Results of Syndesmotic Screw Fixation versus Posterior Malleolus Fixation in Syndesmotic Injury at Pronation External Rotation Stage IV Ankle Fracture with Posterior Malleolus Fracture: Postoperative One Year Follow-up

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.

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Comparison of below knee cast and elasticated support bandage treatment foe an isolated fracture of the lateral malleolus

Journal of Society of Surgeons of Nepal ◽

10.3126/jssn.v17i2.17142 ◽

2017 ◽

Vol 17 (2) ◽

pp. 12-17

Author(s):

Rajram Maharjan

Keyword(s):

Ankle Fracture ◽

External Rotation ◽

Lateral Malleolus ◽

Stage Ii ◽

Group A ◽

The Difference ◽

Group B ◽

Rotation Stage ◽

Supination External Rotation

Introduction: Ankle fractures are the most common type of fractures treated in orthopaedics with isolated malleolar fractures, accounting for two-thirds of fractures. The most common injury mechanism is supination external rotation, which accounts for the majority of all ankle fracture patterns. Supination external rotation stage II is the classic short oblique fracture of the distal fibula without a medial side injury, which responds well to non-operative treatment as it is a stable fracture. The purpose of this study is to compare efficacy of elasticated support bandage versus plaster cast in the patient with isolated lateral malleolus fracture (Lauge-Hansen supination- eversion external stage II.)Method: A prospective comparative study was carried out in the Department of Orthopaedics in Bir Hospital from February 2007 to January 2009. Patients with ankle fracture were initially treated by below knee posterior slab for seven days to allow the swelling to subside and on seventh day follow-up they were grouped in two groups. Group A were patients with below knee cast and Group B were elasticated support bandage. Both groups were followed-up in the 5th week for cast or elasticated bandage removal and were evaluated after a week, thereafter, every monthly for 3 months and finally at 6 month.Result: Of the 48 cases enrolled, the mean age of the patients was 38.85 years. The common mode of injury was fall from height followed by road traffic accident. The modified subjective ankle score of Olerud and Molander (1984) was found more in group B in comparison to group A in all follow ups. In initial three successive follow ups at 6 week, 12 week and at 3 month subjective score was found statistically significant (p> 0.05) however, it was not significant at 6 month follow up. The range of motion was significantly improved in group B in all follow ups but the difference between the two groups at 6 weeks and 10 weeks follow ups was statistically significant. Immobilized group required less analgesic but the difference was not significant statistically.Conclusion: Both below knee cast and elasticated support bandage treatment methods are safe, satisfactory and equally effective with a better early result in elasticated support bandage. Supination External Rotation stage II type fracture can be treated conservatively, if there is no medial tenderness.Journal of Society of Surgeons of NepalVol. 17, No. 2, 2014, Page: 7-11

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Therapeutic effects of internal fixation with support plates and cannulated screws via the posterolateral approach on supination external rotation stage IV ankle fracture

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.36.3.1671 ◽

2020 ◽

Vol 36 (3) ◽

Author(s):

Zhongbing Liu ◽

Genling Tang ◽

Shuguang Guo ◽

Bin Cai ◽

Qingsong Li

Keyword(s):

Ankle Fracture ◽

External Rotation ◽

Stage Iv ◽

Cannulated Screw ◽

Posterolateral Approach ◽

Therapeutic Effects ◽

Cannulated Screws ◽

Support Plate ◽

Rotation Stage ◽

Supination External Rotation

Objective: To evaluate the therapeutic effects of internal fixation with support plates and cannulated screws via the posterolateral approach on supination external rotation stage IV ankle fracture. Methods: Eighty-five patients with SER-IV°ankle fracture and large posterior malleolar fracture treated from June 2016 to June 2018 in our hospital, were randomly divided into a support plate group (n=47) and a cannulated screw group (n=38). The treatment outcomes were compared regarding surgical time, amount of bleeding, time of fracture healing, postoperative complications, as well as the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and excellent rate one year later. Results: The surgical time and intraoperative blood loss of cannulated screw group were significantly lower than those of support plate group (P<0.05). There were four cases of posterior lateral incision redness complicated with obvious bloody exudation in support plate group on the postoperative 2nd day. One case developed into superficial incision infection subsequently, and one case suffered from deep infection. After dressing and treatment with sensitive antibiotics, stitch removal was delayed, and primary healing was obtained. In cannulated screw group, there were two cases of posterior lateral incision redness complicated with obvious bloody exudation on the postoperative 3rd day, without skin incision infection. One case had cannulated screw loosening two months after surgery, and the posterior malleolar fracture block was slightly displaced. The incidence of surgical complications in support plate and cannulated screw groups were 8.51% and 7.89%, respectively (P>0.05). The AOFAS scores of cannulated screw ((81.71 ± 12.39) points) and support plate groups ((86.62 ± 10.12) points) were significantly different (P<0.05). Conclusion: For patients with posterior malleolar fracture or osteoporosis, fixation using support plate is recommended. Cannulated screw fixation is suitable for for patients with poor conditions of skin soft tissues or basic diseases such as diabetes intolerant to long surgery. doi: https://doi.org/10.12669/pjms.36.3.1671 How to cite this:Liu Z, Tang G, Guo S, Cai B, Li Q. Therapeutic effects of internal fixation with support plates and cannulated screws via the posterolateral approach on supination external rotation stage IV ankle fracture. Pak J Med Sci. 2020;36(3):---------. doi: https://doi.org/10.12669/pjms.36.3.1671 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00417 ◽

