Operative Treatment of Syndesmotic Disruptions Without Use of a Syndesmotic Screw: A Prospective Clinical Study

1994 ◽  
Vol 15 (8) ◽  
pp. 407-414 ◽  
Author(s):  
Ken Yamaguchi ◽  
Christopher H. Martin ◽  
Scott D. Boden ◽  
Panos A. Labropoulos
Keyword(s):  
External Rotation ◽  
Clinical Results ◽  
Cadaveric Study ◽  
Deltoid Ligament ◽  
Prospective Clinical Study ◽  
Fibular Fracture ◽  
Static View ◽  
Pronation External Rotation ◽  
Rotation Stress

A new protocol for the selected omission of transsyndesmotic fixation in Weber class C ankle fractures was prospectively evaluated in 21 consecutive patients. As proposed in a previous cadaveric study ( J. Bone Joint Surg., 71A:1548–1555, 1989), the protocol suggested that transsyndesmotic fixation was not required if (1) rigid bimalleolar fracture fixation was achieved or (2) lateral without medial fixation was obtained (i.e., with accompanying deltoid tears) if the fibular fracture was within 4.5 cm of the joint. According to this protocol, only 3 of 21 patients (14%) required transsyndesmotic fixation. Ten of the patients who did not receive transsyndesmotic fixation underwent pronation-external rotation stress radiographs in a fashion analogous to the previous cadaveric study. At 1- to 3-year follow-up, no stress (N = 10) or static view (N = 18) widening of the mortise or syndesmosis was seen in any patient, which supports (with the above guidelines) a limited, rather than routine, use of supplemental transsyndesmotic fixation. Clinical results from this prospective study seem to substantiate previously proposed biomechanical guidelines for the selected omission of transsyndesmotic fixation. Given these guidelines, transsyndesmotic fixation was unnecessary in many cases and the need can be determined before surgery by assessing the integrity of the deltoid ligament and level of the fibular fracture.

scholarly journals Ankle Joint Pressure in Supination-External Rotation Injuries: A Dynamic Biomechanic Cadaveric Study

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0030
Author(s):  
Fabian Krause ◽  
Ivan Zderic ◽  
Angela Seidel ◽  
Boyko Gueorguiev ◽  
Marc C. Attinger ◽  
...  
Keyword(s):  
Operative Treatment ◽  
Contact Area ◽  
Peak Pressure ◽  
External Rotation ◽  
Clinical Results ◽  
Deltoid Ligament ◽  
Type Ii ◽  
Type Iv ◽  
Joint Contact ◽  
Supination External Rotation

Category: Ankle; Basic Sciences/Biologics; Trauma Introduction/Purpose: In isolated lateral malleolar fractures of the supination-external rotation (SER) type and competent medial stabilizers (type II and III), non-operative treatment has yielded excellent outcome. With complete rupture of the deltoid ligament (SER type IV) fracture instability increases substantially. The rationale for operative treatment of SER type IV fractures is based upon good clinical results and previous biomechanical studies. A significant reduction of the ankle contact area that however is caused by an artificially forced lateralization of the talus in the ankle mortise has been demonstrated. Presumed resultant elevated joint contact stresses are thought to lead to ankle arthritis in the longterm. Methods: In 12 lower leg specimen SER type injuries were simulated by gradual bony and ligamentous destabilization of the ankle from lateral to medial according to the mechanism of injury as described by Lauge and Hansen. High-resolution pressure sensors placed in the ankle joint recorded tibio-talar pressure changes at physiologic weightbearing (700N) in three positions (plantigrade, 10° dorsiflexion and 20° plantarflexion). Results: With increasing instability changes of the ankle kinematics were seen in SER II and III fractures with the same trend also in SER IV lesions. In the plantigrade position, the medial clear space (MCS) increased significantly from an average of 2.5+-0.4mm (no fracture) to 3.9+-1.1mm (SER type IV fracture). However, the corresponding peak pressure increased only slightly from 2.6+- 0.5 mPa to 3.0+-1.4 mPa on average, and the contact area decreased slightly from 810+-42 mm2 to 735+-27mm2 on average representing a non-significant reduction of only 9% of the contact area (p=0.08) after the deep deltoid ligament was completely dissected.The comparison of the results in plantigrade and plantarflexed position revealed substantial differences for MCS, contact area and center of force. Conclusion: Under physiologic load SER type IV isolated lateral malleolar fracture with completely disrupted deep deltoid ligament led to a significant increase of the MCS, but neither to a significant decrease of the of the joint contact area nor significant increase of peak pressure. Clinical Relevance: The findings of this biomechanical study support the recently reported good clinical results of non-operative treatment of SER type II to IV fractures.

