Predicting Syndesmotic Injury in OTA/AO 44-B2.1 (Danis-Weber B) Fractures

Context: Ankle syndesmotic injuries present a significant challenge for athletes due to prolonged disability and recovery periods. The optimal management of these injuries and rates of return to sport in athletes remains unclear. Objective: The purpose of this study was to evaluate return to sport for athletes after ankle syndesmotic injuries. Data Source: The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies from database inception to January 15, 2017, and pertinent data were abstracted. Study Selection: Only studies reporting return-to-sport rates after ankle syndesmotic injuries were included. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Two reviewers extracted data from the included studies, which were stored in a standardized collection form (Microsoft Excel). Recorded data included demographics (eg, author, year of publication, study design), descriptive statistics (eg, patient age, percentage male, number of athletes, sample size), and outcomes (eg, time to return to sport, proportion of those who returned to sport, the self-reported questionnaire the Olerud-Molander Ankle Score). Results: A total of 10 studies and 312 patients with ankle syndesmotic injuries were included in this systematic review. The rate of return to preinjury or any injury level of sport after ankle syndesmotic injuries was 93.8% ± 1.2% and 97.6% ± 1.5%, respectively, for the corresponding 7 and 3 studies that reported this characteristic. The mean time to return to sport was 46.4 days (range, 15.4-70 days), with 55.2 ± 15.8 and 41.7 ± 9.8 days for operative and nonoperative management, respectively. Conclusion: This systematic review found a high rate of return to any as well as preinjury level of sport after ankle syndesmotic injury in both operative and nonoperative treatment groups. However, further high-level studies are required to compare operative and nonoperative treatment groups associated with return to sport after ankle syndesmotic injury.

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Ankle Syndesmotic Injury

Journal of the Korean Fracture Society ◽

10.12671/jkfs.2007.20.3.282 ◽

2007 ◽

Vol 20 (3) ◽

pp. 282 ◽

Cited By ~ 1

Author(s):

Keun-Bae Lee

Keyword(s):

Syndesmotic Injury

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Tibial Shaft and Pilon Fractures with Associated Syndesmotic Injury

Journal of Orthopaedic Trauma ◽

10.1097/bot.0000000000002252 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Kevin F. Purcell ◽

Patrick F. Bergin ◽

George V. Russell ◽

Matt L Graves ◽

LaRita C. Jones ◽

...

Keyword(s):

Tibial Shaft ◽

Syndesmotic Injury ◽

Pilon Fractures

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Stress vs. Non-Stress Radiographs in Subtle Syndesmotic Injuries

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00296 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0029

Author(s):

Nicola Krähenbühl ◽

Travis Bailey ◽

Nathan Davidson ◽

Heath Henninger ◽

Charles Saltzman ◽

...

Keyword(s):

