Management of

syndesmotic injuries

Dr Yeap Ewe JuanMBBS (Mal), MS Ortho (Mal)

Fellowship in Foot & Ankle Surgery (USA & Spore)

Tuanku Fauziah Hospital

Head, Clinical Research Centre, Perlis

Honorary Lecturer ACMS, Unimap

Disclosure (ACCME)

Past 12 months

Speaker-MSD, Pfizer

Miscellaneous non-income support

Elli Lilly Elli Lilly

MSD

Pfizer

Rottapharm

Smith & Nephew

Stryker

Tuanku Fauziah Hospital, Kangar

Oldest structure

Normal Anatomy

The fibula is located in the incisural notch of the tibia

Strong anterior, posterior and interosseousligaments hold the fibulaligaments hold the fibula

Allows dynamic movement during gait

JBJS [Am]. 2001 Apr; 83:489-92

Normal Physiology

The fibula has a dynamic relationship with the

tibia

During gait, the fibula can move up to 3mm

and externally rotate up to 5 degrees.and externally rotate up to 5 degrees.

Acta Orthop Scand. 2003 Jun; 74:337-43

Introduction

Syndesmotic injuries

Most controversy

Usually occur with

Pronation-external rotation Pronation-external rotation

Pronation-abduction

Maisonneuve fracture

Some supination-external rotation stage 4

Post ankle sprain

COMPARE!

Signs

Tender over

syndesmosis

Compression test

External rotation test External rotation test

Lateral translation test

Severe ankle sprain

High index of suspicion!

ALWAYS COMPARE!

Maisonneauve fracture

Syndesmotic Injury

with Proximal Fibula

Fracture: A Mild

Variant of

Maisonneuve Injury

Most Maisonneuveinjuries often have concomitant medial malleolar fractures or deltoid ligament ruptures leading to obvious

Maisonneuve Injury

Khairul AH, Yeap EJ,

Yazid D

Poster presentation at

MOA/Asian IFFAS 2010

leading to obvious diastesis of the ankle joint. However the mild variants of Maisonneuveinjuries without medial injuries require a high index of suspicion.

AOFAS score 77/100

Diagnosis

Medial clear space < 4mm

Ankle joint space symmetrical medial & lateral ~ 2 mm

Talo-crural angle 83 4

Talar tilt < 4 Talar tilt < 4

Tibio-fibular clear space < 5 mm

Shentons line

In doubt, compare contra-lateral x-rays

CT both ankles

Diagnosis

Diagnosis

Diagnosis

Jenkinson et al reported in J Orthop Trauma vol19, No 9, Oct 2005

Intraoperative fluoroscopy detected unpredicted syndesmotic instability in 37% of ankles.

In supination-external rotation(OTA 44B) injuries, In supination-external rotation(OTA 44B) injuries, unpredicted syndesmosis instability was found in 10 of 30 patients(33%).

In pronation-external rotation injuries(OTA 44C) 4 of 7 patients(57%) were associated with syndesmosis disruption.

Intra op

Fully threaded 3.5mm cortical screw

2 cm above plafond

Angle 30

Ankle neutral position Ankle neutral position

Lagged screw after clamping

4 cortices

Medial side proud

Sometimes 2 screws

Intra op

Lateral traction on fibula

Check with image intensifier

May need to explore medial side

Pure syndesmotic injury

Ankle sprain

Arthroscopic debridement

Screw fixation

No I/I No I/I

Ankle arthroscopy

Post op

Remove after 6 weeks

minimum. Some leave

for 6 months

Weight bearing after 6

weeks

Paradoxically

Patients with a broken syndesmosis screw had

the best clinical outcome. Our data do not

support the removal of intact or broken

syndesmosis screws, and we caution against syndesmosis screws, and we caution against

attributing post-operative ankle pain to

breakage of the syndesmosis screw.

Hamid et al. Outcome after fixation of ankle fractures with an injury to the

syndesmosis. The effect of a syndesmosis screw. JBJS [Br] August 2009 91-B: 1069-

73

Should the syndesmosis screw be

removed?