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.

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The Importance of the Deep Deltoid Ligament Repair in Treating Supination-External Rotation Stage IV Ankle Fracture: A Comparative Retrospective Cohort Study

BioMed Research International ◽

10.1155/2020/2043015 ◽

2020 ◽

Vol 2020 ◽

pp. 1-8

Author(s):

Hongfeng Chen ◽

Dongsong Yang ◽

Zhen Li ◽

Junke Niu ◽

Pengru Wang ◽

...

Keyword(s):

Functional Performance ◽

External Rotation ◽

Stage Iv ◽

Deltoid Ligament ◽

Ligament Repair ◽

Ligament Rupture ◽

Clear Space ◽

Rotation Stage ◽

Supination External Rotation

Background. The necessity of the deep deltoid ligament repair in the treatment of supination-external rotation (SER) ankle stage IV fracture with deltoid ligament rupture is highly debated. We conducted this retrospective research aimed at exploring the curative effect of the deep deltoid ligament repair in treating SER fracture. Methods. Sixty-three patients with closed SER stage IV fractures received open reduction and internal fixation (ORIF), using either deep deltoid ligament repair (the DDLR group, 31 patients) or nondeep deltoid ligament repair (the NDDLR group, 32 patients). The radiographic parameters examined include the talocrural angle (TA), fibular length (FL), tibiomedial malleolar angle (TMMA), medial clear space (MCS), and tibiofibular clear space (TFCS). The functional performance parameters examined in the study were visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scales, and range of motion of bilateral ankles (RMBA). Complications, including bone nonunion, infection, and fragment displacement, were also recorded and compared. Results. Similar basic characteristics were found in both cohorts. All patients completed follow-up ranging from 12 to 22 months (mean time: 12.41 ± 4.21 months). The DDLR group had significantly reduced VAS score ( p < 0.05 ), with markedly increased RMBA ( p < 0.05 ) compared to the NDDLR group. The two cohorts showed similar follow-up performance at 3 months ( p > 0.05 ), 6 months ( p > 0.05 ), and 12 months ( p > 0.05 ), in terms of parameters including TA, FL, TMMA, MCS, TCS, and AOFAS ankle-hindfoot scales. Conclusion. Although similar radiographic performances were achieved in both cohorts, the DDLR group displayed enhanced functional outcome postsurgery, indicating that DDLR may be a better potential for the treatment of SER stage IV fracture with deltoid ligament rupture.

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Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: A prospective and comparative study

Injury ◽

10.1016/j.injury.2016.04.014 ◽

2016 ◽

Vol 47 (7) ◽

pp. 1574-1580 ◽

Cited By ~ 14

Author(s):

Yu Zhan ◽

Xiaoyu Yan ◽

Ronggang Xia ◽

Tao Cheng ◽

Congfeng Luo

Keyword(s):

Comparative Study ◽

Ankle Fracture ◽

Screw Fixation ◽

External Rotation ◽

Tibiofibular Ligament ◽

Posterior Malleolus ◽

Anterior Inferior Tibiofibular Ligament ◽

Syndesmosis Screw

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Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Journal of Clinical Medicine ◽

10.3390/jcm11020331 ◽

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.

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Health Related Quality of Life in Patients with Supination-External Rotation Stage IV Ankle Fractures

Foot & Ankle International ◽

10.1177/107110070502601207 ◽

2005 ◽

Vol 26 (12) ◽

pp. 1038-1041 ◽

Cited By ~ 18

Author(s):

Ryan Finnan ◽

Luke Funk ◽

Michael S. Pinzur ◽

Steven Rabin ◽

Laurie Lomasney ◽

...

Keyword(s):

Quality Of Life ◽

External Rotation ◽

Stage Iv ◽

Ankle Fractures ◽

Health Related Quality ◽

Related Quality ◽

Health Related ◽

Rotation Stage ◽

Supination External Rotation

Background: While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures. Methods: Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis. Results: There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had “good,” and seven had “fair” reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with “good” operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a “fair” operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population. Conclusions: The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with “fair” radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

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