Arthroscopically Assisted Reduction of Sagittal-Plane Disruption of Distal Tibiofibular Syndesmosis

Sin, Yiu Ho; Lui, Tun Hing

doi:10.1016/j.eats.2019.01.014

Cited by 7 publications

(2 citation statements)

References 19 publications

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“…Syndesmotic instability in the sagittal plane is less well-described in the arthroscopic literature. Those that did investigate sagittal plane instability found that the instability is more visible in the sagittal plane than in the coronal plane in the setting of an unstable syndesmosis [ 6 , 26 , 27 , 30 , 38 , 45 , 53 , 55 ]. However, the total amount of sagittal plane fibular translation that best serves as a clinical threshold for diagnosing syndesmotic instability remains uncertain.…”

Section: Discussionmentioning

confidence: 99%

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Hagemeijer

Elghazy

Waryasz

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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Purpose Ankle arthroscopy is widely used for diagnosis of syndesmotic instability, especially in subtle cases. To date, no published article has systematically reviewed the literature in aggregate to understand which instability values should be used intraoperatively. The primary aim was to systematically review the amount of tibiofibular displacement that correlates with syndesmotic instability after a high ankle sprain. A secondary aim is to assess the quality of such research. Methods Systematic searches of EMBASE (Ovid) and MEDLINE via PubMed, CINAHL, Web of Science, and Google Scholar were used. Inclusion criteria: studies that arthroscopically evaluated the fibular displacement at various stages of syndesmotic ligament injury. Two reviewers independently extracted data and assessed methodological quality using the Anatomical Quality Assessment (AQUA) Tool and methodological index for non-randomized studies (MINORS). Results Eight cadaveric studies and three clinical studies were included for review. All studies reported displacement in the coronal plane, four studies reported in the sagittal plane, and one reported findings in the rotational plane. Four cadaveric studies had a similar experimental set up and the weighted mean associated with instability in the coronal plane could be calculated and was 2.9 mm at the anterior portion of the distal tibiofibular joint and 3.4 mm at the posterior portion. Syndesmotic instability in the sagittal plane is less extensively studied, however available data from a cadaveric study suggests thresholds of 2.2 mm of posterior fibular translation when performing an anterior to posterior hook test and 2.6 mm of anterior fibular translation when performing a posterior to anterior hook test. Conclusions The results have concluded that the commonly used 2.0 mm threshold value of distal tibiofibular diastasis may lead to overtreatment of syndesmotic instability, and that using threshold values of 2.9 mm measured at the anterior portion of the incisura and 3.4 mm at the posterior portion may represent better cut off values. Given the ready availability of 3 mm probes among standard arthroscopic instrumentation, at the very least surgeons should use 3 mm in lieu of 2 mm probes intraoperatively. Level of evidence IV.

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Section: Discussionmentioning

confidence: 99%

Arthroscopic coronal plane syndesmotic instability has been over-diagnosed

Hagemeijer

Elghazy

Waryasz

et al. 2020

Knee Surg Sports Traumatol Arthrosc

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“…Other authors recommend open or arthroscopic approaches to visualize the accuracy of reduction. 1,11,15,19…”

Section: Introductionmentioning

confidence: 99%

Effect of Intraoperative Multidimensional Fluoroscopy Versus Conventional Fluoroscopy on Syndesmotic Reduction

et al. 2020

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Background: Despite multiple techniques to improve syndesmotic reduction accuracy, syndesmotic malreduction in unstable ankle fractures remains prevalent. We performed a prospective, observational study to assess the ability of intraoperative multidimensional fluoroscopy to lead a surgeon to change the syndesmotic reduction obtained by conventional fluoroscopic techniques with the goal of achieving an accurate reduction. Methods: Thirty patients with unilateral malleolar ankle fractures and syndesmotic instability were enrolled. Following fixation of the malleollar fractures, the syndesmosis was provisionally reduced. Once the surgeon believed acceptable reduction was obtained by comparison with the contralateral, uninjured ankle mortise and lateral fluoroscopic images, provisional fixation was used to maintain reduction. Intraoperative, multidimensional fluoroscopy was used to generate cross-sectional images to assess the reduction. The surgeon then decided if a change in the reduction was needed, and fixation proceeded per surgeon preference. Postoperative bilateral computed tomography (CT) scans of the ankles were used to assess the reduction. Results: The main outcome recorded was syndesmotic reduction change by the attending surgeon following 3-dimensional (3D) fluoroscopic imaging. The secondary outcome was syndesmotic reduction accuracy on postoperative CT scan. Fourteen of 30 patients had intraoperative reduction change following 3D fluoroscopic imaging. Three of 30 patients had residual malreduction compared with the contralateral ankle on bilateral postoperative CT scan. Conclusion: Intraoperative 3D fluoroscopy frequently led the surgeon to change the syndesmotic reduction obtained by conventional techniques and provided additional information not available with 2-dimensional fluoroscopy. A 10% syndesmotic malreduction rate was obtained with this technique. Level of Evidence: Diagnostic level II, prospective comparative study.

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