Cerclage Wire and Lag Screw Fixation of the Lateral Malleolus in Supination and External Rotation Fractures of the Ankle

Category: Trauma Introduction/Purpose: The current standard for stabilization of the talus within the ankle mortise after bimalleolar equivalent ankle fracture is open reduction and internal fixation (ORIF) of the lateral malleolus followed by syndesmotic screw fixation of the syndesmosis. Syndesmotic fixation may be associated with complications such as mal-reduction, joint stiffness, altered ankle biomechanics, and potential additional surgery for hardware removal. Consequently, some surgeons advocate ORIF of the lateral malleolus in conjunction with deltoid ligament repair rather than syndesmosis fixation. To our knowledge, clinical reports of this treatment option lack biomechanical evidence to support this approach. The purpose of this investigation was to compare ankle joint stability and contact pressures in a bimalleolar equivalent ankle fracture model treated with trans-syndesmotic screw fixation versus deltoid ligament repair. Methods: We prepared and tested seven fresh frozen cadaveric whole lower leg specimens with an undisturbed proximal tibiofibular joint. We tested each leg was tested under five conditions: (1) intact, (2) syndesmosis disrupted and deltoid ligament sectioned, (3) syndesmosis reduced w/ screw fixation, (4) deltoid repaired, and (5) both syndesmosis and deltoid ligament repaired. Under a nominal axial load, we applied controlled anterior, posterior, lateral, and medial drawer stresses to the foot using a custom-built testing apparatus and documented the resulting talar translation relative to the tibia. We also applied controlled internal and external rotation stresses to the ankle model and measured the provoked ankle joint rotations. In each condition, we measured peak ankle contact pressure (PACP) using a Tekscan pressure sensor under a physiologic axial load simulating single-limb stance. Results: Concurrent disruption of the syndesmosis and the deltoid ligament significantly (p<.05) increased anterior drawer, lateral drawer, and internal and external rotation. Subsequent deltoid repair significantly reduced anterior displacement to normal levels, but syndesmosis fixation did not. Lateral drawer was not significantly corrected until both deltoid ligament and syndesmosis were repaired. Deltoid repair and syndesmosis fixation each reduced internal rotation significantly, with further reduction to normal levels when both were repaired. External rotation remained elevated relative to the intact condition regardless of which structures were repaired. Deltoid repair and syndesmosis fixation achieved similar levels of posterior, lateral and medial drawer reduction, but these measures did not approach normal values until both were repaired. No significant differences in PACP were identified among the five tested conditions. Conclusion: Isolated repair of the deltoid ligament after a bimalleolar equivalent ankle fracture achieves markedly better anterior displacement stability than does fixation of the syndesmosis with a screw. Under the described testing conditions, the two procedures offer similar posterior, medial, and lateral talar displacement stability and similar levels of internal and external rotational stability. Given the complications that may be associated with rigid syndesmotic screw fixation, our investigation suggests that deltoid repair may represent a reasonable alternative to syndesmosis fixation.

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A Biomechanical Comparison of Intramedullary Nail and Crossed Lag Screw Fixation for Tibiotalocalcaneal Arthrodesis

Foot & Ankle International ◽

10.1177/107110079701801007 ◽

1997 ◽

Vol 18 (10) ◽

pp. 639-643 ◽

Cited By ~ 120

Author(s):

Michael Edward Berend ◽

Richard Robert Glisson ◽

James Albert Nunley

Keyword(s):