Ankle Instability ◽

External Rotation ◽

Paired Comparison ◽

Weight Bearing ◽

Deltoid Ligament ◽

Ankle Sprains ◽

X Rays ◽

Syndesmotic Injury ◽

Stress Radiographs ◽

Clear Space

Category: Sports Introduction/Purpose: Between 1-18% of all ankle sprains and 23% of all ankle fractures involve injury to the distal tibio-fibular syndesmosis. Syndesmotic injuries can create a substantial diagnostic and therapeutic challenge for orthopaedic surgeons. While acute injuries can be assessed using conventional radiographs, subtle syndesmotic injuries may be misdiagnosed using X-rays. Misdiagnoses may result in chronic ankle instability, pain and post-traumatic osteoarthritis of the tibio-talar joint. The purpose of this study was to investigate whether syndesmotic injury was more easily diagnosed with stress vs. non-stress radiographs.radiographs.sed with stress vs. non-stress radiographs. Methods: Five pairs of cadavers (tibia plateau to toe-tip, mean 61 years, range 52-70 years) were scanned with weight-bearing CT (170 lb, w/ and w/o 10 Nm static external rotation torque). Digitally reconstructed radiographs (DRRs), which are comparable to conventional radiographs, were reconstructed from the 3D CT data. The following conditions were tested: First, intact ankles (Native) were tested. Second, one specimen from each pair underwent AITFL resection, while the contralateral underwent deltoid resection (Condition 1). Third, the remaining intact deltoid ligament or AITFL was resected in each ankle (Condition 2). Finally, the interosseous membrane (IOM) was resected in all ankles (Condition 3). Condition 3 was defined as acute syndesmotic injury. Using antero-posterior (AP) views, the tibio-fibular clear space (TFCS), tibiofibular overlap (TFO) and medial clear space (MCS) were assessed. Statistical analysis was performed using paired (comparison within groups) and unpaired (comparison between groups) t-test where p=0.05 was considered significant. Results: Regarding the TFCS, Native vs. Condition 3 in 10 Nm stress radiographs was significantly different in the deltoid group (p=0.021). Using TFO in stress and non-stressed radiographs, Native vs. Condition 2 and 3 was significantly different for the deltoid group (p=0.043), and Native vs. Condition 3 in the syndesmotic group (p=0.027). Regarding the MCS in non-stress radiographs, Native vs. Condition 3 was significantly different in the deltoid group (p=0.007), while in stress views, Native vs. Condition 2 was significant different in the syndesmotic (p=0.026) and Native vs. Condition 3 in the deltoid group (p=0.030). No differences were found comparing the conditions of the AITFL with the same conditions of the deltoid group. Conclusion: The TFCS cannot be used to assess subtle or acute syndesmotic injuries in stress and non-stress radiographs. The TFO can be used to assess a combined injury to the AITFL and deltoid ligament in stress and non-stress radiographs. The MCS can be used to assess acute syndesmotic injuries in stress and non-stress radiographs. Radiographs (stress or non-stress) cannot be used to distinguish between injuries to the AITFL or deltoid ligament. Therefore, stress and non-stress radiographs are not useful in assessment of subtle syndesmotic injuries. Stress-radiographs are not superior compared to non-stress radiographs in assessment of acute syndesmotic injuries.

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Hybrid Fixation for Danis-Weber Type C Fractures With Syndesmosis Injury

Foot & Ankle International ◽

10.1177/1071100720964799 ◽

2020 ◽

pp. 107110072096479

Author(s):

Gi Beom Kim ◽

Chul Hyun Park

Keyword(s):

External Rotation ◽

Case Series ◽

Ankle Fractures ◽

Syndesmotic Injury ◽

Hybrid Fixation ◽

Alternative Treatment Option ◽

Syndesmosis Injury ◽

Weber Type ◽

Type C

Background: This study aimed to assess the clinical and radiological outcomes of hybrid fixation for Danis-Weber type C ankle fractures with a syndesmotic injury. Methods: From January 2016 to April 2018, we retrospectively reviewed consecutive patients who underwent hybrid fixation for Danis-Weber type C ankle fractures with syndesmotic injury with a minimum follow-up of 12 months. We excluded patients who achieved syndesmosis stability after fracture fixation. In all patients, we allowed partial weightbearing at 4 weeks postoperatively. We evaluated the visual analog scale for ankle pain, the Olerud-Molander ankle score, and the American Orthopaedic Foot & Ankle Society score. Malreduction of the syndesmosis was defined based on 2 previously reported methods. Fourteen patients (11 men and 3 women) were included in this study. There were 11 patients with pronation external rotation-type fractures and 3 patients with Maisonneuve fractures. The average age at operation was 37.2 years (range, 18-70 years). Results: Clinical scores were significantly improved at the last follow-up. Postoperative malreduction was observed only in 1 patient (7.1%). Conclusion: Hybrid fixation using a suture-button device combined with a syndesmotic screw in Danis-Weber type C fractures with syndesmosis injury showed a high accuracy of reduction, a low rate of diastasis, and favorable clinical outcomes. This combined method could be a good alternative treatment option for Danis-Weber type C ankle fractures with a syndesmosis injury. Level of Evidence: Level IV, case series.

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Normal Kinematics of the Syndesmosis and Ankle Mortise During Dynamic Movements

Foot & Ankle Orthopaedics ◽

10.1177/2473011420933007 ◽

2020 ◽

Vol 5 (3) ◽

pp. 247301142093300

Author(s):

Veronica Hogg-Cornejo ◽

Kenneth J. Hunt ◽

Jonathan Bartolomei ◽

Paul J. Rullkoetter ◽

Casey Myers ◽

...

Keyword(s):

Healthy Volunteers ◽

Clinical Relevance ◽

High Speed ◽

Treatment Guidelines ◽

External Rotation ◽

Syndesmotic Injury ◽

Tibiofibular Syndesmosis ◽

Chronic Instability ◽

Clear Space ◽

Tibiofibular Joint

Background: Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space. Methods: Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition. Results: Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space ( P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space ( P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively. Conclusion: These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics. Clinical Relevance: Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.

