Aim of study Setting an investigation and therapeutical algorythm in paediatric patients with a distal tibiofibular joint injury. Material: The authors present their clinical material collected during the period of last five years (from 1997 to 2001). 222 children with physeal injury of the distal tibia and/or fibula were treated in the Regional Paediatric Trauma Centre in Prague Krè. Methods: In all patients with an injury of the ankle joint, a plain X-ray scanning in two basic planes was performed. In any doubts oblique views or an X-ray scan of the ankle joint in a stress position were added. In some patients it was necessary to complete the investigation by CT scans. Results: Only 9 % of all 222 selected patients sustained the distal tibiofibular joint injury. In 85 % of them the skeletal injury was evident (the juvenile Tillaux fracture of Salter’s type 3 or 4). In the rest 15 % (three cases) there was no skeletal trauma visible on neither plain nor oblique X-ray scans but CT scan showed it. Conclusions: Injury to the distal tibiofibular joint is very rare in the growing skeleton. Most of our patients were of premature age. There is a danger of missing this rare but subsequently serious injury. That’s why we recommend the use of CT in all cases of ankle joint injury in children. Children with fractures (juvenile Tillaux fracture) displaced more than 2 mm should be operated on (closed reduction and internal fixation). In two girls we had to stabilise the distal tibiofibular joint due to severe ligamentous injury

The aim of this study was to investigate the effect of different loading scenarios and foot positions on the configuration of the distal tibiofibular joint (DTFJ). Fourteen paired human cadaveric lower legs were mounted in a loading frame. Computed tomography scans were obtained in unloaded state (75 N) and single-leg loaded stand (700 N) of each specimen in five foot positions: neutral, 15° external rotation, 15° internal rotation, 20° dorsiflexion, and 20° plantarflexion. An automated three-dimensional measurement protocol was used to assess clear space (diastasis), translational angle (rotation), and vertical offset (fibular shortening) in each foot position and loading condition. Foot positions had a significant effect on the configuration of DTFJ. Largest effects were related to clear space increase by 0.46 mm (SD 0.21 mm) in loaded dorsal flexion and translation angle of 2.36° (SD 1.03°) in loaded external rotation, both versus loaded neutral position. Loading had no effect on clear space and vertical offset in any position. Translation angle was significantly influenced under loading by −0.81° (SD 0.69°) in internal rotation only. Foot positioning noticeably influences the measurement when evaluating the configuration of DTFJ. The influence of the weightbearing seems to have no relevant effect on native ankles in neutral position

Purpose: The distal tibiofibular joint is implicated in ankle movement but has been the topic of less work than the talotibial joint. Its mobility within the talo-crural complex has not been described in detail as precisely as its static role. The purpose of this work was to develop a simple noninvasive method for characterising in vivo the mobility of the fibula at the ankle level between is positions in dorsal and plantar flexion. Material and methods: We used 32 computed tomo-graphic studies of the ankle in 16 healthy volunteers (men and women), one study in each position of ankle flexion. We identified one cross-sectional slice through the syndesmosis in each of the two positions. A medio-lateral reference line was drawn tangent to the posterior cortical of the tibial metaphysis. The displacement of the fibula in relation to the tibia when moving between the two positions of ankle flexion was calculated using a remarkable landmark on the tibia, the anterior rim of the posterior tibial incisure, and the polar co-ordinates of the ends of the anteroposterior axis of the fibula.The repeatability and reproducibility of this method were tested. Results: Repeatability was satisfactory for translation movements. Reproducibility was fair except for the reference line where it was good. When the ankle moved from dorsal flexion to plantar flexion, the fibula moved medially 1.25 mm (0.03–2.58 mm) (p< 0.0001) without correlation with the amplitude of the ankle flexion. Mean anterioposterior displacement was 0.46 mm (NS) with a wide range from −1.58 to +7.2 mm. It was correlated with lesser amplitude of ankle flexion. Discussion: This dynamic method confirms published data concerning active mediolateral tibiofibular approach during plantar flexion. The results point out the variability of the anteroposterior movement of the fibula, the influence of the amplitude and the flexion position of the ankle, and the possible antepulsion effect of fibular tendons. The three-dimensional movement of the ankle joint merits further study including its tibio-fibular and talofibular components in view of potential prosthetic repair of the ankle. Conclusion: Distal tibiofibular mobility is undeniable. We call for more work to achieve a better understanding of the lateral component of the talocrural complex

