Examination and Repair of the AITFL in Transmalleolar Fractures

Abstract

The surgical repair of transmalleolar fractures commonly involves reduction and internal fixation of the boney injuries. In the absence of extreme syndesmotic disruptions, little attention has been given in the recent literature to the role of the syndesmosis in general or to the anterior inferior tibiofibular ligament (AITFL) in particular in preserving the stability of the ankle mortise. In this paper, the author describes a surgical approach to evaluate and repair AITFL ligament injuries in transmalleolar ankle fractures. A significant portion of these injuries are associated with an avulsion of the tibial or fibular insertion resulting in an intra-articular fracture in the distal tibiofibular joint which may not be apparent on plain x-rays. Direct visualization of the injury allows accurate assessment of the injury pattern and obviates the need for more costly imaging studies such as computed tomography and magnetic resonance imaging scans. Anatomic repair of the AITFL injury restores the stability of the ankle mortise and improves the stability of the bone repair, allowing for early return to functional exercises and activities. Syndesmotic screw fixation of transmalleolar ankle fractures was not necessary when the AITFL was repaired directly by the techniques described.

Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair

“…In the clinical part of the study by Seitz et al, 11 of the 12 Weber-C injuries regained pre-injury levels at an average follow-up of 3.2 years, there were no device failures, and all were routinely removed after eight to 12 months [49]. The other excluded study was by Nelson [40]; who used three strands of no. 2 nonabsorbable sutures looped around a fibular and tibial screw.…”

“…rigid fixation for an adequate period on one hand versus early return to full range of motion at the syndesmosis on the other, various different strategies have been used throughout the years. Among these are the metallic syndesmotic screw, which is currently considered the 'gold standard', bioabsorbable screws, bolt-fixation, syndesmotic hook, integrated syndesmotic fixation with nail (ANK), staples, direct repair, and the use of suture-loops with or without endobuttons [15, 26, 36, 40, 47, 56]. Of the latter devices the suture-button device is increasingly popular [59].…”

Tibiofibular syndesmosis in acute ankle fractures: additional value of an oblique MR image plane

“…Nelson described 18% fibular avulsions (Wagstaffe type II fractures) and 8% tibial avulsions (Wagstaffe type I or Chaput-Tillaux fractures) in a series of 50 transmalleolar fractures. In some cases the avulsed fragment did wedge the joint open [9]. A Wagstaffe fracture can be easily overlooked because of a fracture hematoma or torn capsule or if it is covered by an intact extensor retinaculum.…”

Acute and Chronic Injuries to the Syndesmosis

“…In addition, there is some limited evidence that repair or reconstruction of the AITFL restores the stability, allows for early return to functional activities, and obviates syndesmotic screw fixation. 156 …”