Effect of the Syndesmotic Screw on Ankle Motion

Foot & Ankle ◽  
1989 ◽  
Vol 10 (1) ◽  
pp. 17-24 ◽  
Author(s):  
Richard L. Needleman ◽  
David A. Skrade ◽  
James B. Stiehl
Keyword(s):  
Axial Load ◽  
Screw Fixation ◽  
External Rotation ◽  
Plantar Flexion ◽  
Biomechanical Testing ◽  
Testing System ◽  
Ankle Motion ◽  
Cortical Screw ◽  
Syndesmotic Screw ◽  
Talar Tilt

The purpose of this study was to determine the effect of syndesmotic screw fixation on ankle motion. Eight unpaired osteoligamentous cadaver ankles were tested. The study quantified ankle flexion, talar tilt, ankle drawer, and tibiotalar rotation for each specimen using an MTS biomechanical testing system. Each specimen was tested under a 15-kg and a 70-kg axial load. The testing was repeated after the placement of a syndesmotic screw, a 4.5-mm cortical screw, in accordance with AO technique. There was a statistically significant decrease ( P < .05) in tibiotalar external rotation. There was no statistical difference in ankle flexion. There was a significant decrease in the anterior and the posterior drawer tests with the foot in plantar flexion. These were the most significant results. Syndesmotic screw fixation is used for the internal fixation of certain unstable ankle fractures. Opinions differ as to whether the screw should be removed at 6 weeks (prior to weightbearing) or left in place indefinitely. It was concluded that the syndesmotic screw should be removed prior to the return to full activity. Leaving it in place will contribute to abnormal ankle motion; this may result in local discomfort and a possible fatigue fracture of the screw.

scholarly journals Talar Motion is Constrained by Tricortical Screw Fixation of the Syndesmosis: A Cadaveric Robotic Study

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0015
Author(s):  
Neel K. Patel ◽  
Thomas Rudolf Pfeiffer ◽  
Jan-Hendrik Naendrup ◽  
Conor Murphy ◽  
Jason Zlotnicki ◽  
...  
Keyword(s):  
Screw Fixation ◽  
External Rotation ◽  
Lateral Shift ◽  
Testing System ◽  
Ankle Sprains ◽  
Suture Button ◽  
Tibiofibular Ligament ◽  
Cortical Screw ◽  
Robotic Testing ◽  
Robotic Testing System

Objectives: High ankle sprains are a common injury that occur in up to 11% of ankle sprains. Injury to the structures of the syndesmosis, the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM), has been shown to be predictive of residual symptoms after ankle injury. When the syndesmosis is unstable, it is typically treated surgically with cortical screw fixation or suture button fixation. Studies have shown that a 1 mm lateral shift of the talus relative to the tibia significantly decreases the tibiotalar contact area by 42%. Thus, restoring the tibiotalar kinematics to those of the intact ankle with appropriate fixation is important to avoid accelerated tibiotalar arthritis. The objective of this study was to quantify tibiotalar joint motion after syndesmotic screw and suture button fixation compared to the intact ankle. Methods: Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system. The subtalar joint was fused and the tibia and calcaneus were rigidly fixed to a robotic manipulator, while fibular length was maintained and fibular motion was unconstrained. Talar motion with respect to the tibia was measured using the robotic testing system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied independently to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included talar medial-lateral (ML) translation, anterior-posterior (AP) translation, and internal/external rotation relative to the tibia in the following syndesmosis states: 1) intact, 2) AITFL transected, 3) AITFL, PITFL, and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, and 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis. Statistical significance was set at p < 0.05. Results: There were significant differences in ML translation of the talus relative to the tibia between the tricortical screw fixation and the intact ankle. These significant changes were only present during states with no loads applied. Tricotical screw fixation resulted in a significant decrease in medial translation of the talus compared to the intact ankle at 30° plantarflexion and increased lateral translation at 0° flexion (p < 0.05) (Figure 1). The talus moved 1.1 mm less medially at 30° plantarflexion and 0.4 mm more laterally at 0° flexion in the tricortical screw fixation state compared to the intact ankle. The total medial translation of the talus relative to the tibia during plantarflexion decreased from 1.1 mm to only 0.4 mm. No significant difference in AP translation or external rotation of the talus existed between the tricortical screw fixation and the intact ankle. No significant differences existed in translation or rotation of the talus between the suture button fixation and intact ankle at any ankle positions. Conclusion: Suture button fixation restored tibiotalar motion in all planes, with no significant differences compared to the intact ankle. Tricortical screw fixation significantly increased lateral shift of the talus in a neutral ankle position and constrained motion during plantarflexion compared to the intact ankle, which can lead to accelerated tibiotalar arthritis. Thus, physicians should consider hardware removal after tricortical screw fixation for syndesmotic repair to avoid post-traumatic arthritis. [Figure: see text]

