Aims. The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. Methods. Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). Results. There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). Conclusion. ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709–1716

Aims. The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods. All patients included in the ‘ROutine vs on DEmand removal Of the syndesmotic screw’ (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results. The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion. This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation. Cite this article: Bone Jt Open 2023;4(12):957–963

Objective: 15 patients (male:female= 9:6, mean age 39,5 years) with ankle fractures treated with osteosynthesis including a syndesmotic screw were enrolled in this prospective study. Instability of the distal syndesmosis was proven intraoperatively and then a tricortical syndesmotic screw was placed. Patients were mobilized with an AirCast®e brace and cranes for six weeks, then the syndesmotic screw was removed and patients started full weight bearing. Follow-Up was 21.7 weeks mean after removal of the syndesmotic screw. Using the x-rays of the ankle after and the CT of both ankles before removal of the syndesmotic screw we evaluated the radiologic results: the syndesmotic interval in the fontal and axial cuts, the Espace claire de Chaput (total clear space, TCS) und the medial clear space (MCS). The functional results were evaluated by the scores of Phillips, Olerud/Molander and Weber. Results: The mean frontal interval difference was 0,3 mm und the mean axial interval difference was 0,5 mm, in one case Fall (6,7%) there was a axial interval difference of 2 mm and in one case the interval had been over corrected. There was no subluxation of the talus in any patient. In 3 patients (20%) the syndesmotic screw had been placed in a second operation, after there was suspection of syndesmotic insufficiency in the x-rays which had been verified by CT. After implantation of the screw the CT scan showed regular syndesmotic intervals. Average TCS was 5.3 (range 3.40 – 7,40), mean MCS was 2.2 (range 1.0 – 4.5). Average functional scores were: Phillips 118.53 (range 53 – 135), Olerud/Molander 93 (range 60 – 100) and Weber 2.33 (range 0 – 12). Conclusions: Only with CT, the correct placement of the syndesmotic screw can be verified, the syndesmotic interval in the axial cuts can be evaluated and the position of the fibula in the Incisura fibularis can be assesed, therefore CT should be postoperative standard after syndesmotic screw placment. If an ankle fracture has not been treated with a syndesmotic screw, postoperative CT of both ankles should be done in any radiological or clinical suspicion of syndesmotic insufficiency

Objective: 36 patients (male:female= 26:10, mean age 40.6 years) with ankle fractures treated with osteosynthesis including a syndesmotic screw were enrolled in this prospective study. Instability of the distal syndesmosis was proven intraoperatively and then a quadricortical syndesmotic screw was placed. Patients were mobilized with an AirCast. ®. ankle brace and cranes for six weeks, then the syndesmotic screw was removed and patients started full weight bearing. Using the x-rays of the ankle before and after and the CT of both ankles before removal of the syndesmotic screw we evaluated the radiologic results: the syndesmotic interval in the axial cuts, the Espace claire de Chaput (total clear space, TCS) und the medial clear space (MCS). Ventralization of the fibula as a measurement for the position of the fibula in the incisura was defined as the difference between the vertical reference lines of tibia and fibula in the CT. The functional results were evaluated by the scores of Phillips, Olerud/Molander and Weber. Results: The mean axial interval difference was 0.83 mm (range -2.6 – 4.5), in seven case (19.4%) the interval had been over corrected. There was one case of subluxation of the talus (2.8%). In 3 patients (8.3%) the syndesmotic screw had been corrected in a second operation after the first CT, in 2 cases (5.6%) the syndesmotic screw had been placed after there was suspection of syndesmotic insufficiency in the x-rays which had been verified by CT. Mean ventralization of the fibula was 2.3mm (range 0–6.4). Average TCS was 5.3 mm (range 3.0 – 8.8), mean MCS was 3.3 mm (range 1.0 – 8.2). The functional scores showed good to very good results in most patients. Conclusions: Only with CT, the correct placement of the syndesmotic screw can be verified, the syndesmotic interval in the axial cuts can be evaluated and the position of the fibula in the Incisura fibularis can be assesed, therefore CT should be postoperative standard after syndesmotic screw placement. If an ankle fracture has not been treated with a syndesmotic screw, postoperative CT of both ankles should be done in any radiological or clinical suspicion of syndesmotic insufficiency