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Diagnosing the Impact of the Syndesmotic Injury on Lateral Ankle Stability using Dynamic Ultrasound

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00132 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0013

Author(s):

Rohan Bhimani ◽

Jirawat Saengsin ◽

Go Sato ◽

Noortje Hagemeijer ◽

Bart Lubberts ◽

...

Keyword(s):

Anterior Talofibular Ligament ◽

Syndesmotic Injury ◽

Lateral Ankle ◽

Anterior Drawer ◽

Intact State ◽

Tibiofibular Ligament ◽

Ankle Stability ◽

Clear Space ◽

Lateral Ankle Ligament ◽

The Impact

Category: Ankle; Basic Sciences/Biologics; Sports; Trauma Introduction/Purpose: There is a high prevalence of coexisting lateral ankle ligament injuries and syndesmotic ligamentous injuries. However, it is unclear whether syndesmotic ligaments directly contribute toward the stability of the lateral ankle. Dynamic ultrasonography (US) is an imaging modality increasingly used for the care of orthopaedic foot and ankle patients because it allows dynamic evaluation of structures at the point of care with little risk to the patient and at low-cost. The aim of this study is to assess the effect of syndesmotic injury as well as combined syndesmotic and lateral ankle injury on the stability of the lateral ankle. Methods: Sixteen fresh frozen above-knee amputated cadaveric specimens, divided into two groups, underwent ultrasound evaluation for lateral ankle stability. In both the groups, the assessment was first done with all ligaments intact and later with sequential transection of anterior inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), posterior inferior tibiofibular ligament (PITFL), anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). In all scenarios, two loading conditions were considered: (1) Anterior drawer test: 50N and 80N and (2) Lateral clear space (LCS): 1.7Nm torque. The talar translation and LCS to the fixed tibial plafond were measured using Image J. Wilcoxon rank-sum test was used to compare the findings of each ligamentous transection state to the intact state. A p-value <0.05 was considered statistically significant. Results: In group 1 after transection of the all syndesmotic ligament and ATFL, an increase in the anterior drawer and lateral clear space values were found as compared to the intact state. Similarly, in group 2 the anterior drawer and lateral clear space values significantly increased after transection of the AITFL and ATFL as compared to the intact state (p-values = 0.01). Conclusion: Ultrasound can be used to evaluate the impact of the syndesmotic injury on lateral ankle stability while performing dynamic stress maneuvers. Lateral ankle instability appears after injury to all syndesmotic ligaments and ATFL, or after one syndesmotic ligament rupture (AITFL) with a concomitant anterior talofibular ligament rupture (ATFL). These findings suggest that surgeons should lower their threshold for stabilizing the syndesmosis if there is a concomitant lateral ankle ligament injury. [Table: see text]

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Radiological outcome from Tight-RopeTM fixation for acute syndesmotic injury

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00148 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0014

Author(s):

Su-Young Bae ◽

Hyung Jin Chung ◽

Jung-Hwan Lee ◽

Woo-Jin Shin ◽

Lee Junseok

Keyword(s):

Statistical Significance ◽

Weight Bearing ◽

Contralateral Side ◽

T Test ◽

Syndesmotic Injury ◽

Early Weight Bearing ◽

Time Points ◽

Clear Space ◽

Overlap Ratio ◽

Screw Group

Category: Trauma Introduction/Purpose: The reduction and maintenance of tibiofibular joint is essential in the treatment of syndesmotic ankle injury. Tight-RopeTM (Arthrex, Naples, FL, USA) has been used recently but suspected in terms of tightening and sustaining power in spite of biomechanical results. We aimed to assess fixation-tightness and delayed syndesmotic widening after rehabilitation in syndesmotic injuries treated with Tight-RopeTM comparing with conventional screws. Methods: 62 consecutive patients with acute syndesmotic injury were retrospectively reviewed. They were divided into 28 cases of Tight-RopeTM(TR) group and 34 cases of conventional screw fixation(Screw) group. We divided them into subgroups along the fixation methods such as 2 screws, 1 screw, TR only, and TR combined with screw. We analyzed syndesmotic widening by percentage. We measured tibiofibular clear space(TFCS) and tibiofibular overlap(TFOL). Tibiofibular clear space ratio and tibiofibular overlap ratio is measured as a ratio of tibiofibular clear space and tibiofibular overlap to the width of talar dome at preoperative, immediate postoperative, 3 months, and last (one year) visit time points and measured as a percentage of each measured value on the injured side to that on the contralateral side at the respective time points. The independent t-test and paired t-test were used for statistical analysis. Results: Mean TFCS ratio at each time point was 145.7±43.8%, 80.6±29.3%, 95.2±32.5%, and 96.3±31.1% in TR group and 126.2±42.6%, 73.9±22.6%, 104.8±59.2%, 106.4±35.0% in screw group. There were no statistical differences between groups in all 4 time points, no meaningful difference between subgroups. TFCS widening at 3 months in TR was less than screw group but no statistical significance. The TFCS was significantly tightened postoperatively then widened at 3 months and no meaningful change until last visit on both group. Mean TFOL ratio at each point was 51.84±43.6%, 119.2±36.7%, 110.7±44.5%, 96.8±27.7% in TR and 65.7±34.5%, 110.8±36.6%, 114.2±45.6%, 102.4±37.8% in screw group. There was no statistical difference between groups and subgroups. The overlap was increased postoperatively and no change between every sequential time points until last visit. Conclusion: The Tight-RopeTM fixation has a similar tightening and sustaining power compared to conventional screws and it was determined that the sustaining capacity did not decreased with time. Tight-RopeTM fixation can be effective treatment because it enables effective fixation, early weight-bearing and rehabilitation after surgery, and maintaining device for longer time in severe injury.

