Pragmatic treatment of ankle fractures of uncertain stability: clinical features and risk of displacement

Abstract

Objective: To determine the functional and radiographic outcome of supra-syndesmotic fibular fractures associated with syndesmotic disruption treated with syndesmosis-only fixation.Methods: A retrospective observational study was performed in 12 patients who had fracture patterns amenable to syndesmosisonly fixation. According to the Lauge-Hansen classification, 10 were pronation external rotation injuries and 2 were pronation abduction injuries. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient each had a single tricortical cortical screw fixation across the syndesmosis. Patients were kept non-weight bearing for 6 weeks followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective (Olerud and Molander Scale) ankle scoring system and by radiographic assessment of the ankle mortise.Results: Ankle mortise was reduced in all cases and all but one fibular fracture united without loss of fixation. At a mean follow up of 13 months, functional outcome score was 75. Six patients had more than one malleolar injury needing either screw or anchor fixations. One patient with trimalleolar fracture had residual ankle stiffness which responded to intensive physiotherapy. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of fibula.Discussion: With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not necessary for fibular fractures combined with diastasis of inferior tibio-fibular joint. In our series, good or excellent results were obtained in majority of the patients. The patient with late diastasis after syndesmotic screw removal was probably due to early screw removal before union of the fibular fracture. Essential to this method of treatment are restoration of the fibular length, anatomical reduction of the syndesmosis and delaying screw removal till the fibular fracture heals.Conclusions: Syndesmotic-only fixation for supra-syndesmotic fibular fractures associated with syndesmotic disruption is a safe and effective method.

Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis

“…Most of the fractures are displaced, and the structure of the ankle mortise is damaged, which affects the stability of the ankle joint. [ 12 ] Unstable displaced ankle fractures should be treated with open reduction and internal fixation. [ 13 ] TF, especially when the posterior malleolus fracture has comminuted blocks, is very difficult to reset.…”