Introduction and Objective. Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries. This complex trauma pattern ruptures the syndesmotic ligaments and induces a three-dimensional deviation from the normal distal tibiofibular joint configuration. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without taking into account ligamentous stabilizers. Therefore, our aim is two-fold: (1) to construct an articulated statistical shape model of the normal ankle with inclusion of ligamentous morphometry and (2) to apply this model in the assessment of a clinical cohort of patients with syndesmotic ankle injuries. Materials and Methods. Three-dimensional models of the distal tibiofibular joint were analyzed in asymptomatic controls (N= 76; Mean age 63 +/− 19 years), patients with syndesmotic ankle injury (N = 13; Mean age 35 +/− 15 years), and their healthy contralateral equivalent (N = 13). Subsequently, the statistical shape model was generated after aligning all ankles based on the distal tibia. The position of the syndesmotic ligaments was predicted based on previously validated iterative shortest path calculation methodology. Evaluation of the model was described by means of accuracy, compactness and generalization. Canonical Correlation Analysis was performed to assess the influence of syndesmotic lesions on the distal tibiofibular joint congruency. Results. Our presented model contained an accuracy of 0.23 +/− 0.028 mm. Mean prediction accuracy of ligament insertions was 0.53 +/− 12 mm. A statistically significant difference in anterior syndesmotic distance was found between ankles with syndesmotic lesions and healthy controls (95% CI [0.32, 3.29], p = 0.017). There was a significant correlation between presence of syndesmotic injury and the morphological distal tibiofibular configuration (r = 0.873, p <0,001). Conclusions. In this study, we constructed a bony and ligamentous statistical model representing the distal tibiofibular joint Furthermore, the presented model was able to detect an elongation injury of the anterior inferior tibiofibular ligament after traumatic syndesmotic lesions in a clinical patient cohort

The quest for optimal treatment of acute distal tibiofibular syndesmotic disruptions is still in progress. Using suture-button repair devices is one of the dynamic stabilization options, however, they may not be always appropriate for stabilization of length-unstable syndesmotic injuries. Recently, a novel screw-suture repair system was developed to address such issues. The aim of this study was to investigate the performance of the novel screw-suture repair system in comparison to a suture-button stabilization of unstable syndesmotic injuries. Eight pairs of human cadaveric lower legs were CT scanned under 700 N single-leg axial loading in five foot positions – neutral, 15° external/internal rotation and 20° dorsi-/plantarflexion – in 3 different states: (1) pre-injured (intact); (2) injured, characterized by complete syndesmosis and deltoid ligaments cuts simulating pronation-eversion injury types III and IV as well as supination-eversion injury type IV according to Lauge-Hansen; (3) reconstructed, using a screw-suture (FIBULINK, Group 1) or a suture-button (TightRope, Group 2) implants for syndesmotic stabilization, placed 20 mm proximal to the tibia plafond. Following, all specimens were: (1) biomechanically tested over 5000 cycles under combined 1400 N axial and ±15° torsional loading; (2) rescanned. Clear space (diastasis), anterior tibiofibular distance, talar dome angle and fibular shortening were measured radiologically from CT scans. Anteroposterior (AP), axial, mediolateral and torsional movements at the distal tibiofibular joint level were evaluated biomechanically via motion tracking. In each group clear space increased significantly after injury (p ≤ 0.004) and became significantly smaller in reconstructed compared with both pre-injured and injured states (p ≤ 0.041). In addition, after reconstruction it was significantly smaller in Group 1 compared to Group 2 (p < 0.001). AP and axial movements were significantly smaller in Group 1 compared with Group 2 (p < 0.001). No further significant differences were identified/detected between the groups (p ≥ 0.113). Although both implant systems demonstrate ability for stabilization of unstable syndesmotic injuries, the screw-suture reconstruction provides better anteroposterior translation and axial stability of the tibiofibular joint and maintains it over time under dynamic loading. Therefore, it could be considered as a valid option for treatment of syndesmotic disruptions