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Tibiotalar Joint Contact Mechanics Following Syndesmosis Fixation with Screws Versus a Flexible Fixation Device (TightRope™)

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00329 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0032

Author(s):

Eric Pang ◽

Katherine Bedigrew ◽

Anthony Behn ◽

Loretta Chou ◽

Kenneth Hunt ◽

...

Keyword(s):

Contact Mechanics ◽

Contact Pressure ◽

Center Of Pressure ◽

External Rotation ◽

Compressive Load ◽

Syndesmotic Injury ◽

Fixation Device ◽

Tibiotalar Joint ◽

Screw Group ◽

With Screws

Category: Ankle, Arthroscopy, Trauma Introduction/Purpose: Background: A shift and increase in mean tibiotalar contact pressure has been demonstrated in simulated syndesmotic injuries. The effect of screw fixation and/or suspensory fixation on restoration of pressure mechanics in the setting of a syndesmotic injury remains largely unknown. Hypothesis/Purpose: The purpose of this study is to examine the contact mechanics of the tibiotalar joint following syndesmosis fixation with screws versus a flexible fixation device for complete syndesmotic injury. Methods: Six matched pairs of cadaveric below knee specimens were randomly assigned fixation with either two 3.5 mm cortical screws or two TightRopes™ (Arthrex). Motion capture trackers were fixed to the tibia, fibula, and talus and a pressure sensor was placed in the tibiotalar joint. Each specimen was first tested intact with an axial compressive load followed by external rotation torque while maintaining axial compression. The syndesmosic ligaments were then completely sectioned and subsequently repaired with either two TightRopes™ or two screws and the protocol was repeated. Mean contact pressure (MCP), peak pressure (PP), reduction in contact area (CA), translation of the center of pressure (COP), and relative talar and fibular motion were calculated. Specimens were then cyclically loaded in external rotation to failure. Comparisons were made using paired t-tests and/or Welch’s t-tests. Results: No differences in MCP, PP, or CA were observed between the intact and instrumented states during AL alone for either group. MCP relative to intact testing was increased in the screw group at 5 Nm (4.8±4.1 MPa vs 3.6±0.8 MPa, p=0.033) and 7.5 Nm torque (6.2±1.4 MPa vs 4.2±1.2 MPa, p=0.024). Likewise, PP was increased in TightRope™ group at 7.5 Nm torque (14.4±3.1 MPa vs 10.8±1.6 MPa, p=0.046). There was no change in COP in the TightRope™ group at any threshold; however, at every threshold tested there was significant medial and anterior COP translation in the screw group relative to the intact state. Conclusion: Either screws or TightRope™ fixation is adequate with AL alone. With lower amounts of torque, the TightRope™ group exhibits contact and pressure mechanics that more closely match native mechanics.

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Anatomy of the tibial incisura as a risk factor for syndesmotic injury

Foot and Ankle Surgery ◽

10.1016/j.fas.2017.08.003 ◽

2019 ◽

Vol 25 (1) ◽

pp. 51-58 ◽

Cited By ~ 8

Author(s):

Andrzej Boszczyk ◽

Sławomir Kwapisz ◽

Martin Krümmel ◽

Rene Grass ◽

Stefan Rammelt

Keyword(s):

Risk Factor ◽

Syndesmotic Injury

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