scholarly journals Comparison of Syndesmotic Malreduction Rate following Trans-Syndesmotic Screw Fixation in SER versus PER Type Ankle Fracture: A Prospective Analytic Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0041
Author(s):  
Chamnanni Rungprai ◽  
Yantarat Sripanich
Keyword(s):  
Ankle Fracture ◽  
Screw Fixation ◽  
External Rotation ◽  
Syndesmotic Injury ◽  
Distal Fibula ◽  
Normal Side ◽  
Cortical Screw ◽  
Syndesmotic Screw ◽  
Prospective Comparative Study ◽  
Arthroscopic Examination

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic injury frequently presents in severe rotational ankle fracture and a trans-syndesmotic screws fixation is commonly used technique. Bases on previous literatures, syndesmotic malreduction rate can occur between 20- 70 percent following traditional trans-syndesmotic screw fixation in all type of ankle fracture. However, there is a little evidence regarding the malreduction rate in each type of ankle fractures. The purpose of this study is to demonstrate malreduction rate of syndesmosis using simultaneously bilateral post-operative CT measurement after trans-syndesmotic screw fixation between supination external rotation and pronation external rotation type ankle fracture. Methods: A prospective comparative study of patients who had acute ankle fracture with syndesmotic injury between January 2015 and December 2017 were enrolled. Lague-Hansen classification was used to classify all patient into 2 groups: SER and PER based on mechanism of injury. Syndesmotic injury was confirmed by ankle arthroscopic examination in all patients and they were treated with ORIF distal fibula using either 1/3 tubular plate or anatomical locking plate under direct visualization of syndesmosis. Syndesmosis was fixed by one or two of 3.5-mm cortical screw with three or four cortices. The accuracy of syndesmotic reduction was evaluated by simultaneously bilateral post-operative CT scan. Syndesmotic reduction was measured using anterior to posterior distance (AP) and medial to lateral distance (ML). A widening of distance between anterior tibia and fibula at 1-cm above the ankle joint more than 2 mm compared to uninjured sides considered a malreduction of syndesmosis. Results: There were 67 patients were enrolled in this study (SER=48 and PER=15). The syndesmotic injury was present 60% (48/70) in SER and 100% (15/15) in PER group respectively. The malreduction was significant higher in PER than SER (2.1% in SER vs 20% in PER). Operative time was 58.2 and 79.2 minutes in SER and PER. The tibiofibular clear space was 4.0mm versus 4.8mm in SER and PER. The AP distance was -0.33mm and -0.51mm and ML distance was 1.91 mm and 1.59mm for SER compared to normal side and 0.19 mm and -0.21 and ML distance was 2.59mm and 1.63mm for PER compared to normal side. There were significant improvements of functional outcomes (FAAM, SF-36, and VAS) but no significant different between the two groups. Conclusion: The incidence of concomitant syndesmotic injury and syndesmotic malreduction rate following trans-syndesmotic screw fixation was significantly higher in PER type compared SER type ankle fracture. The malposition of distal fibula was displaced anteriorly and laterally (undercompression) compared to uninjured side.