Manjoo et al presented at OTA meeting 2007

Broken, loosened, or removed syndesmosis

screws resulted in a better functional outcome

compared to intact retained screws.compared to intact retained screws.

The syndesmosis allows fibular rotation,

shortening, and translation during gait; the

presence of an intact syndesmosis screw may

restrict this motion. There was no disadvantage

to leaving broken or loosened screws in situ.

Screw removal morbidity

Following removal of the syndesmotic screw six patients had superficial wound infection, four patients had pain due to instability, one patient had DVT and one patient had broken screw. The functional outcome using ankle scores compared functional outcome using ankle scores compared to the other studies in the literature did not show any significant difference.

S. Hakkalamani et al. Syndysmotic screw removal in Weber C ankle fractures. Injury Extra. 2007 Jan; 38:14

Ankle position during fixation

Maximal dorsiflexion of the ankle during syndesmoticfixation is not required in order to avoid loss of dorsiflexion. It is likely that the most important aspect of syndesmoticfixation is anatomic reduction of the syndesmosis and that the degree of ankle dorsiflexion during fixation is not important.important.

Tornetta et al. Overtightening of the Ankle Syndesmosis: Is it really possible? JBJS [Am]. 2001 Apr; 83:489-92

Sequelae

Clinically, 13 of 21 patients were without complaint at their last clinic visit. Five patients had only mild activity related pain, one had tenderness over a retained fibular plate, and only one had moderated constant pain.

Widening of the syndesmosis following routine removal of a syndesmotic screw is normal and for the most part clinically syndesmotic screw is normal and for the most part clinically insignificant. The higher the fibular fracture the more widening will occur.

Wahlquist et al. Late Diastatsis of the syndesmosis following syndesmosis screw removal. AAOS Podium presentation, San Diego, USA

New options

Tightrope, theoretically

faster rehab and no

need for removal

But some have to be

removed for infection,

etc

New options

Downside is cost

~ RM 1,700

Transosseous fixation of the syndesmosis: Comparison

of suture-endobutton to screw fixation in 50 cases

The cohort consisted of 50 patients; 25 in the screw fixation group and 25 in the interosseous wire with endobuttons group. The mean patient age was 34.68 (15 to 55) years in the interosseous suture endobutton group and 36.68 (17 to 74) years in the screw group, and the mean follow-up was 10.78 (range 6 to 12) months in the interosseous suture endobutton group, and 8.20 (range 4 to 24) months in the screw group. No statistically significant differences (P months in the screw group. No statistically significant differences (P .05) were noted in regard to age, follow-up duration, time to postoperative weight bearing, or subjective outcome scores between the fixation groups; although statistically significant improvements were noted in the subjective scores for each fixation group between the preoperative and postoperative measurements.

Cottom et al. Journal Foot Ankle Surgery 2009; 48:620-630

Late/Missed diagnosis

Tibio-fibular diastasis

Chronic instability of syndesmosis

Sequelae of inadequate closed or poorly

performed surgery

Usually:- Usually:-

Shortened fibular buttress

Widened mortise

Heterotrophic syndesmotic ossification

Options

Early recognition < 8 weeks Post ankle sprain X 6 weeks, still unable to weight bear.

AOFAS score 58/100

Weight bearing x-rays widened mortise

May need to explore deltoid

If fibula malrotated, osteotomy and derotation If fibula malrotated, osteotomy and derotation

Kelikian. Operative treatment of the foot and ankle. Appleton & Lange 1999

Options

Widened mortise with symptomatic instability

Peroneus longus tenodesis Dynamic 3 point fixation

Anterior tibio-fibular ligament

Interosseous tibio-fibular ligament

Posterior tibio-fibular ligament

Distal pedicled half of peroneus longus Distal pedicled half of peroneus longus

Grass & Zwipp. Peroneus Longus Tenodesis for Chronic Instability of the Distal Tibio-fibular Syndesmosis. Operat Orthop Traumatol 2003;15:208-25