Anatomically Fixed Posterior Malleolar Fractures in Syndesmosis Injuries without Transsyndesmotic Screw Fixation

2021 ◽  
pp. 107110072110600
Author(s):  
Ceyhun Çağlar ◽  
Serhat Akçaalan ◽  
Mustafa Akkaya
Keyword(s):  
Screw Fixation ◽  
Case Series ◽  
First Year ◽  
Malleolar Fractures ◽  
Clear Space ◽  
Posterior Malleolus ◽  
Trimalleolar Fractures ◽  
Anatomic Reduction ◽  
The Mean ◽  
The Stability

Background: The stability of the syndesmosis is extremely important in terms of syndesmosis injury, ankle instability, and posttraumatic osteoarthritis development following ankle fractures. The aim of this study is to evaluate 1-year radiographic outcomes after posterior malleolar fixation in lateral and posterior malleolar fractures and trimalleolar fractures without transsyndesmotic screw fixation. Methods: Ninety-four patients who underwent posterior malleolar fixation with posterolateral approach between January 2017 and June 2019 were evaluated retrospectively. The patients were evaluated with parameters such as demographic characteristics, fracture type, injury mechanism, physical examination, and radiographic measurements. The stability of the syndesmosis was evaluated by an intraoperative Cotton test and by measuring the tibiofibular overlap, tibiofibular clear space, and medial clear space parameters preoperatively on the immediate postoperative, first-year weightbearing ankle anteroposterior radiographs. Results: In immediate postoperative measurements on radiographs, although the mean tibiofibular overlap ( P < .001) increased, the mean tibiofibular clear space ( P < .001) and mean medial clear space ( P < .001) decreased compared with preoperative radiographs. Immediate postoperative mean tibiofibular overlap, tibiofibular clear space, and medial clear space compared with postoperative first-year mean tibiofibular overlap ( P = .39), tibiofibular clear space ( P = .23), and medial clear space ( P = .43) were not statistically significant. Bone union was completed radiographically at a median of 3.4 ± 1.8 months after surgery. Conclusion: After posterior malleolar fractures, anatomic reduction of the posterior malleolus and posterior inferior tibiofibular ligament complex provides strong syndesmosis stability as measured radiographically at 1 year. Patients may not need additional transsyndesmotic screw fixation. Level of Evidence: Level IV, case series.

Slippage of Tightrope Button in Syndesmotic Fixation of Weber C Malleolar Fractures: A Case Series

2018 ◽  
Vol 39 (5) ◽  
pp. 613-617 ◽  
Author(s):  
Mas’uud Ibnu Samsudin ◽  
Ming Quan Wayne Yap ◽  
Ang Wei Luong ◽  
Ernest Beng Kee Kwek
Keyword(s):  
Dynamic Compression ◽  
Case Series ◽  
Ankle Pain ◽  
Level Of Evidence ◽  
Persistent Symptoms ◽  
Suture Button ◽  
Malleolar Fractures ◽  
Clear Space ◽  
The Mean

Background: Tightrope fixation is an emerging technique for syndesmotic fixation with promising results. However, our case series highlights the slippage of Tightrope buttons as a complication of suture button syndesmotic fixation of Weber C malleolar fractures using limited contact dynamic compression (LCDCP) plates. Methods: We report a series of cases from our database in which slippage of the Tightrope button through the LCDCP holes in Weber C malleolar fractures was noted. We measured the medial clear space (MCS), tibiofibular clear space (TFCS), and distal tibiofibular overlap (DTFO) and computed the largest change in these measurements from the first postoperative follow-up radiographs. Patient records were reviewed for persistent symptoms that could be attributed to the loss of syndesmotic fixation and stability. Results: Follow-up radiographs of 3 patients showed a slippage of the Tightrope button through the LCDCP holes. Two of the patients reported persistent ankle pain and swelling with prolonged activity. The mean increases in MCS and TFCS among these patients were 0.7 (±0.081) mm and 1.5 (±0.798) mm, respectively. The mean decrease in DTFO was 2.2 (±0.864) mm. We next highlight 3 patients with Weber C malleolar fractures who underwent suture button syndesmotic fixation using double-stacked one-third tubular plates instead of the LCDCP. Conclusion: This case series reported Tightrope button slippage as an early complication of syndesmotic fixation of Weber C malleolar fractures. We propose the use of double-stacked one-third tubular plates instead of the LCDCP to avoid this complication. Level of Evidence: Level V, expert opinion.

scholarly journals Posterior malleolar fractures. New classification and treatment algorithm

