Advertisement

Arthroscopy-Assisted Syndesmotic Reduction in Ankle Fractures

  • Gaston Slullitel
  • Daniel Slullitel
  • Valeria Lopez
Chapter

Abstract

It is estimated that 10% of all ankle fractures and 20% of operatively treated ankle fractures are accompanied by a syndesmotic injury. The syndesmotic ligaments virtually prevent the lateral translation of the fibula. Syndesmotic instability represents a challenging problem. Complete disruption of the syndesmosis is generally evident on radiographs; however, studies have shown the inaccuracy of attempting to diagnose incomplete syndesmotic injuries using traditional radiographic measures. In this context, arthroscopic evaluation of distal tibiofibular joint stability is of considerable value in syndesmosis injury diagnosis. Despite the abundance of ankle fracture treatment literature, the need for distal tibiofibular syndesmotic fixation after ankle fracture remains controversial. Ankle arthroscopy provides a means of achieving complete intra-articular visualization and management of potential pathologic findings. The advantage of this technique is that it enables the assessment of different planes of instability and assists with anatomic syndesmosis reduction. The use of arthroscopic assistance in ankle fracture reduction is not routine for most surgeons, and there is insufficient evidence from which to derive specific indications. This technique has the advantages of assessing syndesmosis instability severity, checking fracture reduction quality, and enabling a thorough assessment of associated injuries.