Intramedullary Nail ◽

Screw Fixation ◽

External Rotation ◽

Fusion Rate ◽

Tibiotalocalcaneal Arthrodesis ◽

Lag Screw ◽

Ankle Joints ◽

Mechanical Bending ◽

Cantilever Bending ◽

Biomechanical Comparison

This study compared the mechanical bending and torsional properties of intramedullary nail fixation and lag screw fixation for tibiotalocalcaneal arthrodesis. Seven matched pairs of human cadaver lower extremities were studied, with one hindfoot in each pair stabilized with a 12 mm × 150 mm interlocked intramedullary nail inserted retrograde across the subtalar and ankle joints. The contralateral hindfoot was stabilized with two crossed 6.5 mm cannulated screws inserted across both the ankle and subtalar joints. Specimens were subjected to cantilever bending tests in plantarflexion, dorsiflexion, inversion, and eversion and to torsional tests in internal and external rotation. The intramedullary nail construct was significantly ( P < 0.05) stiffer than the crossed lag screw construct in all four bending directions and both rotational directions: plantarflexion (nail, 42.8 N/mm; screws, 16.4 N/mm; P = 0.0003), dorsiflexion (nail, 43.0 N/mm; screws, 10.3 N/mm; P = 0.0005), inversion (nail, 37.7 N/mm; screws, 12.3 N/mm; P = 0.0024), eversion (nail, 35.4 N/mm; screws, 10.8 N/mm; P = 0.0004), internal rotation (nail, 1.29 N-m/°; screws, 0.82 N-m/°; P = 0.01), external rotation (nail, 1.35 N-m/°; screws, 0.44 N-m/°; P = 0.0001). Intramedullary fixation is biomechanically stiffer than crossed lag screws in all bending and torsional directions tested and therefore this construct may aid in maintaining alignment of the hindfoot during union and may help increase fusion rate through increased stability of the internal fixation.

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Outcomes of Bridge Plating Versus Standard Fixation in Geriatric Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00220 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0022

Author(s):

Russell E Holzgrefe ◽

Amalie Erwood ◽

Samuel Maidman ◽

William Runge ◽

Michael Gottschalk ◽

...

Keyword(s):

Screw Fixation ◽

Lateral Malleolus ◽

Ankle Fractures ◽

Medial Malleolus ◽

Lag Screw ◽

Plate Group ◽

Bridge Plate ◽

Sf 36 ◽

One Year ◽

Bridge Plating

Category: Ankle, Trauma Introduction/Purpose: Ankle fractures represent one of the most common injuries encountered by foot and ankle specialists. Internal fixation of the lateral malleolus can be achieved by several different techniques, most commonly by lag screw and neutralization plating. However, ankle fractures in older patients often present technical challenges as osteoporotic bone is more commonly encountered which may require bridge plating techniques. This study compares outcomes in patients over age 50 years who underwent ORIF of the lateral malleolus with either a bridge plate or lag screw and neutralization plate technique. Methods: This retrospective study evaluated 56 patients with closed ankle fractures, aged over 50 years who underwent open reduction internal fixation of the lateral malleolus. These were divided into two groups: 36 patients had fixation with one or more lag screws and a neutralization plate, and 20 patients had fixation with a bridge plate technique. Fractures were stabilized with lag screw fixation when feasible, while bridge plating was utilized in patients where lag screw fixation was not possible. SF-36 scores were attained at a minimum one-year post-op. Final radiographs and complications were recorded. Results: The lag group had a mean age of 63 years, 17% men, 61% with syndesmotic screw fixation, and 56% with medial malleolus fixation. The bridge group had a mean age of 65 years, 15% men, 60% with syndesmotic screw fixation, and 70% with medial malleolus fixation. At minimum one-year, SF-36 physical component summary score was 74.2 ± 19.4 in the lag group vs 63.2 ± 24.8 in the bridge plate group (p=0.049). The SF-36 mental component summary score was 89.2 ± 12 in the lag group vs 75.5 ± 22.7 in the bridge plate group (p=0.009). One patient in each group required return to the OR for irrigation and debridement for infection. No patients experienced fixation failure and all fractures demonstrated union on final radiograph. Conclusion: In the present study of patients over age 50 years who underwent ORIF of an ankle fracture, as compared with bridge plating, lag screw and neutralization plating is associated with superior one-year SF-36 physical and mental summary scores with similar rates of complications. However, additional research is needed to determine to what degree this difference is causative or correlative with confounding variables as fixation technique was not found to be an independent predictor of SF-36 outcomes in this small cohort.

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Effect of Ankle Position on Tibiotalar Motion With Screw Fixation of the Distal Tibiofibular Syndesmosis in a Fracture Model

Foot & Ankle International ◽

10.1177/1071100718759966 ◽

2018 ◽

Vol 39 (6) ◽

pp. 746-750 ◽

Cited By ~ 5

Author(s):

Mark P. Pallis ◽

David N. Pressman ◽

Kenneth Heida ◽

Tyler Nicholson ◽

Susan Ishikawa

Keyword(s):