Ankle fractures are one of the most common bony injuries presenting to the trauma surgeon. The more severe ones result in disruption of the tibiofibular syndesmosis and hence worse outcome. The outcome depends on accurate reduction of syndesmosis. The two main options in managing these injuries are syndesmotic screws or tightrope. The aim of this study is to compare the rate of complications between these two techniques and their radiographic results. Retrospective data from 62 patients between September 2009 and March 2011 who had fixation of syndesmosis was obtained from theatre logbooks. 46 patients had syndesmotic screws inserted while 16 had tightrope. The average age was comparable in both groups (51 years v/s 41). 25 of the 46 syndesmotic screws inserted were removed. No tightropes had to be removed for any reason. 2 patients with syndesmotic screws had wound complications while 1 patient which tightrope insertion had a persistent diastasis. There were no differences in radiological outcome between the two groups with regards to reduction of syndesmosis (measured by talofibular clear space minus medial clear space) (p-value 0.283). The difference between the talocrural angles was also of no significance (p-value 0.344). Our results indicate that tightropes achieve radiologically similar reduction of syndesmosis as screws without any significant difference in complications. The need for a second operation is significantly lower with tightrope fixation

Introduction. Ankle fractures represent approximately 10% of the fracture workload and are projected to increase due to ageing population. We present our 5 years outcome review post-surgical management of ankle fractures in a large UK Trauma unit. Methods. A total of 111 consecutive patients treated for an unstable ankle fracture were entered into a database and prospectively followed up. Baseline patient characteristics, complications, further intervention including additional surgery, functional status were recorded during five-year follow-up. Pre-injury and post-fixation functional outcome measures at 2-years were assessed using Olerud-Molander Ankle Scores (OMAS) and Lower Extremity Functional Scales (LEFS). A p value < 0.05 was considered significant. Results. The mean age was 46 with a male:female ratio of 1:1.1. The distribution of comorbidities was BMI >30 (25%), diabetes (5%), alcohol consumption >20U/week (15%) and smoking (26%). Higher BMI was predictive of worse post-op LEFS score (p = 0.02). Between pre-injury and post fixation functional scores at 2 years, there was a mean reduction of 26.8 (OMAS) and 20.5(LEFS). Using very strict radiological criteria, 31 (28%) had less than anatomical reduction of fracture fragments intra-operatively. This was, however, not predictive of patients' functional outcome in this cohort. Within 5-year period, 22 (20%) patients had removal of metalwork from their ankle, with majority 13 (59%) requiring syndesmotic screw removal. Further interventions included: joint injection (3), deltoid reconstruction (1), arthroscopic debridement (1), superficial sinus excision (2), and conversion to hindfoot nail due to failure of fixation (1). Reduction in OMAS was predictive of patients' ongoing symptoms (p=0.01). Conclusion. There is a significant reduction in functional outcome after ankle fracture fixation and patients should be counselled appropriately. Need for removal of metalwork is higher in patients who require syndesmosis stabilisation with screw(s)