References

  1. Beumer A, Heijboer R, Fontijne W, Swierstra B (2000) Technical note. Late reconstruction of the anterior distal tibiofibular syndesmosis. Acta Orthop Scand 71:519–521CrossRefGoogle Scholar
  2. Beumer A, van Hemert WL, Niesing R et al (2004) Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res 423:227–234CrossRefGoogle Scholar
  3. Beumer A, Valstar E, Garling E et al (2006) Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment. Acta Orthop 77:531–540CrossRefGoogle Scholar
  4. Boden SD, Labropoulos PA, McCowin P, Lestini WF, Hurwitz SR (1989) Mechanical considerations for the syndesmosis screw. A cadaver study. J Bone Joint Surg Am 71:1548–1555CrossRefGoogle Scholar
  5. Boytim MJ, Fischer DA, Neumann L (1991) Syndesmotic ankle sprains. Am J Sports Med 19:294–298CrossRefGoogle Scholar
  6. Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ (2004) Instability of the tibiofibular syndesmosis: have we been pulling in the wrong direction? Injury 35:814–818CrossRefGoogle Scholar
  7. Cesar de Cesar P, Avila EM, de Abreu MR (2011) Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int 32:1110–1114CrossRefGoogle Scholar
  8. Cotton FJ (1910) Fractures and joint dislocations. WB Saunders, Philadelphia, PA, p 549Google Scholar
  9. Court-Brown CM, McBirnie J, Wilson G (1998) Adult ankle fractures—an increasing problem? Acta Orthop Scand 69:43–47CrossRefGoogle Scholar
  10. DeGroot H, Al-Omari AA, El Ghazaly SA (2011) Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int 32:250–256CrossRefGoogle Scholar
  11. Ebraheim NA, Elgafy H, Padanilam T (2003) Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res 409:260–267CrossRefGoogle Scholar
  12. Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA (1997) Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int 18:693–698CrossRefGoogle Scholar
  13. Ebraheim NA, Taser F, Shafiq Q, Yeasting RA (2006) Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surg Radiol Anat 28:142–149CrossRefGoogle Scholar
  14. Ebramzadeh E, Knutsen AR, Sangiorgio SN, Brambila M, Harris TG (2013) Biomechanical comparison of syndesmotic injury fixation methods using a cadaveric model. Foot Ankle Int 34:1710–1717CrossRefGoogle Scholar
  15. Edwards GS Jr, DeLee JC (1984) Ankle diastasis without fracture. Foot Ankle 4:305–312CrossRefGoogle Scholar
  16. Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ (2010) Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma 24:7–11CrossRefGoogle Scholar
  17. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG (2006) Malreduction ofthe tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27:788–792CrossRefGoogle Scholar
  18. Glazebrook MA, Ganaphaty V, Bridge MA, Stone JW, Allard JP (2009) Evidence-based indications for ankle arthroscopy. Arthroscopy 25:1478–1490CrossRefGoogle Scholar
  19. Han S, Lee J, Kim S, Suh J, Choi Y (2007) Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 28:336–342CrossRefGoogle Scholar
  20. Heim D, Schmidlin V, Ziviello O (2002) Do type B malleolar fractures need a positioning screw? Injury 33:729–734CrossRefGoogle Scholar
  21. Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH (1990) Syndesmosis sprains of the ankle. Foot Ankle 10:325–330CrossRefGoogle Scholar
  22. Hsu AR, Gross CE, Lee S (2013) Intraoperative O-arm computed tomography evaluation of syndesmotic reduction: case report. Foot Ankle Int 34:753–759CrossRefGoogle Scholar
  23. Hunt KJ, George E, Harris AH, Dragoo JL (2013) Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data 2004-2005 to 2008-2009. Clin J Sport Med 23:278–282CrossRefGoogle Scholar
  24. Joy G, Patzakis MJ, Harvey JP Jr (1974) Precise evaluation of the reduction of severe ankle fractures. J Bone Joint Surg Am 56:979–993CrossRefGoogle Scholar
  25. Lauge-Hansen N (1950) Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60:957–985CrossRefGoogle Scholar
  26. Lui T, Ip K, Chow H (2005) Comparison of radiologic and arthroscopic diagnosis of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy 21:1370–1374PubMedGoogle Scholar
  27. Mcbryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P (1997) Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int 18:262–266CrossRefGoogle Scholar
  28. Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM (2013) Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma 27:100–106CrossRefGoogle Scholar
  29. Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG (2009) Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int 30:419–426CrossRefGoogle Scholar
  30. Miller RS, Weinhold PS, Dahners LE (1999) Comparison of tricortical screw fixation versus a modified suture construct for fixation of ankle syndesmosis injury: a biomechanical study. J Orthop Trauma 13:39–42CrossRefGoogle Scholar
  31. Miyamoto W, Takao M (2011) Management of chronic disruption of the distal tibiofibular syndesmosis. World J Orthop 2:1–6CrossRefGoogle Scholar