The quest for optimal treatment of acute distal tibiofibular syndesmotic disruptions is still in full progress. Using suture-button repair devices is one of the dynamic stabilization options, however, they may not be always appropriate for stabilization of length-unstable syndesmotic injuries. Recently, a novel screw-suture repair system was developed to address such issues. The aim of this study was to investigate the performance of the novel screw-suture repair system in comparison to a suture-button stabilization of unstable syndesmotic injuries. Eight pairs of human cadaveric lower legs were CT scanned under 700 N single-leg axial loading in five foot positions – neutral, 15° external/internal rotation and 20° dorsi-/plantarflexion – in 3 different states: (1) pre-injured (intact); (2) injured, characterized by complete syndesmosis and deltoid ligaments cuts simulating pronation-eversion injury types III and IV, and supination-eversion injury type IV according to Lauge-Hansen; (3) reconstructed, using a screw-suture (FIBULINK, Group 1) or a suture-button (TightRope, Group 2) implants for syndesmotic stabilization, placed 20 mm proximal to the tibia plafond/joint surface. Following, all specimens were: (1) biomechanically tested over 5000 cycles under combined 1400 N axial and ±15° torsional loading; (2) rescanned. Clear space (diastasis), anterior tibiofibular distance, talar dome angle and fibular shortening were measured radiologically from CT scans. Anteroposterior, axial, mediolateral and torsional movements at the distal tibiofibular joint level were evaluated biomechanically via motion tracking. In each group clear space increased significantly after injury (p ≤ 0.004) and became significantly smaller in reconstructed compared with both pre-injured and injured states (p ≤ 0.041). In addition, after reconstruction it was significantly smaller in Group 1 compared to Group 2 (p < 0.001). Anteroposterior and axial movements were significantly smaller in Group 1 compared with Group 2 (p < 0.001). No further significant differences were detected between the groups (p ≥ 0.113). Conclusions. Although both implant systems demonstrate ability for stabilization of unstable syndesmotic injuries, the screw-suture reconstruction provides better anteroposterior translation and axial stability of the tibiofibular joint and maintains it over time under dynamic loading. Therefore, it could be considered as a valid option for treatment of syndesmotic disruptions

Background. Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws. Methods. Retrospective review of all patients undergoing primary ankle fixation between May 2008 and October 2009. Exclusions included revision procedures, or ankle fixation prior to the current fracture. Those undergoing Tightrope or diastasis screw fixation were studied for any complications or further procedures. Clinical records and XRAYs were reviewed, family practitioners of the patients were contacted and any consultations for ankle related problems noted. Results. 187 primary ankle fixation procedures were performed. 35 ankles required stabilisation of the distal tibiofibular joint. In 12, this was achieved using the Tightrope and in 23, syndesmotic screws were used. There was no difference in the adequacy of reduction in the two groups. Of those stabilised with a Tightrope, 6 were Maisonneuve injuries, 5 Weber C and 1 Weber B. 1 was lost to followup. Of the remaining 11, none had complications attributable to the method of fixation documented in hospital or family practitioner records. One had a small stitch abscess that settled on removal of the suture material. None underwent subsequent procedures. Of 23 stabilised with screws, 4 were Weber B, 14 Weber C, 4 Maisonneuve and 1 syndesmotic injury associated with an isolated posterior malleolus fracture. In this group of patients with primary ankle fixation involving a diastasis screw there was 1 deep infection requiring removal of metalwork, 1 superficial wound infection after syndesmotic screw removal and 1 wound breakdown after syndesmotic screw removal. A patient developed superficial peroneal nerve palsy at operation and 1 syndesmotic fixation failed and underwent revision surgery. This patient subsequently developed infection and had revision to a hindfoot nail. 19 patients underwent screw removal. The 23 patients underwent 45 procedures (mean 1.96 procedures per patient). Conclusion. In a consecutive series of 187 ankle procedures, 12 had the distal tibiofibular joint stabilised with a Tightrope with no noted complications attributable to the implant and no additional procedures. 23 patients underwent diastasis screw fixation with 19 screw removal procedures and 5 complications of various severity, 2 of which were attributable to screw removal. Tightrope fixation has provided stable fixation of the injured syndesmosis in our unit and we have not to date encountered complications previously described in the literature