scholarly journals Effect of Deltoid Ligament Repair versus Syndesmosis Fixation on Ankle Joint Stability After Bimalleolar Equivalent Ankle Fracture

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0008 ◽  
Author(s):  
Pablo Mococain ◽  
Richard Glisson ◽  
Diana Lorena Bejarano-Pineda ◽  
James Nunley ◽  
Mark Easley
Keyword(s):  
Ankle Joint ◽  
Ankle Fracture ◽  
Axial Load ◽  
Screw Fixation ◽  
External Rotation ◽  
Lateral Malleolus ◽  
Deltoid Ligament ◽  
Joint Stability ◽  
Ligament Repair ◽  
Syndesmotic Screw

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.

scholarly journals Restoration of Tibiofibular Kinematics with a Tricortical Screw or Suture Button Fixation After Syndesmotic Ankle Injuries

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Conor Murphy ◽  
Thomas Pfeiffer ◽  
Jason Zlotnicki ◽  
Volker Musahl ◽  
Richard Debski ◽  
...  
Keyword(s):  
Screw Fixation ◽  
External Rotation ◽  
Tracking System ◽  
Optical Tracking ◽  
Ankle Injuries ◽  
Suture Button ◽  
Tibiofibular Ligament ◽  
Cortical Screw ◽  
Significant Difference ◽  
Posterior Translation

Category: Ankle, Sports, Trauma Introduction/Purpose: Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after ankle injury. In unstable injuries, the syndesmosis is treated operatively with cortical screw fixation or a suture button apparatus. Biomechanical analyses of suture button versus cortical screw fixation methods show contradicting results regarding suture button integrity and maintenance of fixation. The objective of this study is to quantify tibiofibular joint motion in syndesmotic screw and suture button fixation models compared to the intact ankle. Methods: Five fresh-frozen human cadaveric specimens (mean age 58 yrs.; range 38-73 yrs.) were tested using a 6-degree-of- freedom robotic testing system. The tibia and calcaneus were rigidly fixed to the robotic manipulator and the subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p<0.05). Results: Significant differences in fibular motion were only during the inversion moment. Fibular posterior translation was significantly higher with complete syndesmosis injury compared to the intact ankle at 0°, 15°, and 30° plantarflexion and the tricortical screw at 15° and 30°. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 15° and 30 plantarflexion and to the tricortical screw at 15°. ER was significantly increased with complete injury compared to the tricortical screw at 0° and 30° plantarflexion. The suture button demonstrated significantly greater ER at 0° plantarflexion and 10° dorsiflexion compared to the intact ankle. The only significant difference in ML translation exists between the tricortical screw and complete injury at 30° plantarflexion. Conclusion: The suture button did not restore physiologic motion of the syndesmosis. It only restored fibular ML translation. Significant differences in AP translation and ER persisted compared to the intact ankle. The tricortical screw restored fibular motion in all planes. No significant differences were observed compared to the intact ankle. These findings are consistent with previous studies. This study utilized a novel setup to measure unconstrained motion in a full length, intact fibula. Physicians should evaluate AP translation and ER as critical fibular motions when reconstructing the syndesmosis with suture button fixation.

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

2018 ◽  
Vol 39 (6) ◽  
pp. 746-750 ◽  
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.

scholarly journals Posterior Translation of the Fibula is a Critical Factor in the Stability of the Syndesmosis After Injury and Repair

2018 ◽  
Vol 6 (7_suppl4) ◽  
pp. 2325967118S0012
Author(s):  
Neel Patel ◽  
Thomas Rudolf Pfeiffer ◽  
Jan-Hendrik Naendrup ◽  
Conor Murphy ◽  
Jason Zlotnicki ◽  
...  
Keyword(s):  
Sagittal Plane ◽  
Screw Fixation ◽  
External Rotation ◽  
Tracking System ◽  
Optical Tracking ◽  
Ankle Injuries ◽  
Suture Button ◽  
Tibiofibular Ligament ◽  
Cortical Screw ◽  
Posterior Translation