Varus External Rotation Stress Test for Radiographic Detection of Deep Deltoid Ligament Disruption With and Without Syndesmotic Disruption

2013 ◽  
Vol 34 (2) ◽  
pp. 251-260 ◽  
Author(s):  
John E. Femino ◽  
Tanawat Vaseenon ◽  
Phinit Phistkul ◽  
Yuki Tochigi ◽  
Donald D. Anderson ◽  
...  
Keyword(s):  
External Rotation ◽  
Stress Test ◽  
Deltoid Ligament ◽  
Ligament Disruption ◽  
Rotation Stress

Stabilization of Ankle Syndesmosis Injuries With a Syndesmosis Screw

Foot & Ankle ◽  
1989 ◽  
Vol 9 (6) ◽  
pp. 290-293 ◽  
Author(s):  
Robert A. Kaye
Keyword(s):  
Screw Fixation ◽  
External Rotation ◽  
Medical Center ◽  
Joint Line ◽  
Interosseous Membrane ◽  
Santa Clara Valley ◽  
Syndesmosis Screw ◽  
Fracture Motion ◽  
Pronation External Rotation

A retrospective review was made of 30 patients who had disruption of the ankle syndesmosis that was treated at Santa Clara Valley Medical Center with a transfixation screw. Follow-up ranged from 3 months to 3 years. There were 21 pronation external rotation injuries and 9 Maisonneuve fractures. Screw size ranged from 3.5 cortical to 6.5 cancellous Synthes screws. Most were placed transversely from 1.5 to 3.5 cm above the joint line. Intraoperative difficulties with screw placement occurred in 2 patients, resulting in one bent screw and one screw placed directly into the ankle joint. Most patients were mobilized prior to screw removal; lucent lines developed around the syndesmosis screw before it was removed in two-thirds of the patients. No screw broke prior to removal. In 6 patients, calcification of the interosseous membrane was seen and, in 4, this progressed to a distal tibiofibular synostosis. It was found that transfixation screws provided satisfactory stability of the syndesmosis to permit stable healing of the interosseous membrane and distal ligaments after ankle fracture. Motion between the tibia and fibula developed despite screw fixation, as shown by the lytic bony changes that occurred with time.

scholarly journals Minimum Two-Year Follow-Up of Cases with Recurrent Disc Herniation Treated with Microdiscectomy and Posterior Dynamic Transpedicular Stabilisation

2010 ◽  
Vol 4 (1) ◽  
pp. 120-125 ◽  
Author(s):  
Tuncay Kaner ◽  
Mehdi Sasani ◽  
Tunc Oktenoglu ◽  
Ahmet Levent Aydin ◽  
Ali Fahir Ozer
Keyword(s):  
Disc Herniation ◽  
Clinical Results ◽  
Prospective Clinical Study ◽  
Low Back ◽  
Failed Back Syndrome ◽  
Recurrent Disc Herniation ◽  
Rod System ◽  
Disc Herniations ◽  
Vas Scores