The syndesmosis ligament complex stabilizes the distal tibiofibular joint, while allowing for the subtle fibular motion that is essential for ankle congruity. Flexible fixation with anatomic syndesmosis reduction results in substantial improvements in functional outcomes. New dynamic CT technology allows real-time imaging, as the ankle moves through a range of motion. The aim of this study was to determine if dynamic CT analysis is a feasible method for evaluating syndesmosis reduction and motion following static and flexible syndesmosis fixation. This is a subgroup analysis of a larger multicenter randomized clinical trial, in which patients with AO 44-C injuries were randomized to either Tightrope (one knotless Tightrope, Group T) or screw fixation (two 3.5-mm cortical screws, Group S). Surgical techniques and rehabilitation were standardized. Bilateral ankle CT scans were performed at one year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). Three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: anterior, midpoint, and posterior tibiofibular distances. T-tests compared Group T and Group S, and injured and uninjured ankles in each group. Fifteen patients (six Group T [three male], nine Group S [eight male]) were included. There was no difference for mean age (T = 42.8 ± 14.1 years, S = 37 ± 12.6, P = 0.4) or time between injury and CT scan (T = 13 ± 1.8 months, S = 13.2 ± 1.8, P = 0.8). Of note in Group S, seven of nine patients had at least one broken screw and one additional patient had screws removed by the time of their dynamic CT. There was no significant difference between treatment groups for tibiofibular distance measurements in maximal PF or DF. Group T showed no significant difference between the injured and uninjured side for tibiofibular measurements in maximal PF and DF, suggesting anatomic reduction. For Group S, however, there was a significantly larger distance for all three measurements at maximal PF compared to the uninjured ankle (all P < 0 .05). In all but one Group S patient, screws were broken or removed prior to their dynamic CT, allowing possible increased syndesmotic motion, similar to Group T. Despite this, dynamic CT analysis detected increased tibiofibular distance in Group S as ankles moved into maximal PF when compared with the uninjured ankle. Given the importance of anatomic syndesmosis reduction, dynamic ankle CT technology may provide valuable physiologic information warranting further investigation

High ankle sprains (HAS) cause subtle lesions in the syndesmotic ligaments of the distal tibiofibular joint (DTFJ). Current intrinsic anatomical parameters of the DTFJ are determined based on 2D imaging and uncertainty remains whether they differ in a HAS patients. The aim of this study is therefore two-fold: radiographic parameters will be determined in 3D and compared in a healthy vs sprained group. Ten patients with a mean age of 42,56 (SD = 15,38) that sustained a HAS and twenty-five control subjects with a mean age of 47,44 (SD = 6,55) were retrospectively included. The slices obtained from CT analysis were segmented to have a 3D reconstruction. The following DTFJ anatomical parameters were computed using CAD software: incisura width, incisura depth, incisura length, incisura angle, and incisura-tibia ratio. The mean incisura depth in the sprained group was 3,93mm (SD = 0,80) compared to 4,76 mm (SD = 1,09) in the control group, which showed a significant difference (P < 0.05). The mean incisura length in the group of patients with HAS was 30,81 mm (SD = 3,17) compared to 36,10mm (SD = 5,27) in the control group which showed a significant difference (P < 0.05). The other DTFJ anatomical parameters showed no significant difference. This study shows a significant difference in both incisura depth and incisura length between HAS patients and control subjects. These parameters could be used to identify potential anatomical intrinsic risk factors in sustaining a HAS

Traditional screw fixation of the syndesmosis can be prone to malreduction. Suture button fixation however, has recently shown potential in securing the fibula back into the incisura even with intentional malreduction. Yet, if there is sufficient motion to aid reduction, the question arises of whether or not this construct is stable enough to maintain reduction under loaded conditions. To date, there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress CT model. Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator frame that allows for the application of sustained torsional (5 Nm), axial (500 N) and combined torsional/axial (5Nm/500N) loads. Baseline CT scans of the intact ankle under unloaded and loaded conditions were obtaining. The syndesmosis and the deltoid ligament complex were then sectioned. The limbs were then randomised to receive a suture button construct tightened at 4 kg force (loose), 8 kg (standard), or 12 kg (maximal) of tension and CT scans under loaded and unloaded conditions were again obtained. Eight previously described measurements were taken from axial slices 10 mm above the tibiotalar joint to assess the joint morphology under the intact and repair states, and the three loading conditions: a measure of posterolateral translation (a, b), medial/lateral translation (c, g), a measure of anterior-posterior translation (f), a ratio of anterior-posterior translation (d/e), an angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula, and an angle (Angle 2) created between the medial surfaces of two malleoli. These measurements have all been previously described. Each measurement was taken at baseline and compared with the three loading scenarios. A repeated measures ANOVA with a Bonferroni correction for multiple comparisons was used to test for significance. Significant lateral (g, maximum 5.26 mm), posterior (f, maximum 6.42 mm), and external rotation (angle 2, maximum 11.71°) was noted with the 4 kg repair when compared to the intact, loaded state. Significant posterior translation was also seen with the both the 8 kg and 12 kg repairs, however the incidence and magnitude was less than with the 4 kg repair. Significant overcompression (g, 1.69 mm) was noted with the 12 kg repair. Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. If inserted too loosely, these constructs allow for supraphysiologic motion which may have negative implications on ligament healing. These constructs also demonstrate overcompression of the syndesmosis when inserted at maximal tension however the clinical effect of this remains to be determined

