comparing suture button with single 3.5 mm syndesmotic screw for ankle syndesmosis injury: similar results at 2 years.

Background and purpose - Better outcomes are reported for suture button (SB) compared with syndesmotic screws (SS) in patients treated for an acute ankle syndesmotic injury. One reason could be that screws are more rigid than an SB. A single tricortical 3.5 mm syndesmotic screw (TS) is the most dynamic screw option. Our hypothesis is that 1 SB and 1 TS provide similar results. Therefore, in randomized controlled trial, we compared the results between SB and TS for syndesmotic stabilization in patients with acute syndesmosis injury. Patients and methods - 113 patients with acute syndesmotic injury were randomized to SB (n = 55) or TS (n = 58). The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was the primary outcome measure. Secondary outcome measures included Manchester Oxford Foot Questionnaire (MOXFQ), Olerud-Molander Ankle score (OMA), visual analogue scale (VAS), EuroQol- 5D (EQ-5D), radiologic results, range of motion, complications, and reoperations (no implants were routinely removed). CT scans of both ankles were obtained after surgery, and after 1 and 2 years. Results - The 2-year follow-up rate was 84%. At 2 years, median AOFAS score was 97 in both groups (IQR SB 87-100, IQR TS 90-100, p = 0.7), median MOXFQ index was 5 in the SB group and 3 in the TS group (IQR 0-18 vs. 0-8, p = 0.2), and median OMA score was 90 in the SB group and 100 in the TS group (IQR 75-100 vs. 83-100, p = 0.2). The syndesmotic reduction was similar 2 years after surgery; 19/55 patients in the SB group and 13/58 in the TS group had a difference in anterior syndesmotic width ≥ 2 mm (p = 0.3). 0 patients in the SB group and 5 patients in the TS group had complete tibiofibular synostosis (p = 0.03). At 2 years, 10 TS were broken. Complications and reoperations were similar between the groups. Interpretation - We found no clinically relevant differences regarding outcome scores between the groups. TS is an inexpensive alternative to SB.

Surgically treated talar fractures. A retrospective study of 50 patients.

BACKGROUND: Talar fractures are associated with a high incidence of avascular necrosis (AVN), osteoarthritis (OA) and malunion. The aim of this study was to evaluate the complications, the functional outcome, and the need for secondary surgery following surgically treated talar fractures. METHODS: Fifty patients with 52 talar fractures were included in the study. The health related quality of life was evaluated using visual analogue scale (VAS). The ankle function was scored using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. OA and AVN were evaluated on plain radiographs and computerized tomography (CT) scans. RESULTS: VAS score was 69±18 (mean±SD) and AOFAS ankle-hindfoot score was 73±17 (mean±SD). OA was seen in 98% and AVN in 65% of the talar bones. Secondary surgery had been performed in 38% of the feet. CONCLUSION: Long-term complications were commonly seen after talar fractures and had a significant impact on daily life activities and quality of life. The need for secondary surgery was high. Prolonged follow-up is necessary to detect long-term complications, and the patients should be offered a low threshold for recontact.