The objective of this article is to evaluate two-year clinical and radiological follow-up results for patients who were treated with microdiscectomy and posterior dynamic transpedicular stabilisation (PDTS) due to recurrent disc herniation. This article is a prospective clinical study. We conducted microdiscectomy and PDTS (using a cosmic dynamic screw-rod system) in 40 cases (23 males, 17 females) with a diagnosis of recurrent disc herniation. Mean age of included patients was 48.92 ± 12.18 years (range: 21-73 years). Patients were clinically and radiologically evaluated for follow-up for at least two years. Patients’ postoperative clinical results and radiological outcomes were evaluated during the 3rd, 12th, and 24th months after surgery. Forty patients who underwent microdiscectomy and PDTS were followed for a mean of 41 months (range: 24-63 months). Both the Oswestry and VAS scores showed significant improvements two years postoperatively in comparison to preoperative scores (p<0.01). There were no significant differences between any of the three measured radiological parameters (α, LL, IVS) after two years of follow-up (p > 0.05). New recurrent disc herniations were not observed during follow-up in any of the patients. We observed complications in two patients. Performing microdiscectomy and PDTS after recurrent disc herniation can decrease the risk of postoperative segmental instability. This approach reduces the frequency of failed back syndrome with low back pain and sciatica.

Pronation External Rotation Stress Test for calcaneofibular ligament insufficiency

2017 ◽  
Vol 23 ◽  
pp. 136
Author(s):  
S. Ozeki ◽  
Y. Tochigi ◽  
M. Ogawa ◽  
T. Yamazaki ◽  
Y. Masuda
Keyword(s):  
External Rotation ◽  
Stress Test ◽  
Calcaneofibular Ligament ◽  
Pronation External Rotation ◽  
Rotation Stress

scholarly journals Does Foot Position and Local of Measurement Influence on Ankle Medial Clear Space?

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000
Author(s):  
Tiago Baumfeld ◽  
Daniel Baumfeld ◽  
João Cangussú ◽  
Benjamim Macedo ◽  
Thiago Silva ◽  
...  
Keyword(s):  
Gold Standard ◽  
External Rotation ◽  
Plantar Flexion ◽  
Deltoid Ligament ◽  
Anatomical Site ◽  
Neutral Position ◽  
Foot And Ankle ◽  
Clear Space ◽  
Foot Position ◽  
Rotation Stress

Category: Ankle, Sports, Trauma Introduction/Purpose: The ankle Medial Clear Space (MCS) is frequently used in foot and ankle surgery for determining the competence of the deltoid ligament in Weber B ankle fractures. A widened MCS indicates deltoid ligament incompetence, requiring surgery to prevent lateral talar shift. Controversy still exists regarding Medial Clear Space (MCS) normal and abnormal values, and its possible variation in previously uncontrolled biases. Sex, height, foot position, and type of radiograph were all described as possible influencing factors. The objective of this study was to access how much different degrees of plantar flexion, all performed with and without stress, influence on MCS width. Methods: We submitted 30 volunteers to six different anteroposterior non-weight bearing digital radiographs of the ankle in the following positions: neutral, neutral with external rotation stress, physiologic plantar flexion (FPF), physiologic plantar flexion with external rotation stress, maximum plantar flexion (MPF) and maximum plantar flexion with external rotation stress. The medial clear space MCS oblique (MCSo) and perpendicular (MCSp) were measured in all images by an experienced foot and ankle surgeon. Results: The data analysis showed with statically significance that the position of the foot does influence in the value of both MCSp and MCSo (p<0,05), regardless of three exceptions. MCSo does not change statistically between FPF with stress and MPF with stress. On the other hand, MCSp did not change in two situations: between FPF and Neutral with stress and between MPF and FPF with stress. It is noteworthy that MCSo, on average, was 15% wider than MCSp in all positions tested. It is also noticeable that, from the neutral position, plantar flexing the ankle has a great impact on MCS than external rotation stress, increasing MCSp by 25% and 22% respectively. MCSo follows the same pattern, with 21% and 17% respectively. Conclusion: This study is unique on showing that many different ways of positioning the foot and making stress radiographs do result in completely different MCS values, and that these values differ depending on the anatomical site they are measured. All these data indicates that we need to establish a gold standard for measuring MCS, taking into account patient sex, height, local of measurement of MCS, position of the foot and type of radiograph (AP or Mortise). This study was not able to address all variables that influence directly on MCS and therefore did not intended to establish this new gold standard.