2020 ◽  
Vol 14 (3) ◽  
pp. 254-259
Author(s):  
Diego Yearson ◽  
Ignacio Melendez ◽  
Federico Anain ◽  
Santiago Siniscalchi ◽  
Juan Drago
Keyword(s):  
Posterior Approach ◽  
Treatment Algorithm ◽  
Case Series ◽  
Fracture Pattern ◽  
Joint Surface ◽  
Medial Malleolus ◽  
New Classification ◽  
Level Of Evidence ◽  
Malleolar Fractures ◽  
Posterior Malleolus

Objective: This study proposes a new classification of posterolateral malleolar fractures and a treatment algorithm. Methods: We divided the posterolateral malleolus, which we considered as the posterior malleolus, from the posteromedial one, which we considered as being part of the medial malleolus fracture. The experience with 77 patients treated from February 2017 to February 2020 was assessed. All of them were assessed by frontal and profile radiographies and computed tomography (CT). Among the parameters to classify these fractures, we believe the most determining ones are fracture size, followed by presence of fracture displacement. Results: Fractures were divided into those whose posterior fragment was 25% smaller than the tibial joint surface and those that compromised more than 25% of this joint. The first group underwent syndesmotic opening and was subclassified into 1A (stable fractures), which do not require surgical treatment, and 1B (unstable), which require syndesmotic stabilization. The second group, which comprised the larger fractures, was subclassified into 2 A (non-displaced fractures, or with a displacement below 2 mm), which underwent percutaneous osteosynthesis, 2B (displaced fractures), and 2C (comminuted fractures), which underwent open reduction and internal fixation using a posterior approach. Conclusion: The classifications published so far are anatomic or descriptive, but none of them proposes a therapeutic algorithm for each type of fracture. We believe it will be helpful for its interpretation and decision-making on the need to perform a posterior approach, prioritizing the anatomical reduction of the joint fragment and resolution of syndesmotic instability linked to each fracture pattern using the most simple and effective method. Level of Evidence IV; Therapeutic Studies; Case Series.

scholarly journals Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

2022 ◽  
Vol 11 (2) ◽  
pp. 331
Author(s):  
Markus Regauer ◽  
Gordon Mackay ◽  
Owen Nelson ◽  
Wolfgang Böcker ◽  
Christian Ehrnthaller
Keyword(s):  
Surgical Treatment ◽  
Systematic Reviews ◽  
Treatment Guidelines ◽  
Screw Fixation ◽  
External Rotation ◽  
Treatment Algorithm ◽  
Evidence Based ◽  
Posterior Malleolus ◽  
Anatomic Reduction

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

scholarly journals Syndesmotic Fixation Utilizing a Novel Metal Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0041
Author(s):  
Derek S. Stenquist ◽  
Brian Velasco ◽  
Patrick K. Cronin ◽  
Jorge Briceno ◽  
Christopher Miller ◽  
...  
Keyword(s):  
External Rotation ◽  
Case Series ◽  
Break Point ◽  
The Novel ◽  
Suture Button ◽  
Radiographic Outcomes ◽  
Clear Space ◽  
Anatomic Reduction ◽  
Screw Breakage

Category: Ankle Introduction/Purpose: Syndesmotic disruption occurs in nearly 1 in 5 ankle fractures and requires anatomic reduction and internal stabilization to maximize functional outcomes. There is growing evidence to support retaining syndesmotic hardware from both a functional and economic standpoint. However, although broken screws are typically of little consequence, the location of screw breakage can be unpredictable and cause painful bony erosion and difficulty with extraction. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw with a more predictable break point and design features to allow for easier extraction. Methods: We performed a retrospective review of all consecutive patients who underwent syndesmotic fixation utilizing the novel syndesmotic screw over a one year period. Demographic data were obtained such as age, gender, fracture classification and relevant comorbidities. Screw specific data were obtained such as number of screws utilized and length. Screw loosening or breakage was documented. Postoperative radiographs were reviewed and tibiofibular overlap, tibiofibular clear space and medial clear space were measured. Results: 18 patients met inclusion criteria. Mean length of clinical follow-up was 4.67 months (range 0.5 to 8.5 months). Per the Lauge Hansen classification, 14 injuries were supination external rotation type, two were pronation abduction and two pronation external rotation type. Three screws (12.5%) fractured at the break point with no screws fracturing at a different location. 21 screws did not fracture with 10 (42%) of the screws demonstrated to be loose. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow up of the cohort. No screws required removal during the study period. There were no other complications of any type (Table 1). Conclusion: Early reporting of outcomes is essential to maximize both safety and value in healthcare technology innovation. This study provides the first clinical data on a novel alternative to traditional screws and suture button devices for fixation of syndesmotic injuries. At short-term follow up, there were no complications and the novel screw provided adequate fixation to allow healing and prevent diastasis. While initial results are favorable, longer term follow-up is required to determine whether this novel implant can reduce rates of symptomatic hardware requiring removal, which could ultimately make them more cost- effective than suture-button fixation.

