Suture-button Versus Screw Fixation in Adolescent Syndesmotic Injuries: Functional Outcomes and Maintenance of Reduction.

BACKGROUND: Fixation of the tibiofibular syndesmosis is often performed with a trans-syndesmotic screw (SS) or suture-button (SB). SB fixation has been shown to have lower rates of postoperative syndesmotic malreduction, late diastasis, and implant removal, though some studies have found complications related to infection and implant subsidence. The purpose of this study was to compare maintenance of reduction, complications, implant removal and functional outcomes of SB versus SS fixation in adolescents. METHODS: A retrospective chart review identified patients who underwent syndesmotic fixation from 2010 to 2019 at a single institution. Loss of syndesmotic reduction (diastasis) was defined as either a >2 mm increase in tibiofibular clear space or >2 mm decrease in tibiofibular overlap, and corresponding incongruence of the ankle mortise (medial clear space 1 millimeter greater than superior clear space). Functional outcomes were collected at a minimum of 1 year postsurgery using the Foot and Ankle Ability Measure (FAAM). RESULTS: Seventy-seven adolescents (45 SS, 32 SB) were included (mean age: 16±1.5 y). Forty-five patients had Weber C fibula fractures, 27 Weber B fractures, and 5 had isolated syndesmotic injuries or small posterior malleolus fractures. Fifty-one patients (66%) had functional outcomes available. There was no significant difference in mean FAAM Sports score between the 2 groups (SB=94.8%, SS=89.8%) at mean follow-up of 4.0±2.1 years. Syndesmotic implant removal occurred in 36/45 patients (80%) in the SS group compared with 4/32 patients (13%) in the SB group. There was 1 case of syndesmotic malreduction requiring revision surgery in the SS group, and no cases of postoperative malreduction or diastasis in the SB group. Nine patients in the SB group and 8 in the SS group weighed over 100 kilograms, with no cases of diastasis in these larger patients. There were 4 superficial infections and 1 deep infection in the screw group, with 1 superficial infection in the SB group. CONCLUSIONS: While both SB and screw fixation maintained syndesmotic reduction, SB fixation led to lower rates of implant removal surgery. SB fixation was equally effective at preventing recurrent diastasis in adolescents weighing over 100 kilograms, and functional outcomes were at least equivalent to screw-fixation at mean follow-up of 4.0 years. LEVEL OF EVIDENCE: Level III.

Plate Versus Lag Screw Only Fixation of Unstable Ankle Fractures Involving the Fibula in Adolescent Patients.

BACKGROUND: Plate fixation has been the traditional technique for fracture repair of unstable ankle injuries with an associated lateral malleolus fracture. Recently, biomechanical and clinical data have demonstrated lag screw only fixation to be an effective alternative to plate fixation in the adult population. This comparison has yet to be studied in the adolescent or pediatric population. The objective of this study was to compare lag screw only fixation with traditional plating for lateral malleolus fractures in adolescents. METHODS: A retrospective review was conducted of 83 adolescents with unstable oblique lateral malleolus fractures treated at a single pediatric level-1 trauma center between 2011 and 2019 with a minimum clinical follow-up until fracture union. Patients were divided into 2 surgical groups: (1) plate fixation (n=51) or (2) lag screw fixation (n=32). Radiographic and clinical outcomes and complications were measured in both groups. RESULTS: All patients in both groups achieved our primary outcome measure of fracture union without loss of reduction. The mean surgical time for subjects treated with a plate was 15 minutes longer (64 vs. 49 min) (P=0.001) and these patients were 3.8 times more likely to have symptomatic implants (P<0.044) than subjects treated with screws. Approximately 50% of the cohort was available by phone for patient-reported outcomes at a mean follow-up of 50 months. The mean Single Assessment Numerical Evaluation scores, Foot and Ankle Ability Measure Activities of Daily Living scores, Foot and Ankle Ability Measure sports scores, and return to sports rates were similar (92 vs. 93, 98.2 vs. 98.1, 93.2 vs. 94.0, 95% vs. 86%, respectively; P>0.05) between the 2 treatment methods. CONCLUSIONS: Lag screw only fixation is a safe and effective procedure for noncomminuted, oblique fibula fractures in the adolescent population as demonstrated by equivalent fracture healing rates without loss of reduction and similar outcome scores. Given these comparable results with the additional benefits of shorter surgical time and less symptomatic implants, lag screw only fixation should be considered as a viable treatment alternative to traditional lateral plating in the adolescent population. LEVEL OF EVIDENCE: Level III.

Functional Outcomes of Unstable Ankle Fractures in Adolescents.

