The Radiographic Fate of the Syndesmosis after Trans-syndesmotic Screw Removal in Displaced Ankle Fractures

Category: Ankle, Trauma Introduction/Purpose: Syndesmotic fixation with screws is commonly used for ankle fractures with syndesmotic disruption. Few studies have reported the development of heterotopic ossification (HO) within the syndesmosis following ankle injuries, which may lead to abnormal joint kinematics and even joint synostosis. However, there is little data on the prevalence and on the risk factors associated with the development of HO. The purpose of this study is to determine the (1) prevalence and (2) risk factors associated with the development of HO within the distal tibiofibular syndesmosis following ankle fractures requiring syndesmotic fixation. We hypothesized that screws within the syndesmosis articulation and broken screws would be associated with a higher incidence of HO than extraarticular and intact screws, respectively. Methods: A retrospective review was conducted for patients who sustained an ankle fracture with syndesmotic disruption. Inclusion criteria: age between 18 and 65 years old, a closed ankle fracture treated operatively with syndesmotic screw fixation. Exclusion criteria: additional lower extremity injury, history of prior ankle fracture, lack of radiographic follow-up and fixation other than 1 or 2 syndesmosis screws. Medical records were reviewed for: age, sex, high or low energy injury mechanism, smoking status, diabetes, BMI, perioperative complications, and further procedures. Fractures were classified by Lauge-Hansen and Weber systems. Immediate postoperative radiographs were reviewed for the number of syndesmotic screws, whether screws were intraarticular or extraarticular and the number of cortices each screw crossed. Final postoperative radiographs were reviewed for retention or screw removal and the presence of HO. The presence of HO was defined as new or increased bone formation within the syndesmosis compared to immediate postoperative radiographs. Results: Included were 264 patients, mean radiographic follow-up of 10.5+/-10.2 months. The mean age was 39.2+/-12.6 years (38.7% female) with a mean BMI of 32.1+/-7.8. Current smokers made up 39.4% of patients and 10.6% were diabetic. The mean time to fracture fixation was 12.6+/-3.2 days and 198 patients (75%) had a low energy injury. There was no significant difference in HO formation for demographics, injury mechanism or time to fixation. Overall, HO developed in 160 patients (60.6%). There was no difference, additionally for fracture pattern, number screws or fixation construct (Table 1). HO developed in 92% of broken, 75% of loose and 44% of intact screws (P<0.001). Screws were removed in 107 patients (40.5%) with no difference in HO formation compared to patients with intact screws. Conclusion: Heterotopic ossification is commonplace following screw fixation for syndesmotic injuries with a prevalence of 60.6%. Broken screws and loosened screws are a significant risk factor for the development of HO. However, no other risk factors in this study were found to be associated with the development of HO, including intraarticular syndesmotic screw placement. Patients should be counseled on the prevalence although further research is needed to determine the effect on ankle motion and progression of post-traumatic osteoarthritis.

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Risk Factors for Recurrent Syndesmotic instability after Syndesmotic Screw Fixation in Rotational Ankle Fractures

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00048 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0004

Author(s):

Sunghyun Lee ◽

Hoiyoung Kwon

Keyword(s):

Risk Factors ◽

Screw Fixation ◽

Significant Risk ◽

Ankle Fractures ◽

Binary Logistic Regression Analysis ◽

Malleolar Fracture ◽

Syndesmotic Screw ◽

Posterior Malleolar Fracture ◽

The Mean ◽

Recurrence Group

Category: Ankle Introduction/Purpose: Rotational ankle fractures often have unstable syndesmotic injuries the require reduction and stabilization. Though multiple studies have focused on methods to assess accurate syndesmotic reduction, fairly high rates of recurrent syndesmosis diastasis were reported. However, there was no study to investigate possible risk factors for syndesmosis widening after surgical fixation. The purpose of this study was to identify the risk factors for recurrent syndesmosis widening after screw fixation. We hypothesized that risk factors for recurrence syndesmosis widening could be identified from patient demographic, intraoperative variables and the extent of the pathologic condition associated with fractures. Methods: We performed a retrospective review between 2009 and 2015 of consecutive patients who had sustained rotational ankle fractures with intraoperative evidence of syndesmotic instability requiring syndesmotic reduction and stabilization. The exclusion criteria included syndesmosis screws placed for diabetic neuropathy, skeletal immaturity, tibial pilon fractures, polytrauma, open fracture. Patients were sorted into 2 groups according to the presence of recurrent syndesmosis instability which was defined as a difference in the tibiofibular distance of =2 mm between the injured and uninjured ankles on CT at postoperative 1 year and a positive external rotation test. Furthermore, the statistical analysis by binary logistic regression analysis included the significance of various risk factors including age at surgery, sex, diabetes, smoking, body mass index (BMI), dominant side, type of fracture, associated fracture, initial tibiofibular distance on CT, number and size of screws, cortices. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: A total 126 patients met the study inclusion criteria and underwent analysis. The overall postoperative recurrent instability rate was 25.4% (without recurrence group: 94 patients, recurrence group: 32). It was significantly affected by the BMI (p=0.018; adjusted odds ratio, OR, = 30, 6.21) and concomitant posterior malleolar fracture (p=0.040, adjusted OR 3.31). The other variables were not found to be significant risk factors. There was a significant improvement in the mean clinical scores at one years postoperatively (both p < 0.001), but the mean scores in the group with recurrence were significantly lower than those in the group without recurrence (p=0.021) Conclusion: Among the risk factors, obesity and concomitant posterior malleolar fracture were significant risk factors for the recurrent syndesmotic instability after syndesmotic screw fixation. The overall results suggest meticulous attention to concomitant posterior malleolar fracture, especially in obese patients.