Effect of CT on Management Plan in Malleolar Ankle Fractures

2017 ◽  
Vol 39 (1) ◽  
pp. 59-66 ◽  
Author(s):  
Ashwani Kumar ◽  
Puneet Mishra ◽  
Anupama Tandon ◽  
Rajesh Arora ◽  
Manish Chadha
Keyword(s):  
Ct Scan ◽  
Case Series ◽  
Management Plan ◽  
Ankle Fractures ◽  
X Rays ◽  
Level Of Evidence ◽  
Plain Radiographs ◽  
Posterior Malleolus ◽  
Trimalleolar Fractures ◽  
Type C

Background: Conventionally ankle fractures have been classified using plain radiographs. Because of complex 3-dimensional anatomy and complexity of injuries, plain radiographs may not always be able to clearly depict the complete fracture pattern. There is a paucity of studies regarding the utility of computed tomography (CT) scanning in malleolar ankle fractures (MAFs). Hence, we conducted this study to further understand the role of the CT scan in MAFs. Methods: A prospective study of 56 consecutive malleolar ankle fractures was conducted. In the first evaluation by a team of 3 observers, a management plan was made based on plain radiographs. All patients received a CT scan evaluation with a standard protocol. The second evaluation by the same team included formulating an operative plan based on the CT. Results: In 13 (23.2%) cases, the management plan changed after CT evaluation. In most of the cases, the change in the management plan included an alteration in fixation of the posterior malleolus followed by lateral malleolus in 4 cases. Most of the changes took place in AO 44 type C followed by types B and A. Maximum change was noted in trimalleolar fractures followed by bimalleolar and unimalleolar. The most common morphological characteristic fracture identified on CT scan that was not evident on plain radiography was Chaput fracture in 17 cases. Conclusion: CT scan evaluation of MAFs changed the management plan in a significant number of cases, especially if the fractured fragment included a posterior malleolus, AO type C, and/or if 2 or more malleoli were fractured as noted on plain x rays. Level of Evidence: Level IV, case series.

scholarly journals Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescence: management and outcome

2020 ◽  
Author(s):  
quanwen yuan ◽  
Zhixiong Guo ◽  
Xiaodong Wang ◽  
Jin Dai ◽  
Fuyong Zhang ◽  
...  
Keyword(s):  
Computerized Tomography ◽  
Articular Surface ◽  
High Energy ◽  
Fracture Pattern ◽  
Malleolar Fracture ◽  
Malleolar Fractures ◽  
Ankle Stability ◽  
Anatomic Reduction ◽  
The Mean ◽  
Tillaux Fracture

Abstract Background The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescence commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis and treatment of this complex fracture pattern. Methods The charts and radiographs of six patients were reviewed. The functional was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. Talar subluxation laterally with medial space widening in three, and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6–8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

scholarly journals Injury Mechanism Affects the Stability of Suture-Button Syndesmosis Fixation.

2020 ◽  
Author(s):  
Kuan-Hao Chen ◽  
Chih-Hwa Chen ◽  
Yu-Min Huang ◽  
Hsieh-Hsing Lee ◽  
Yang-Hwei Tsuang
Keyword(s):  
Injury Mechanism ◽  
Level Of Evidence ◽  
Suture Button ◽  
Clear Space ◽  
Anatomic Reduction ◽  
Injury Mechanisms ◽  
Syndesmosis Injury ◽  
Registration Number ◽  
The Stability

Abstract Background: Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure-syndesmosis injury, Weber-B and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation.Methods: We retrospectively reviewed 63 patients with ankle syndesmosis injury underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope were evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure-syndesmosis injury, Weber-B and Weber-C type fractures were performed. Results: Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 mm to 4.04 mm, the tibiofibular overlap was increased from 3.05 mm to 6.44 mm, and the medial clear space was reduced from 8.12 mm to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS: 3.82 to 4.45 mm, p < 0.01 and TFO: 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05). Conclusions: Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored.Trial registration: This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020.Level of evidence: III

scholarly journals Operative Treatment of Posterior Malleolar Fractures

2017 ◽  
Vol 11 (1) ◽  
pp. 732-742 ◽  
Author(s):  
Xiaojun Duan ◽  
Anish R. Kadakia
Keyword(s):  
Postoperative Complications ◽  
Internal Fixation ◽  
Operative Treatment ◽  
Screw Fixation ◽  
Surgical Approaches ◽  
Indirect Reduction ◽  
Percutaneous Screw Fixation ◽  
Malleolar Fractures ◽  
Posterior Malleolus ◽  
Direct Exposure