BACKGROUND: The purpose of this study was to describe the functional outcomes and complications of unstable supination external rotation (SER) and pronation external rotation (PER) ankle fractures in adolescents. A secondary outcome was to compare functional outcomes of SER stage IV injuries that were treated definitively with closed reduction and cast application to a similar group of minimally displaced fractures treated with open reduction and internal fixation (ORIF). METHODS: A retrospective review of adolescents aged 10 to 18 years with unstable ankle fractures treated at a single institution between 2009 and 2017 was conducted. All patients had functional outcomes data from the Foot and Ankle Ability Measure obtained at a minimum of 1-year follow-up. RESULTS: In total, 67 adolescents (41 SER, 26 PER) were included (mean follow-up: 52.3±24.8 mo). A total of 56 were treated with ORIF and 11 were closed reduced and casted. No patients treated nonsurgically had a loss of reduction and none required subsequent surgical intervention. Preoperative radiographic predictors of syndesmotic injury (>6 mm of tibiofibular clear space or <2 mm of tibiofibular overlap) were not sensitive and only moderately specific predictors of intraoperative syndesmotic injury. There was no difference in functional outcome between the 11 SER stage IV fractures treated nonoperatively and a group of minimally displaced SER injuries treated with ORIF. Patients with open or partially open physes had better functional outcomes. Patients with syndesmotic injuries, medial malleolus fractures, or fracture-dislocations were not associated with lower functional outcome scores in our adolescent cohort. CONCLUSIONS: Unstable SER and PER injuries in adolescents have favorable functional outcomes at intermediate-term follow-up, though a minority continue to have impaired ankle function. Minimally displaced SER stage IV injuries with near anatomic alignment after closed reduction can be successfully treated with continued closed management, and have no difference in functional outcomes compared with similar injuries treated with ORIF. LEVEL OF EVIDENCE: Level III.

Comparing Propofol With Fentanyl and Midazolam for Sedation in Closed Reductions of Traumatic Hip Dislocations.

Traumatic native hip dislocations require prompt reduction of the dislocation to limit the risk of avascular necrosis and resultant hip arthrosis. Although closed reduction under sedation is frequently attempted, there is minimal evidence about which sedative agent is most safe and effective. The goal of this study was to compare the efficacy of propofol vs combination fentanyl/midazolam for closed reduction under sedation of traumatic native hip dislocations. This was a single-center retrospective review. The main outcome measures were the rate of successful closed reduction with propofol vs combination fentanyl/midazolam and time from the start of sedation to radiographic evidence of reduction. Fifty-four patients with traumatic native hip dislocations were identified. Closed reduction under sedation with propofol was successful in 11 of 14 attempts compared with 4 of 11 attempts with combination fentanyl/midazolam (P=.04). The fentanyl/midazolam group had 6.4 times the odds (95% CI, 1.1-37.7) of failed closed reduction compared with the propofol group. The median time to reduction in the propofol group was 14 minutes vs 45 minutes for the fentanyl/midazolam group (P=.18). Patients who had failed closed reduction with fentanyl/midazolam had a median time to reduction of 100 minutes. There was no difference in sedation-related complications between the 2 groups. We therefore conclude that sedation with propofol is significantly more effective than combination fentanyl/midazolam for closed reduction of native hip dislocations. To minimize unsuccessful reduction attempts and shorten total time to reduction, we recommend against the use of combination fentanyl/midazolam because of the high risk of failure. [Orthopedics. 2023;46(2):86-92.].

Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population.

PURPOSE: The purpose of this study was to compare functional outcomes of adolescents with and without ankle syndesmotic injuries and identify predictors of functional outcome after operative ankle fractures. METHODS: A retrospective review was conducted on operative adolescent ankle fractures treated between 2009 and 2019 with a minimum of one-year follow-up (mean 4.35 years). Patients who underwent syndesmotic fixation (SF) (n = 48) were compared with operative ankle fractures without syndesmotic injury (n = 63). Functional outcomes were assessed using standardized questionnaires, specifically the Foot and Ankle Ability Measure (FAAM) and Single Assessment Numerical Evaluation. RESULTS: There were no differences in patient-reported outcomes, rates of return to sport or complications between groups with and without SF. The SF group had a longer tourniquet time (p = 0.04), duration of non-weight-bearing (p = 0.01), more Weber C fibula fractures (p < 0.001), fewer medial malleolus fractures (p = 0.03) and more frequently underwent implant removal (p < 0.0001). Male sex, lower body mass index (BMI) and longer duration of follow-up were significant predictors of a higher FAAM sports score using multivariable linear regression. SF was not a predictor of functional outcome. CONCLUSION: This study demonstrated that patients that undergo surgical fixation of syndesmotic injuries have equivalent functional outcomes compared to operative ankle fractures without intraoperative evidence of syndesmotic injury. We also identified that male sex, lower BMI and longer duration of follow-up are predictors of a good functional outcome. LEVEL OF EVIDENCE: III.