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The Clinical, Radiologic Outcomes of Indirect Anteroposterior Screw Fixation for Posterior Malleolar Fracture in Rotational Ankle Fractures: Comparison with Syndesmosis Fixation

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00270 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0027

Author(s):

Sunghyun Lee ◽

Hoiyoung Kwon

Keyword(s):

Functional Outcomes ◽

Screw Fixation ◽

Fragment Size ◽

Fracture Repair ◽

Ankle Fractures ◽

Posterolateral Approach ◽

Malleolar Fracture ◽

Syndesmotic Screw ◽

Posterior Malleolus

Category: Ankle Introduction/Purpose: The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. Recent studies suggested that direct fixation of a sizable posterior malleolar (PM) fracture through posterolateral approach would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. Indirect anteroposterior (AP) screw fixation was an alternative method, which represent relatively low complication. However, there were few studies to evaluate the stability of syndesmosis after indirect anteroposterior screw. The purpose of this study was to define the rate of syndesmotic instability after anteroposterior screw fixation and to compare to the clinical and anatomical outcomes with indirect reduction without fixation. Methods: We performed a retrospective review between 2009 and 2015 of consecutive patients who underwent surgery with sustained rotational ankle fractures including PM fractures. The exclusion criteria included age <18 years, diabetic neuropathy, tibial pilon fractures, previous ankle fracture repair and not available at minimum 1 year follow up. After the fibula and medial malleolar fracture fixation, the PM was fixed with an AP screw, leaving some of relatively smaller and indirect reduced PM fractures unfixed. Patients were sorted into 2 groups according to the presence (group F) or absence (group N) of AP screw fixation of PM. Then, both groups were divided according to the intraoperative necessity of syndesmotic fixation. The demographics, PM fragment size and syndesmosis widening comparing intact ankle on CT at 1 year postoperatively were recorded for each fracture. The functional outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: A total 126 patients met the study inclusion criteria and underwent analysis. Syndesmotic fixation was required in 17 of 78 (21.8%) and 24 of 88 (72.7%) in group F and N, respectively (p=0.012). Postoperative and follow-up FAOS scores were similar in the four subgroups. The tibiofibular distance on CT was greater in the patients without syndesmotic screw fixation in group F and N (p=0.036 and 0.021, respectively). Conclusion: Indirect AP screw fixation of the PM fracture in rotational ankle fractures might be support syndesmotic stability and, thus, lower the rate of syndesmotic fixation. Also, these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation. However, in AP screw fixation group, syndesmosis widening was evaluated without syndesmosis fixation, which could be resulted in degenerative arthritis change. Therefore, our data demonstrate that indirect AP screw fixation of PM fracture alone could not restore syndesmotic stability perfectly.

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Comparing Different Surgical Techniques for Addressing the Posterior Malleolus in Supination External Rotation Ankle Fractures and the Need for Syndesmotic Screw Fixation

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2017.01.053 ◽

2017 ◽

Vol 56 (4) ◽

pp. 730-734 ◽

Cited By ~ 16

Author(s):

Mengnai Li ◽

Rachel C. Collier ◽

Brian W. Hill ◽

Nathaniel Slinkard ◽

Thuan V. Ly

Keyword(s):

Screw Fixation ◽

External Rotation ◽

Surgical Techniques ◽

Ankle Fractures ◽

Syndesmotic Screw ◽

Posterior Malleolus ◽

Supination External Rotation

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Patterns and Implications of Early Syndesmotic Screw Failure in Rotational Ankle Fractures

Foot & Ankle International ◽

10.1177/1071100720935119 ◽

2020 ◽

Vol 41 (9) ◽

pp. 1065-1072

Author(s):

Omar A. Behery ◽

Jessica Mandel ◽

Sara J. Solasz ◽

Sanjit R. Konda ◽

Kenneth A. Egol

Keyword(s):

Clinical Outcome ◽

Range Of Motion ◽

Ankle Fractures ◽

Consecutive Series ◽

Retrospective Case ◽

Level Of Evidence ◽

Patient Demographics ◽

Syndesmotic Screw ◽

Screw Breakage ◽

Male Patients

Background: The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome. Methods: A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS). Results: A total of 113 patients (67%) had intact screws and 56 patients (33%) demonstrated either screw breakage or backout. Patients with SS failure were younger ( P = .002) and predominantly male ( P = .045). Fracture classification and energy level of injury were not associated with screw failure. Nine screws (11%) demonstrated backout (2 also broke) and 56 other screws broke. There was no association between the number of screws or cortices of purchase and screw failure. There was a trend toward a higher proportion of screw removal (20%) in this failed SS group compared with the intact SS group (12%) ( P = .25), but with similar ankle ROM and MFS ( P > .07). Conclusion: Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal. Level of Evidence: Level III, retrospective case-control study.

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