scholarly journals Value of Ultrasound for Stability Assessment of Isolated Lateral Malleolar Fractures Compared to Stress Radiography and Arthroscopy

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0003
Author(s):  
Young-Uk Park ◽  
Youngwook Seo ◽  
Hyuk Jegal ◽  
Kyung-Tai Lee
Keyword(s):  
Ankle Fracture ◽  
External Rotation ◽  
Ligament Injury ◽  
Deltoid Ligament ◽  
Stability Assessment ◽  
Stress Radiography ◽  
X Ray ◽  
Malleolar Fractures ◽  
The Stability ◽  
Rotation Stress

Category: Ankle, Trauma Introduction/Purpose: Isolated Lateral malleolus fracture, like any other fractures can be treated by operative or conservative treatment. Stability of ankle joint is the most important factor in deciding the type of treatment. Unstable ankle joints present superior clinical outcomes with surgical management. There are many methods to assess the stability of ankle joint such as plain x- ray films, stress radiographies and physical examination. Many studies have suggested the usage of ultrasound for diagnosis of ankle ligament injury. But, there are no reports about its use for stability assessment of isolated lateral malleolar ankle fracture. Therefore, the purpose of this study is to evaluate the value of ultrasound for stability assessment of isolated lateral malleolar fractures, compared to simple x-ray, stress radiography and arthroscopy. Methods: We have conducted a prospective study which included 13 consecutive patients who underwent arthroscopic exam and subsequent open reduction and internal fixation for isolated lateral malleolar ankle fracture. Before operation simple x-ray, external rotation stress radiographs were done. Stress ultrasound was performed to assess the anterior inferior tibiofibular ligament (AITFL) and medial deltoid ligament prior to operation. The arthroscopic findings were used as the reference standard. A standardized physical examination (tenderness and ecchymosis, external rotation stress test), simple radiography, stress radiography and ultrasound images were compared to assess the stability. Results: Deltoid ligament injury and or syndesmosis injury were verified arthroscopically in 12 cases with a clinical diagnosis (92.3%). There were 9 cases who showed unstable ankle fracture on the simple radiography. (69.2%). There were all cases who showed unstable ankle fracture on the external rotation stress radiography. (100%) In addition, for 12/13, there were acute tear of the deltoid ligament or AITFL injury on the ultrasound (92.3%). Conclusion: The results suggest that ultrasound could be used for the assessment of the instability of isolated lateral malleolar fracture.

scholarly journals One-step bone marrow-derived cell transplantation in talarosteochondral lesions: mid-term results

Joints ◽  
2013 ◽  
Vol 01 (03) ◽  
pp. 102-107 ◽  
Author(s):  
Roberto Buda ◽  
Francesca Vannini ◽  
Marco Cavallo ◽  
Matteo Baldassarri ◽  
Simone Natali ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Scale Score ◽  
Case Series ◽  
Clinical Results ◽  
Osteochondral Lesions ◽  
Prospective Clinical Study ◽  
One Step ◽  
Bone Marrow Derived Cells ◽  
The Mean

Purpose: to verify the capability of scaffold-supported bone marrow-derived cells to be used in the repair of osteochondral lesions of the talus. Methods: using a device to concentrate bone marrow-derived cells, a scaffold (collagen powder or hyaluronic acid membrane) for cell support and platelet gel, a one-step arthroscopic technique was developed for cartilage repair. In a prospective clinical study, we investigated the ability of this technique to repair talar osteochondral lesions in 64 patients. The mean follow-up was 53 months. Clinical results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. We also considered the influence of scaffold type, lesion area, previous surgery, and lesion depth. Results: the mean preoperative AOFAS scale score was 65.2 ± 13.9. The clinical results peaked at 24 months, before declining gradually to settle at a score of around 80 at the maximum follow-up of 72 months. Conclusions: the use of bone marrow-derived cells supported by scaffolds to repair osteochondral lesions of the talus resulted in significant clinical improvement, which was maintained over time. Level of Evidence: level IV, therapeutic case series.

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