Introduction. Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation. Materials and Methods. A retrospective audit identified patients who were treated for syndesmosis injuries over a two year period. Theatre and clinic costs were obtained to compare the cost of syndesmosis fixation using diastasis screws with the estimated cost of primary syndesmosis fixation using a Tightrope suture. Results. 79 patients received diastasis screw fixation of syndesmosis injuries between January 2007 and January 2009. The mean number of follow up clinic appointments was 3.7 following initial surgery, and 2.2 following diastasis screw removal. Allowing for device, theatre time and clinic appointment costs, and an estimated average of 4 follow up appointments following Tightrope syndesmosis fixation, primary fixation with this device could a saving of 34 theatre slots, 68 outpatient clinic appointments, and £12,138 per year at our hospital. Discussion. Biomechanical studies have demonstrated a reduction in normal tibiotalar external rotation with the presence of a diastasis screw, and there are several published reports of complications when these screws are retained. The Tightrope suture provides reduction of the syndesmosis whilst allowing normal physiological movement at the distal tibiofibular joint and negates the need for a second operation to remove the implant. In addition there may be improvements in foot and ankle scores and a faster return to work when these devices are used compared with traditional screw fixation. Conclusion. In addition to the patient benefits, our audit suggests that there may be significant financial benefits associated with primary syndesmosis fixation with Tightrope sutures

Ankle sprains have been shown to be the most common sports related injury. Ankle sprain may be classified into low ankle sprain or high ankle sprain. Low ankle sprain is a result of lateral ligament disruption. It accounts for approximately 25% of all sports related injuries. The ankle lateral ligament complex consists of three important structures, namely the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL) and posterior talofibular ligament (PTFL). The ATFL is the weakest and most easily injured of these ligaments. It is often described as a thickening of the anterolateral ankle capsule. The ATFL sits in a vertical alignment when the ankle is plantarflexed and thus is the main stabiliser against an inversion stress. T he CFL is extracapsular and spans both the tibiotalar and talocalcaneal joints. The CFL is vertical when the ankle is dorsiflexed. An isolated injury to the CFL is uncommon. Early diagnosis, functional management and rehabilitation are the keys to preventing chronic ankle instability following a lateral ligament injury. Surgery does not play a major role in the management of acute ligament ruptures. Despite this up to 20% of patients will develop chronic instability and pain with activities of daily living and sport especially on uneven terrain. Anatomic reconstruction for this group of patients is associated with 90% good to excellent results. It is important that surgery is followed by functional rehabilitation. One of the aims of surgery in patients with recurrent instability is to prevent the development of ankle arthritis. It should be noted that the results of surgical reconstruction are less predictable in patients with greater than 10 year history of instability. Careful assessment of the patient with chronic instability is required to exclude other associated conditions such as cavovarus deformity or generalised ligamentous laxity as these conditions would need to be addressed in order to obtain a successful outcome. High ankle sprain is the result of injury to the syndesmotic ligaments. The distal tibiofibular joint is comprised of the tibia and fibula, which are connected by anterior inferior tibiofibular ligament, interosseous ligament and the posterior inferior tibiofibular ligament (superficial and deep components). The mechanism of injury is external rotation and hyperdorsiflexion. High index of suspicion is required as syndesmotic injuries can occur in association of low ankle sprains. The clinical tests used in diagnosing syndesmotic injuries (external rotation, squeeze, fibular translation and cotton) do not have a high predictive value. It is important to exclude a high fibular fracture. Plain radiographs are required. If the radiograph is normal then MRI scan is highly accurate in detecting the syndesmotic disruption. Functional rehabilitation is required in patients with stable injuries. Syndesmotic injuries are often associated with a prolonged recovery time. Accurate reduction and operative stabilisation is associated with the best functional outcome in patients with an unstable syndesmotic injury. Stabilisation has traditionally been with screw fixation. Suture button syndesmosis fixation is an alternative. Early short-term reviews show this alternate technique has improved patient outcomes and faster rehabilitation without the need for implant removal

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

The December 2014 Foot & Ankle Roundup360 looks at: Charcot feet, biomarkers and diabetes; weight bearing following Achilles tendon rupture; endobuttons and mal-reduced diastasis; evidence for stem cell therapies in osteochondral lesions of the talus; syndesmosis fixation in SER ankle fractures; and self-reporting for foot and ankle outcomes.

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

The April 2014 Foot & Ankle Roundup³⁶⁰ looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion.

Objectives

Overlap between the distal tibia and fibula has always been quoted to be positive. If the value is not positive then an injury to the syndesmosis is thought to exist. Our null hypothesis is that it is a normal variant in the adult population.