Summary. Syndesmotic malreduction or failure to restore fibular length are the leading causes for early reoperation after ankle fracture surgery. Anatomic fracture reduction and congruent ankle mortise can be achieved in the majority of cases following revision surgery. Introduction. The goal of ankle fracture surgery is to restore anatomical congruity. However, anatomic reduction is not always achieved, and residual talar displacement and postoperative malreduction predispose a patient to post-traumatic arthritis and poor functional outcomes. The present study aimed to determine the most common surgical errors resulting in early reoperation following ankle fracture surgery. Patients & Methods. We performed a chart review to determine the most common types of malreductions that led to reoperation within the first week following ankle fracture surgery. From 2002 to 2011, we identified 5123 consecutive ankle fracture operations in 5071 patients. 79 patients (1.6%) were reoperated on due to malreduction (residual fracture displacement > 2mm) detected in postoperative radiographs. These patients were compared with an equal number of age- and sex-matched control patients. Surgical errors were classified according to the anatomical site of malreduction: fibula, medial malleolus, posterior malleolus, Chaput-Tillaux fragment, and syndesmosis. Problems related to syndesmotic reduction or fixation were further divided into four categories: malreduction of the fibula in the tibiofibular incisura due to malpositioning of a syndesmotic screw, persistent tibiofibular widening (TFCS > 6 mm), positioning of a syndesmotic screw posterior to the posterior margin of the tibia, and unnecessary use of a syndesmotic screw. Results. The mean patient age was 44 years (18 to 80), and 49% were women. There were no differences between the groups regarding diabetes, tobacco use, peripheral vascular disease, or alcohol abuse. The most common indication for reoperation was syndesmotic malreduction (47 of 79 patients; 59%). Other frequent indications for reoperation were fibular shortening and malreduction of the medial malleolus. We identified four main types of errors related to syndesmotic reduction or fixation, the most common being fibular malreduction in the tibiofibular incisura. The most commonly combined errors were malreductions of the fibula and syndesmosis, which occurred together in 16 of 79 patients (20%). Fracture-dislocation (p = 0.011), fracture type (p = 0.001), posterior malleolar fracture (p = 0.005), associated medial malleolar fracture (p = 0.001), duration of index surgery (p = 0.001), and associated medial malleolar fixation other than with two parallel screws (p = 0.045) were associated with reoperation. Correction of the malreduction was achieved in 84% of reoperated cases. Conclusion. Early reoperation after ankle fracture surgery was most commonly caused by errors related to syndesmotic reduction or failure to restore fibular length. In the majority of cases, postoperative malreduction was successfully corrected in the acute setting

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

Introduction: Rotational forces in ankle injuries can present as isolated lateral malleolus fracture with talar shift or ankle subluxation. It results in medial joint space [clear space] widening, and more than 4 mm is considered significant. The extent of medial soft tissue injury and exploration as a routine is always a debate. Aim: To see if medial clear space widening correlate with medial soft tissue injury. Also to evaluate the out come of these fracture fixation. Materials and Methods: Retrospective study on the management of isolated lateral malleolus fractures with significant medial clear space widening. N=40. Patient group A [25] under went only lateral side fixation and in group B [15] had additional medial side soft tissue exploration as a routine based on medial clear space widening. Fractures were Classified based on the Weber’s system. Pre-operative medial clear space measurement was done by 2 independent observer using PACS measurement tool. Intraoperative details for the method of fixation and the medial soft tissue were analysed. Most common method of fixation is Neutralisation plate for the lateral side. In Weber B type 1/3 rd of the cases had both plate on the lateral side and syndesmotic screw fixation. 2/3rd of them had only plate fixation. In Webers C type, only syndesmotic screw in n=3, Plate and screw n=4, only plate in n=9 cases. Radiological measurement of medial clear space average = 9.08mm, range= 5 –22 mm. Less than 50% of the patients only had medial clinical signs. 26.6% had soft tissue (periosteal injury) and only 6.6% had deltoid ligament injury Out come assessment criterias:. The failure of fixation or any on going medial symptoms in group A. – one case of failure of fixation. Final clinical assessment with ankle score (Olerud and Molander score.) at 6 months average (between 3–18 months). No significant difference in the score, on follow up. Conclusion:. Medial clear space does not correlate with any degree of medial soft tissue injury. Exploration is indicated if widening persist after lateral side fixation. Routine exploration of the medial side has no long term impact on the clinical outcome

Introduction. The distal part of the interosseous membrane (IM) may contribute to ankle joint stability and therefore partly explain the results of a study that reported no difference in outcome in patients with low Weber C fractures treated with or without a syndesmotic screw. The aim of the current study was to compare the strength of the IM to the interosseous ligament (IL). Method. Six paired cadaveric lower extremities were stripped, leaving only the IM and the IL intact. The tibia was fixed and a load was applied via a steel plate to the lateral surface of the fibula to displace it with respect to the tibia along the line of the fibers of the IM and IL. In group one the interosseous ligament was sectioned and the interosseous membrane was mechanically tested until failure. In group two, the interosseous membrane was sectioned and the interosseous ligament was tested. Results. The interosseous membrane was 30% stronger than the interosseous ligament (1040 ± 183 N versus 798 ± 322 N, respectively; mean ± SD). Conclusion. The current biomechanical study found that the IM was 30% stronger than the IL. The interosseous membrane has considerable strength and may play a role in ankle stability