Objectives: Anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after an ankle injury. Unstable syndesmotic injuries are typically treated surgically with cortical screw or suture button fixation. Previous studies have shown contradicting findings regarding the effects of partial syndesmotic injuries and different surgical fixation methods on tibiofibular kinematics. Thus, the objective of this study was to quantify tibiofibular joint motion with sequential disruption of the syndesmosis and with syndesmotic screw and suture button fixation compared to the intact ankle. Methods: Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system. The subtalar joint was fused and the tibia and calcaneus were rigidly fixed to a robotic manipulator, while complete fibular length was maintained and fibular motion was unconstrained. A 5 Nm external rotation moment and 5 Nm inversion moment were independently applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) AITFL, PITFL, and IOM transected (complete injury), 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p < 0.05). Results: All significant differences in fibular motion between ankle states occurred during the inversion moment. An isolated AITFL injury caused significant increases in fibular posterior translation at 15° and 30° plantarflexion compared to the intact ankle. A complete syndesmotic injury caused significant increases in fibular posterior translation in all 4 ankle positions and in fibular ER at 0° flexion and 15° plantarflexion compared to the intact ankle. No significant differences were detected in fibular motion between an isolated AITFL injury and complete injury at any ankle positions. No significant differences existed between the tricortical screw fixation and the intact ankle. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 0° flexion, 30° and 15° plantarflexion. (Figure 1) Conclusion: An isolated AITFL injury resulted in a significant increase in fibular posterior translation relative to the tibia, comparable to that a complete injury, especially in positions of plantarflexion. Current diagnostic protocols after injury focus on the evaluation of fibular ML translation. However, these findings show that it is important to also evaluate syndesmotic stability in the sagittal plane and at different ankle positions. Restoration of native tibiofibular kinematics is essential to prevent post-traumatic arthritis. Tricortical screw fixation was able to restore tibiofibular kinematics in all planes. However, suture button fixation was not able to restore tibiofibular AP translation, which suggests that physicians should critically evaluate fibular AP translation and individualize treatment of unstable ankle injuries when reconstructing the syndesmosis with suture button fixation. [Figure: see text]

Ankle Instability: In Vitro Kinematics in Response to Axial Load

1994 ◽  
Vol 15 (3) ◽  
pp. 134-140 ◽  
Author(s):  
Joseph R. Cass ◽  
Harry Settles
Keyword(s):  
Internal Rotation ◽  
Axial Load ◽  
Ankle Instability ◽  
External Rotation ◽  
Axial Rotation ◽  
Intact Specimen ◽  
Articular Surfaces ◽  
The Subject ◽  
Talar Tilt

This study was undertaken to elucidate the kinematics of hindfoot instability. An axial load was applied to the inverted hindfoot. Unlike prior studies, axial rotation was not constrained. Using computerized tomography, measurements were made on the axial views of external or internal rotation of the leg, talus, and calcaneus. On the coronal views, tilting of the talus at the ankle and subtalar joints was assessed. No tilting of the talus in the mortise occurred with isolated release of the anterior talofibular (ATF) or calcaneofibular (CF) ligament. In every specimen, talar tilt occurred only after both ligaments were released, averaging 20.6°. External rotation of the leg occurred with inversion averaging 11.1° in the intact specimen. The leg averaged a further external rotation of 4.9° after ATF release and 12.8° further than the intact inverted specimens when both ligaments (ATF-CF) had been released. In earlier reports on the subject, the articular surfaces were believed to be the main constraint against tilting of the talus. In those studies, either axial rotation was constrained while inversion was allowed, or vice versa. Based on the data reported here, the ATF and the CF work in tandem to prevent tilting of the talus, and the articular surfaces do not seem to prevent tilting of the talus in the mortise.

Sign in / Sign up

Export Citation Format

Share Document