Abstract:Background: To compare the accuracy of arthroscopic sagittal versus coronal plane distal tibiofibular motion toward diagnosing syndesmotic instability. Methods: Arthroscopic assessment of the syndesmosis was performed on 21 above-knee cadaveric specimens, first with all ligaments intact and subsequently with sequential transection of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and the deltoid ligament. A lateral hook test, an anterior-to… Show more
“…The intraoperative open hook test was performed to confirm the instability of the syndesmosis. 7 If the posterior malleolus was fractured and the involved articular surface was more than 25% of the tibial plafond, it was fixed with cannulated screws after reduction.…”
Background: This study aims to evaluate the results and the safety of a novel fixation method we developed for syndesmosis injuries that we call the “embrace” technique. Methods: Between March 2018 and October 2020, a total of 67 patients with ankle fractures and syndesmotic injuries underwent syndesmosis fixation with the embrace technique at our institute. Plain radiographs and computed tomographic (CT) scans were obtained preoperatively. Postoperative radiographic assessment included anteroposterior (AP) and lateral radiographs and CT scans of both ankles. Additionally, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Olerud-Molander Ankle Score, and visual analog scale (VAS) score were used for postoperative assessment. Results: The mean age was 27.6 ± 10.9 (range, 14-56) years. The mean follow-up time was 30.3 ± 6.2 (range, 24-48) months. There were no malreductions indicated by any CT parameter except fibular rotation in a postoperative comparison between 2 sides. We found significant preoperative-postoperative changes in anterior difference, posterior difference, and fibular rotation but no significant preoperative-postoperative difference in fibular translation. There was no significant postoperative difference between the affected-side and normal-side measurements of any parameter. Complications included delayed wound healing, lateral pain because of wire knot irritation (11.9%), and medial fiber wire irritation (7.5%). The mean AOFAS, Olerud-Molander, and VAS scores at the last follow-up were 94.4 ± 6.8 (range, 84-100), 95.4 ± 6.1 (range, 80-100), and 0.68 ± 1.0 (range, 0-3) points, respectively. Conclusion: In our cohort, this novel technique proved to be an effective method for syndesmosis fixation in patients with ankle fractures associated with very good radiologic and patient-reported outcomes. Level of Evidence: Level IV, case series.
“…The intraoperative open hook test was performed to confirm the instability of the syndesmosis. 7 If the posterior malleolus was fractured and the involved articular surface was more than 25% of the tibial plafond, it was fixed with cannulated screws after reduction.…”
Background: This study aims to evaluate the results and the safety of a novel fixation method we developed for syndesmosis injuries that we call the “embrace” technique. Methods: Between March 2018 and October 2020, a total of 67 patients with ankle fractures and syndesmotic injuries underwent syndesmosis fixation with the embrace technique at our institute. Plain radiographs and computed tomographic (CT) scans were obtained preoperatively. Postoperative radiographic assessment included anteroposterior (AP) and lateral radiographs and CT scans of both ankles. Additionally, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, Olerud-Molander Ankle Score, and visual analog scale (VAS) score were used for postoperative assessment. Results: The mean age was 27.6 ± 10.9 (range, 14-56) years. The mean follow-up time was 30.3 ± 6.2 (range, 24-48) months. There were no malreductions indicated by any CT parameter except fibular rotation in a postoperative comparison between 2 sides. We found significant preoperative-postoperative changes in anterior difference, posterior difference, and fibular rotation but no significant preoperative-postoperative difference in fibular translation. There was no significant postoperative difference between the affected-side and normal-side measurements of any parameter. Complications included delayed wound healing, lateral pain because of wire knot irritation (11.9%), and medial fiber wire irritation (7.5%). The mean AOFAS, Olerud-Molander, and VAS scores at the last follow-up were 94.4 ± 6.8 (range, 84-100), 95.4 ± 6.1 (range, 80-100), and 0.68 ± 1.0 (range, 0-3) points, respectively. Conclusion: In our cohort, this novel technique proved to be an effective method for syndesmosis fixation in patients with ankle fractures associated with very good radiologic and patient-reported outcomes. Level of Evidence: Level IV, case series.
“…92 (Figure 6) Arthroscopy helps measure dynamic diastasis and distinguish instability in multiple planes. 20,93 Bhimani et al 94 performed a cadaveric study and reported that arthroscopic measurement of sagittal plane fibular translation is more accurate than coronal plane diastasis for evaluating syndesmotic instability.Figure 6.Arthroscopic view is demonstrated widening of syndesmosis (long white arrow) and rupture of AITFL (*) (4(a)), drive-through is positive by inserting 3-mm shaver (S) into syndesmotic joint (4(b)), the syndesmotic joint is reduced after syndesmotic fixation (4(c), small white arrow), and AITFL is intact after open repair (4(d), *) (Ti = Tibia, Ta = Talus, F = fibula, * = AITFL, and S = Shaver).(With copyright permission from Chamnanni Rungprai; Salubris Publishers).…”
Section: Investigationsmentioning
confidence: 99%
“…128 Arthroscopy is another method used to identify instability as well as verify reduction. 20,93,94 Operative treatment of syndesmotic Injuries with assisted arthroscopic reduction has been reported. 129…”
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
“…The specimens were mounted to a wooden board using 5-mm Schanz pins inserted anteroposteriorly into the proximal, middle, and distal aspects of the tibia. 3,20…”
Background: There is a high prevalence of concomitant lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Therefore, the aim of this study was to fluoroscopically evaluate the role of the syndesmotic ligaments in stabilizing the lateral ankle. Methods: Twenty-four cadaveric specimens were divided into 3 groups and fluoroscopically evaluated for lateral ankle stability with all syndesmotic and ankle ligaments intact and then following serial differential ligamentous transection. Group 1: (1) anterior talofibular ligament (ATFL), (2) calcaneofibular ligament (CFL), and (3) posterior talofibular ligament (PTFL). Group 2: (1) anterior inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), (3) posterior inferior tibiofibular ligament (PITFL), (4) ATFL, (5) CFL, and (6) PTFL. Group 3: (1) AITFL, (2) ATFL, (3) CFL, (4) IOL, (5) PTFL, and (6) PITFL. At each transection state, 3 loading conditions were used: (1) anterior drawer test performed using 50 and 80 N of direct force, (2) talar tilt <1.7 Nm torque, and (2) lateral clear space (LCS) <1.7 Nm torque. These measurements were in turn compared with those of the stressed intact ligamentous state. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A P value <.05 was considered statistically significant. Results: The lateral ankle remained stable after transection of all syndesmotic ligaments (AITFL, IOL, PITFL). However, after additional transection of the ATFL, the lateral ankle became unstable in varus and anterior drawer testing conditions ( P values ranging from .036 to .012). Lateral ankle instability was also observed after transection of the ATFL and AITFL in varus and anterior drawer testing conditions ( P values ranging from .036 to .012). Subsequent transection of the CFL and PTFL worsened the lateral ankle instability. Conclusion: Our findings suggest that isolated syndesmosis disruption does not result in lateral ankle instability. However, the lateral ankle became unstable when the syndesmosis was injured along with ATFL disruption. Clinical Relevance: When combined with ATFL release, disruption of the syndesmosis appeared to destabilize the lateral ankle.
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