Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries

Franke, Jochen; von Recum, Jan; Suda, Arnold J.; Grützner, Paul Alfred; Wendl, Klaus

Affiliations

¹BG Trauma Center Ludwigshafen at Heidelberg University Hospital

²MINTOS-Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany

Abstract

Backround: Acute unstable syndesmotic ankle injuries are treated primarily by reduction and stabilization with a syndesmotic screw. Examination with fluoroscopy or standard radiographs may not provide reliable information about the quality of the reduction. There is evidence that intraoperative three-dimensional imaging can demonstrate a large proportion of malreductions. The aim of this study was to determine whether intraoperative three-dimensional imaging improves the detection of inadequate positioning of the distal aspect of the fibula in the tibiofibular incisura after syndesmotic screw insertion compared with the findings on standard intraoperative fluoroscopy.

Methods: Of 2286 ankle fractures treated operatively from August 2001 to February 2011, 251 consecutive cases (11%) were identified in a retrospective chart review. All had an unstable syndesmosis and underwent syndesmosis stabilization on the basis of an intraoperative hook test. After fluoroscopy, an intraoperative three-dimensional scan was performed. The result of this scan was documented by the surgeon and analyzed retrospectively with regard to the incidence and nature of the need for intraoperative revisions.

Results: The intraoperative three-dimensional scan altered the surgical outcome in eighty-two ankles (32.7%). In most ankles (seventy-seven; 30.7%), the reduction was improved, with the most common improvement being the alignment of the fibula in the tibiofibular incisura in sixty-four patients (25.5%) followed by correction of the fracture reduction in thirteen patients (5.2%). The other five alterations involved implant corrections. The most common malpositions requiring correction after insertion of a positioning screw, with or without additional fixation, were anterior displacement and internal rotation of the distal aspect of the fibula.

Conclusions: Following open reduction and internal fixation of an ankle fracture, the correct position of the syndesmosis cannot be evaluated reliably with use of conventional radiographs or intraoperative fluoroscopy. In view of the high proportion of positive findings in this study, we believe that any treatment of a syndesmotic injury should include intraoperative three-dimensional imaging or at least a postoperative computed tomography scan.

Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Links

DOI: 10.2106/JBJS.K.01122

PubMed: 22854991

WoS: 000306939000006

Cited Works (16)

Year	Entry
2004	Beumer A, van Hemert WLW, Niesing R, Entius CA, Ginai AZ, Mulder PGH, Swierstra BA. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227-234.
1997	Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. November 1997;18(11):693-698.
2005	Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. February 2005;19(2):102-108.
2010	Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma. January 2010;24(1):2-6.
1995	Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg. June 1995;77A(6):847-856.
1983	Robert RS. Surgical treatment of displaced ankle fractures. Clin Orthop Relat Res. January 1983;(172):164-170.
2006	Taser F, Shafiq Q, Ebraheim NA. Three-dimensional volume rendering of tibiofibular joint space and quantitative analysis of change in volume due to tibiofibular syndesmosis diastases. Skel Radiol. 2006;35(12):935-941.
1989	Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle. 1989;9(6):290-293.
1995	Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. J Bone Joint Surg. May 1995;77B(3):435-438.
1984	Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg. April 1984;66A(4):490-503.
1989	Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. December 1989;10(3):156-160.
1976	Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg. April 1976;58A(3):356-357.
2003	Ebraheim NA, Elgafy H, Padanilam T. Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res. April 2003;409:260-267.
2002	Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. February 2002;23(2):107-111.
2010	Wikerøy AKB, Høiness PR, Andreassen GS, Hellund JC, Madsen JE. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. January 2010;24(1):17-23.
2003	Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, Ochi M. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. April 2003;227(1):155-161.

Cited By (1)

Year	Entry
2016	Lareau CR, Hsu AR, Cohen BE. Acute syndesmotic injuries. In: Valderrabano V, Easley M, eds. Foot and Ankle Sports Orthopaedics. Cham, Switzerland: Springer International Publishing; 2016:265-277.