Screw Fixation ◽

External Rotation ◽

Fracture Model ◽

Tibiofibular Syndesmosis ◽

Traumatic Injuries ◽

Lag Screw ◽

Syndesmotic Screw ◽

Distal Tibiofibular Syndesmosis ◽

Anatomic Reduction ◽

Pronation External Rotation

Background: Anatomic reduction and fixation of the syndesmosis in traumatic injuries is paramount in restoring function of the tibiotalar joint. While overcompression is a potential error, recent work has called into question whether ankle position during fixation really matters in this regard. Our study aimed to corroborate more recent findings using a fracture model that, to our knowledge, has not been previously tested. Methods: Twenty cadaver leg specimens were obtained and prepared. Each was tested for tibiotalar motion under various conditions: intact syndesmosis, intact syndesmosis with lag screw compression, pronation external rotation type 4 (PER-4) ankle fracture with syndesmotic disruption, and single-screw syndesmotic fixation followed by plate and screw fracture and syndesmotic screw fixation. In each situation, the ankle was held in alternating plantarflexion and dorsiflexion when inserting the syndesmotic screw with the subsequent amount of maximal dorsiflexion being recorded following hand-tight lag screw fixation. Results: While ankle range of motion increased significantly with creation of the PER-4 injury, under no condition was there a statistically significant change in maximal dorsiflexion angle. Conclusion: Ankle position during distal tibiofibular syndesmosis fixation did not limit dorsiflexion of the ankle joint. Clinical Relevance: Our findings suggest that maximal dorsiflexion during syndesmotic screw fixation may not be necessary.

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Single column plate plus other column lag screw fixation vs. both column plate fixation for anterior column with posterior hemitransverse acetabular fractures – a biomechanical analysis using different loading protocols

Injury ◽

10.1016/j.injury.2020.12.041 ◽

2021 ◽

Author(s):

Huy Le Quang ◽

Werner Schmoelz ◽

Richard A. Lindtner ◽

Dietmar Dammerer ◽

Peter Schwendinger ◽

...

Keyword(s):

Screw Fixation ◽

Plate Fixation ◽

Biomechanical Analysis ◽

Anterior Column ◽

Acetabular Fractures ◽

Lag Screw ◽

Single Column

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Biomechanical Evaluation of Tarsometatarsal Fusion Comparing Crossing Lag Screws and Lag Screw With Locking Plate

Foot & Ankle International ◽

10.1177/10711007211033541 ◽

2021 ◽

pp. 107110072110335

Author(s):

Sarah Ettinger ◽

Lisa-Christin Hemmersbach ◽

Michael Schwarze ◽

Christina Stukenborg-Colsman ◽

Daiwei Yao ◽

...

Keyword(s):

Locking Plate ◽

Screw Fixation ◽

Operative Procedure ◽

Fixation Technique ◽

Lag Screw ◽

Group 15 ◽

Fresh Frozen ◽

Biomechanical Evaluation ◽

The Stability ◽

End Stage

Background: Tarsometatarsal (TMT) arthrodesis is a common operative procedure for end-stage arthritis of the TMT joints. To date, there is no consensus on the best fixation technique for TMT arthrodesis and which joints should be included. Methods: Thirty fresh-frozen feet were divided into one group (15 feet) in which TMT joints I-III were fused with a lag screw and locking plate and a second group (15 feet) in which TMT joints I-III were fused with 2 crossing lag screws. The arthrodesis was performed stepwise with evaluation of mobility between the metatarsal and cuneiform bones after every application or removal of a lag screw or locking plate. Results: Isolated lag-screw arthrodesis of the TMT I-III joints led to significantly increased stability in every joint ( P < .05). Additional application of a locking plate caused further stability in every TMT joint ( P < .05). An additional crossed lag screw did not significantly increase rigidity of the TMT II and III joints ( P > .05). An IM screw did not influence the stability of the fused TMT joints. For TMT III arthrodesis, lag-screw and locking plate constructs were superior to crossed lag-screw fixation ( P < .05). TMT I fusion does not support stability after TMT II and III arthrodesis. Conclusion: Each fixation technique provided sufficient stabilization of the TMT joints. Use of a lag screw plus locking plate might be superior to crossed screw fixation. An additional TMT I and/or III arthrodesis did not increase stability of an isolated TMT II arthrodesis. Clinical Relevance: We report the first biomechanical evaluation of TMT I-III arthrodesis. Our results may help surgeons to choose among osteosynthesis techniques and which joints to include in performing arthrodesis of TMT I-III joints.

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Augmented cerclage wire improves the fixation strength of a two-screw construct for humerus split type greater tuberosity fracture: a biomechanical study

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04215-7 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Chao-Jui Chang ◽

Wei-Ren Su ◽

Kai-Lan Hsu ◽

Chih-Kai Hong ◽

Fa-Chuan Kuan ◽

...

