Background: Ankle fractures with syndesmotic injury treated via standard trans-syndesmotic fixation have a high percentage of syndesmotic malreduction.10 We established a protocol involving both direct syndesmosis visualization and meticulous tibial incisura reconstruction via the posterior malleolus fracture fragment, when present, via the attached, intact PITFL, then compared this with historic controls to assess improvement after this type of syndesmosis reconstruction.
Materials and Methods: One hundred forty-nine consecutive direct visualization patients were treated prospectively with either open posterior malleolus reduction and fixation, regardless of fragment size (“PM”: 38 patients), or, with no posterior malleolar fracture, open fixation with locked syndesmotic screws (“S”: 97 patients); fracture-dislocations combined both fixation types (“C”: 16 patients). The syndesmosis was opened and debrided in all. All patients had preoperative MRI and postoperative CT. Distances between the fibula and anterior and posterior incisura facets were measured on axial CT. An incongruent joint was defined as an A-P difference greater than 2 mm. Our historic controls were 25 patients previously fixed via indirect, fluoro-scopic reduction and syndesmotic screws.
Results: In the direct visualization group, 24 ankles (16%) had incongruity, compared with 13 controls (52%). The average difference between anterior and posterior colliculi measurements between PM and C was significant (p = 0.017).
Conclusion: Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixa-tion in our study.
Level of Evidence: III, Case Control
|2002||Hovis WD, Kaiser BW, Watson JT, Bucholz RW. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg. January 2002;84A(1):26-31.|
|1993||Burns WC II, Prakash K, Adelaar R, Beaudoin A, Krause W. Tibiotalar joint dynamics: indications for the syndesmotic screw: a cadaver study. Foot Ankle. March–April 1993;14(3):153-158.|
|2006||Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. October 2006;27(10):788-792.|
|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.|
|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.|
|2001||Takao M, Ochi M, Naito K, Iwata A, Kawasaki K, Tobita M, Miyamoto W, Oae K. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy. October 2001;17(8):836-843.|
|2008||Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. J Bone Joint Surg. April 2008;90B(4):405-410.|
|1994||Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. October 1994;10(5):558-560.|
|1979||Hughes JL, Weber H, Willenegger H, Kuner EH. Evaluation of ankle fractures: non-operative and operative treatment. Clin Orthop Relat Res. January–February 1979;138:111-119.|
|2001||Tornetta P III, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg. April 2001;83A(4):489-492.|
|1983||Pettrone FA, Gail M, Pee D, Fitzpatrick T, van Herpe LB. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg. June 1983;65A(5):667-677.|
|2005||Nielson JH, Gardner MJ, Peterson MGE, Sallis JG, Potter HG, Helfet DL, Lorich DG. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. July 2005;436:216-221.|
|1994||Yamaguchi K, Martin CH, Boden SD, Labropoulos PA. Operative treatment of syndesmotic disruptions without use of a syndesmotic screw: a prospective clinical study. Foot Ankle Int. August 1994;15(8):407-414.|
|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.|
|1993||Harper MC. An anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 1993;14(8):455-458.|
|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.|
|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.|
|2007||Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. November–December 2007;21(10)(suppl):S1-S133.|
|2000||Kennedy JG, Soffe KE, Dalla Vedova P, Stephens MM, O'Brien T, Walsh MG, McManus F. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma. June–July 2000;14(5):359-366.|
|1985||Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, Laros GS. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg. January 1985;67A(1):67-78.|
|1950||Lauge-Hansen N. Fractures of the ankle, II: combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60(5):957-985.|
|1974||Joy G, Patzakis MJ, Harvey JP Jr. Precise evaluation of the reduction of severe ankle fractures: technique and correlation with end results. J Bone Joint Surg. July 1974;56A(5):979-993.|
|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.|
|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.|
|2013||Yang Y, Zhou J, Li B, Zhao H, Yu T, Yu G. Exploração operatória e redução de sindesmose em lesão de tornozelo de Weber tipo C = Operative exploration and reduction of syndesmosis in Weber type C ankle injury. Acta Ortop Bras. 2013;21(2):103-108.|
|2012||Schepers T, Zuuren WJv, Bekerom MPJvd, Vogels LMM, Lieshout EMMv. The management of acute distal tibio-fibular syndesmotic injuries: results of a nationwide survey. Injury. October 2012;43(10):1718-1723.|