Introduction: Mal-united ankle fractures are uncommon. When they occur they produce symptoms of pain, joint effusion, limitation of dorsiflexion and are likely to lead to ankle arthritis. In such cases it has been shown that, even many months after the original fixation, correction of the ankle alignment can improve the final outcome. Method: From May 2004 to April 2006, seven patients with a mal-united fibular fracture aged 25–62 years (average 44yrs, male: female ratio 5:2) were treated in the Foot and Ankle unit at the Royal Liverpool University Hospital. All the patients were referred with persistent pain. The range of time delay between injury and secondary surgical intervention was 3 to 16 months (average 6 months). All the patients were assessed using clinical examination, functional scoring using the AOFAS Ankle-Hindfoot score and plain radiographs. They were followed for an average of 11 months (range 6–24 months) after the surgery. Surgical procedure: The surgical procedure involves a transverse fibular osteotomy made just above the ankle joint and below the tibio-fibular syndesmosis. The osteotomy is then distracted and internally rotated to gain the fibular length and to correct talar tilt using an image intensifier. A tri-cortical iliac bone graft and a lateral fibular plate are applied to maintain the reduction. We do not use a syndesmotic screw. Results: We managed to regain the fibular length and reconstruct ankle mortise in all the cases. All patients showed radiological evidence of bony union on follow-up. The average time to bony union was 8 weeks. Talar shift was corrected in all patients and all had good hind foot alignment. Average AOFAS score was 82 (pain: 31.43 function: 40.57 and alignment: 10). Conclusion: We present our early experience with fibular osteotomy aiming to correct ankle joint mal-alignment following fibular fractures. We believe this is a technique with reproducible results in our short term follow-up. It shows satisfactory functional outcome improving pain and function especially in younger patients

Introduction and Aims: To assess the efficacy of fibular osteotomy on the rate of arthrodesis at the tibiofibular syndesmosis in patients with Total Ankle Replacement (TAR). Method: A prospective trial of fibular osteotomy was performed in 16 consecutive TAR (13F/3M), mean age 67 (41–82). All operations were performed by the same surgeon, as described by the inventor of the procedure, Dr. Frank Alvine, MD. After completion of the syndesmotic fusion, the fibula was exposed proximal to the proximal syndesmotic screw. An oblique osteotomy of the fibula was performed. Importantly, the angle of the cut was made such that the proximal fibula was trapped by the distal cut surface. The osteotomy was directed from medial distal to lateral proximal. All cases were followed until radiographic and clinical signs of healing were seen. Results: Union occurred in all cases, with a mean time to fusion of seven weeks, with six patients achieving union within five weeks. No patient developed pain at the osteotomy site. All osteotomies showed signs of radiographic healing and none of these were symptomatic. There were no neuromas related to this procedure, and no patient experienced sensory changes along the nerve distribution. One patient developed symptomatic prominence of the screw on the medial malleolus and was asypmtomatic after implant removal. Conclusion: The addition of a fibular osteotomy resulted in a 100% rate of syndesmosis fusion. We postulate that the osteotomy is successful because it removes the micromotion at the syndesmosis, which occurs with loading of the intact fibula. As the fibula only functions as a lateral strut in patients with an Agility total ankle, we felt that the osteotomy would cause minimal if any concerns. Our findings corroborate our hypothesis in that all the fusions were successful and none of the patients experienced secondary problems related to the osteotomy. We would recommend this technique as an adjunct to standard ankle replacement using the Agility system

Aims

Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.

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.

The December 2012 Foot & ankle Roundup³⁶⁰ looks at: correcting the overcorrected club foot; syndesmotic surgery; autograft for osteochondral defects; sesamoidectomy after fracture in athletes; complications in ankle replacement; the arthroscope as a treatment for ankle osteoarthritis; whether da Vinci was a modern foot surgeon; and a popliteal block in ankle fixation.

The October 2015 Foot & Ankle Roundup³⁶⁰ looks at: TightRope in Weber C fractures; A second look at the TightRope; Incisional VAC comes of age?; Platelet-derived growth factor and ankle fusions; Achilles tendon rehab in the longer term following surgery; Telemedicine for diabetic foot ulcer