Keyword(s):

Screw Fixation ◽

Biomechanical Study ◽

Fixation Strength ◽

Myotendinous Junction ◽

Steel Cable ◽

Simple Modification ◽

Greater Tuberosity ◽

Cerclage Wire ◽

Group A ◽

Group B

Abstract Background Poor functional outcome can result from humeral greater tuberosity (GT) fracture if not treated appropriately. A two-screw construct is commonly used for the surgical treatment of such injury. However, loss of reduction is still a major concern after surgery. To improve the biomechanical strength of screw fixation in GT fractures, we made a simple modification of the two-screw construct by adding a cerclage wire to the two-screw construct. The purpose of this biomechanical study was to analyze the effect of this modification for the fixation of GT fractures. Materials and methods Sixteen fresh-frozen human cadaveric shoulders were used in this study. The fracture models were arbitrarily assigned to one of two fixation methods. Group A (n = 8) was fixed with two threaded cancellous screws with washers. In group B (n = 8), all screws were set using methods identical to group A, with the addition of a cerclage wire. Horizontal traction was applied via a stainless steel cable fixed directly to the myotendinous junction of the supraspinatus muscle. Displacement of the fracture fixation under a pulling force of 100 N/200 N and loading force to construct failure were measured. Results The mean displacements under 100 N and 200 N traction force were both significantly decreased in group B than in group A. (100 N: 1.06 ± 0.12 mm vs. 2.26 ± 0.24 mm, p < 0.001; 200 N: 2.21 ± 0.25 mm vs. 4.94 ± 0.30 mm, p < 0.001) Moreover, the failure load was significantly higher in group B compared with group A. (415 ± 52 N vs.335 ± 47 N, p = 0.01), Conclusions The current biomechanical cadaveric study demonstrated that the two-screw fixation construct augmented with a cerclage wire has higher mechanical performance than the conventional two-screw configuration for the fixation of humeral GT fractures. Trial registration Retrospectively registered.

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Transverse Lag Screw Fixation in Midline Mandibulotomy

Annals of Otology Rhinology & Laryngology ◽

10.1177/000348940010900318 ◽

2000 ◽

Vol 109 (3) ◽

pp. 334-339 ◽

Cited By ~ 7

Author(s):

Joseph M. Serletti ◽

John U. Coniglio ◽

Salvatore J. Pacella ◽

John D. Norante

Keyword(s):

Reliable Method ◽

Screw Fixation ◽

Postoperative Radiotherapy ◽

Major Complication ◽

Recurrent Tumor ◽

Minor Complication ◽

Anterior Cortex ◽

Lag Screw ◽

The Mean

Vertical midline mandibulotomy has provided a relatively simple and efficient means of obtaining access to intraoral tumors that are too large or too posterior to be removed transorally. Midline mandibulotomy has had the advantage of nerve and muscle preservation and places the osteotomy outside the typical field of radiotherapy, in contrast to lateral and paramedian osteotomies. Plate and screw fixation has been the usual means of osteosynthesis for these mandibulotomies; however, plate contouring over the symphyseal surface has been a time-consuming process. Unless the plate was contoured exactly, mandibular malalignment and malocclusion in dentulous patients has occurred. Use of parallel transverse lag screws has become a popular method of osteosynthesis for parasymphyseal fractures, and we have extended their use for mandibulotomy fixation. This paper reports our clinical experience with transverse lag screw fixation of midline mandibulotomies in 9 patients from 1994 to 1997. There were 7 men and 2 women with a mean age of 56 (range 35 to 71 years). The pathological diagnosis in all patients was squamous cell carcinoma; 8 cases were primary, and 1 patient presented with recurrent tumor. No tumors involved the mandibular periosteum. One patient had had previous radiotherapy, and 3 patients underwent postoperative radiotherapy. The mean follow-up has been 17 months (range 9 to 27). There was 1 minor complication and 1 major complication related to our technique. The major complication was a delayed nonunion of the mandibulotomy. This occurred because the 2 parallel screws were placed too close to one another, and this placement resulted in a delayed sagittal fracture of the anterior cortex and subsequent nonunion. Transverse lag screw fixation has not affected occlusion in our dentulous patients. Speech and diet were normal in the majority of our patients. Transverse lag screw fixation of the midline mandibulotomy has been a relatively safe, rapid, and reliable method for tumor access and postextirpation mandibular stabilization and has significant advantages over other current methods of mandibulotomy and fixation.

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