  32. Muratli HH, Bicimoglu A, Celebi L, Boyacigil S, Damgaci L, Tabak AY (2005) Magnetic resonance arthrographic evaluation of syndesmotic diastasis in ankle fractures. Arch Orthop Trauma Surg 125:222–227CrossRefGoogle Scholar
  33. Naqvi GA, Cunningham P, Lynch B, Galvin R, Awan N (2012a) Fixation of ankle syndesmotic injuries: comparison of TightRope Fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med 40:2828–2835CrossRefGoogle Scholar
  34. Naqvi GA, Shafqat A, Awan N (2012b) Tightrope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification. Injury 43:838–842CrossRefGoogle Scholar
  35. Nielson JH, Gardner MJ, Peterson MG et al (2005) Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res 436:216–221CrossRefGoogle Scholar
  36. Ogilvie-Harris DJ, Reed SC (1994) Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery. Arthroscopy 10:561–568CrossRefGoogle Scholar
  37. Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB (1983) Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am 65:667–677CrossRefGoogle Scholar
  38. Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL (2012) Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg Am 94:2256–2261CrossRefGoogle Scholar
  39. Pneumaticos S, Noble P, Chatziioannou S, Trevino S (2002) The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int 23:107–111CrossRefGoogle Scholar
  40. Riegels-Nielsen P, Christensen J, Greiff J (1983) The stability of the tibio-fibular syndesmosis following rigid internal fixation. Injury 14:357–360CrossRefGoogle Scholar
  41. Sagi HC, Shah AR, Sanders RW (2012) The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma 26:439–443CrossRefGoogle Scholar
  42. Sarkisian JS, Cody GW (1976) Closed treatment of ankle fractures: a new criterion for evaluation—a review of 250 cases. J Trauma 16:323–326CrossRefGoogle Scholar
  43. Sarrafian SK, Kelikian AS (2011) Syndesmology. In: Kelikain AS (ed) Sarrafian’s anatomy of the foot and ankle, 3rd edn. Lippincott, Williams & Wilkin, Philadelphia, PA, pp 163–222Google Scholar
  44. Schepers T (2011) To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg 131:879–883CrossRefGoogle Scholar
  45. Seitz WH Jr, Bachner EJ, Abram LJ et al (1991) Repair of the tibiofibular syndesmosis with a flexible implant. J Orthop Trauma 5:78–82CrossRefGoogle Scholar
  46. Sman AD, Hiller CE, Refshauge KM (2013) Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med 47:620–628CrossRefGoogle Scholar
  47. Snedden MH, Shea JP (2001) Diastasis with low distal fibula fractures: an anatomic rationale. Clin Orthop Relat Res 382:197–205CrossRefGoogle Scholar
  48. Sri-Ram K, Robinson AH (2005) Arthroscopic assessment of the syndesmosis following ankle fracture. Injury 36:675–678CrossRefGoogle Scholar
  49. Stoffel K, Wysocki D, Baddour E, Nicholls R, Yates P (2009) Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 91:2646–2652CrossRefGoogle Scholar
  50. Takao M, Ochi M, Naito K et al (2001) Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 17:836–843CrossRefGoogle Scholar
  51. Takao M, Ochi M, Oae K, Naito K, Uchio Y (2003) Diagnosis of a tear of the tibiofibular syndesmosis. The role of arthroscopy of the ankle. J Bone Joint Surg Br 85:324–329CrossRefGoogle Scholar
  52. Teitz CC, Harrington RM (1998) A biomechanical analysis of the squeeze test for sprains of the syndesmotic ligaments of the ankle. Foot Ankle Int 19:489–492CrossRefGoogle Scholar
  53. Thornes B, Shannon F, Guiney AM, Hession P, Masterson E (2005) Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clin Orthop Relat Res 431:207–212CrossRefGoogle Scholar
  54. Van den Bekerom MPJ, Lamme B, Hogervorst M, Bolhuis HW (2007) Which ankle fractures require syndesmotic stabilization? J Foot Ankle Surg 46:456–463CrossRefGoogle Scholar
  55. Van den Bekerom MP, Haverkamp D, Kerkhoffs GM, van Dijk CN (2010) Syndesmotic stabilization in pronation external rotation ankle fractures. Clin Orthop Relat Res 468:991–995CrossRefGoogle Scholar
  56. Vasarhelyi A, Lubitz J, Gierer P et al (2006) Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int 27:1115–1121CrossRefGoogle Scholar
  57. Watson BC, Lucas DE, Simpson GA, Berlet GC, Hyer CF (2015) Arthroscopic evaluation of syndesmotic instability in a cadaveric model. Foot Ankle Int 36:1362–1368CrossRefGoogle Scholar
  58. Weening B, Bhandari M (2005) Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 19:102–108CrossRefGoogle Scholar
  59. Wuest TK (1997) Injuries to the distal lower extremity syndesmosis. J Am Acad Orthop Surg 5:172–181CrossRefGoogle Scholar
  60. Zalavras C, Thordarson D (2007) Ankle syndesmotic injury. J Am Acad Orthop Surg 16:330–339CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Gaston Slullitel
    • 1
  • Daniel Slullitel
    • 1
  • Valeria Lopez
    • 1
  1. 1.J Slullitel Institute of OrthopaedicsRosarioArgentina

Personalised recommendations