Fractures of the posterior malleolus can occur in conjunction with fibular and medial malleolar fractures or in isolation. The indications for fixation of the posterior malleolus remain controversial except for the fragment sizes. A number of different surgical approaches and techniques for internal fixation of posterior malleolar fractures have been reported. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation. These attributes help to minimize the occurrence of postoperative complications.

scholarly journals Concurrent ipsilateral Tillaux fracture and medial malleolar fracture in adolescents: management and outcome

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Quanwen Yuan ◽  
Zhixiong Guo ◽  
Xiaodong Wang ◽  
Jin Dai ◽  
Fuyong Zhang ◽  
...  
Keyword(s):  
Computerized Tomography ◽  
Articular Surface ◽  
High Energy ◽  
Fracture Pattern ◽  
Malleolar Fracture ◽  
Malleolar Fractures ◽  
Ankle Stability ◽  
Anatomic Reduction ◽  
The Mean ◽  
Tillaux Fracture

Abstract Background The concurrent ipsilateral Tillaux fracture with medial malleolar fracture in adolescents commonly suffer from high-energy injury, making treatment more difficult. The aim of this study was to discuss the mechanism on injury, diagnosis, and treatment of this complex fracture pattern. Methods The charts and radiographs of six patients were reviewed. The function was assessed by the American Orthopedic Foot and Ankle Society ankle-hindfoot scores. Results The mean age at operation was 12.8 years. The mean interval from injury to operation was 7.7 days. Five Tillaux fractures and all medial malleolar fractures were shown on AP plain radiographs. One Tillaux fracture and two cases with avulsion of posterolateral tibial aspect were confirmed in axial computerized tomography. There was talar subluxation laterally with medial space widening in three and syndesmotic disruption in one. There were five patients sustaining ipsilateral distal fibular fractures. All fractures, except nonunion in two medial malleolar fractures and in one Tillaux fracture, healed within 6–8 weeks. There was one case of osteoarthritis of ankle joint. The average AOFAS score was 88.7. Conclusions Computerized tomography is helpful in identifying the fracture pattern. Anatomic reduction and internal fixation of Tillaux and medial malleolar fracture was recommended to restore the articular surface congruity and ankle stability.

scholarly journals Weightbearing Radiographs and stability in SER II - IV Ankle Fractures

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0001
Author(s):  
Henrik Baecker ◽  
Timo Schmid ◽  
Fabian Krause ◽  
Harald Marcel Bonel ◽  
Marc Attinger
Keyword(s):  
Ankle Joint ◽  
Structural Integrity ◽  
Deltoid Ligament ◽  
Medial Malleolus ◽  
Malleolar Fractures ◽  
Ligament Rupture ◽  
Clear Space ◽  
Complete Rupture ◽  
Physiological Load ◽  
The Stability

Category: Ankle, Sports, Trauma, Radiography, Weber B Fracture Introduction/Purpose: SER lateral malleolar fractures are common. The assessment of the stability of the ankle fracture is crucial for decision making of treatment which is associated with the integrity of the deltoid ligament (SERII-III). Slight talar shift can lead to extensive decrease of tibio-talar contact area (Ramsey 1999). Several clinical tests have been proposed of which static weightbearing radiography is used to measure the lateral talar shift with the medial clear space to detect medial instability (SERIV). However, the correlation of a stable ankle joint under weightbearing load with the structural integrity of the deltoid ligament has not been shown yet which we want to investigate. Methods: 17 patients with lateral malleolar fractures were investigated who underwent an MRI and weightbearing radiography examination. In the MRI, the deep deltoid ligament was assessed as intact, partial und complete rupture. The medial clear space was measured - distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome (millimeter). Results: 7 patients suffered from deep deltoid ligament rupture (4 partial; 3 complete).The medial clear space in patients with intact deep deltoid ligament was 2.96+0.41 mm in mean, in partial rupture 2.8+0.38 mm, in complete rupture 3.43+0.23 mm. When counting the complete and partial ruptures together the mean was 3.07+0.45 mm and in partial ruptures plus the intact ones 2.91+0.40 mm. Conclusion: Our results show no significant correlation between the medial clear space and the integrity of the deep deltoid ligament (figure1). A negative weightbearing radiograph does not exclude deep deltoid ligament rupture. This fact might indicate the importance of the intrinsic stability provided by the osseous contour of the highly congruent ankle joint. In our opinion, malleolar fracture with deep deltoid ligament rupture (SERIV) can therefore be treated conservatively as long as ankle stability is provided under physiological load.

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