Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’ procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals.

We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy’s scale (0 to 7). The mean maximum force and the force–time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory.

Cite this article: Bone Joint J 2014;96-B:502–7.

Aims. The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures. Methods. We reviewed clinical records of a single surgical practice from its entire 2014 calendar year. In total, 71 patients (121 surgical feet) qualified for the study with a mean follow-up of 20.3 months (SD 6.2). We measured their metatarsus adductus angle with the Sgarlato’s method (SMAA), and the intermetatarsal angle (IMA) and metatarsophalangeal angle (MPA) with Hardy’s mid axial method. We also assessed their American Orthopaedic Foot & Ankle Society (AOFAS) clinical scale score, and photographic and pedobarographic images for clinical function results. Results. SMAA increased from preoperative 15.9° (SD 4.9°) to 17.2° (5.0°) (p < 0.001). IMA and MPA corrected from 14.6° (SD 3.3°) and 31.9° (SD 8.0°) to 7.2° (SD 2.2°) and 18.8° (SD 6.4°) (p < 0.001), respectively. AOFAS score improved from 66.8 (SD 12.0) to 96.1 (SD 8.0) points (p < 0.001). Overall, 98% (119/121) of feet with preoperative plantar calluses had them disappeared or noticeably subsided, and 93% (113/121) of feet demonstrated pedobarographic medialization of forefoot force in walking. We reported all complications. Conclusion. This study, for the first time, reported the previously unknown metatarsus adductus side-effect of the syndesmosis procedure. However, it did not compromise function restoration of the forefoot by evidence of our patients' plantar callus and pedobarographic findings. Level of Clinical Evidence: III. Cite this article: Bone Jt Open 2021;2(3):174–180

Aims. Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles. Methods. Three observers reviewed 213 bilateral lower limb CT scans of uninjured ankles. Multiple measurements were recorded on the axial CT 1 cm above the plafond: anterior syndesmotic distance; posterior syndesmotic distance; central syndesmotic distance; fibular rotation; and sagittal fibular translation. Previously studied malreduction standards were evaluated on bilateral CT, including differences in: anterior, central and posterior syndesmotic distance; mean syndesmotic distance; fibular rotation; sagittal translational distance; and syndesmotic area. Unilateral CT was used to compare the anterior to posterior syndesmotic distances. Results. A difference of anterior to posterior syndesmotic distance > 2 mm was observed in 89% of ankles (n = 190) on unilateral CT assessment. Using bilateral CT, we found that 35% (n = 75) of normal ankles would be considered malreduced by current malreduction parameters. In 50 patients (23%), only one parameter was anomalous, 18 patients (8%) had two positive parameters and seven patients (3%) had three. Difference in fibular rotation had the lowest false positive rate of all parameters at 6%, whereas posterior syndesmotic distance difference had the highest at 15%. Conclusion. In this study, 35% of native, uninjured syndesmoses (n = 75) would be classified as malreduced by current diagnostic standards on bilateral CT and 89% had an asymmetric incisura on unilateral CT (n = 190). Current radiological parameters are insufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis. Cite this article: Bone Joint J 2021;103-B(1):178–183

Aims. Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views. Patients and Methods. A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation. Results. The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation. Conclusion. We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348–352

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (. sd. 13.59) in the intact screw group, 92.40 (. sd. 12.69) in the broken screw group, and 85.80 (. sd. 11.33) in the removed screw group (p = 0.0466). There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. 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 attributing post-operative ankle pain to breakage of the syndesmosis screw

The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis

Introduction. In this cohort study, the TightRope® fixation technique has been compared with the traditional screw fixation for ankle syndesmosis injuries, with respect to the accuracy of the syndesmotic reduction and their clinical correlation. Patients and Methods. This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial CT scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. More than 2 mm widening of syndesmosis as compared to normal contra-lateral ankle was considered as significant malreduction. Clinical outcomes were measured using AOFAS and FADI Scores. Results. Forty-six out of 55 eligible patients attended for the study. Twenty three patients were in the tightRope group and 23 in the syndesmosis screw group. Mean follow-up was 2.5 (1.5–3.5) years. Average age was 41.6 years in tightrope group and 39.8 years in syndesmosis screw group. The mean width of normal syndesmosis was 4.01 + 0.89 mm. In tightRope group the mean width of syndesmosis was 4.37 + 1.12 mm (t-test, p = 0.30) as compared to 5.16 + 1.92 mm in screw group (t-test, p = 0.01). Five (21.7%) out of 23 ankles in screw group had syndesmotic mal reduction, while none of the tightRope group showed mal-reduction on CT scans (fisher's exact test, p = 0.04). There was no significant difference in mean post operative AOFAS score (89.56 and 86.52) and FADI score (82.42 and 81.22) between two groups. Conclusion. The results of this study indicate that tightRope provides more accurate method of syndesmosis stabilization as compared with screw fixation. Syndesmosis malreduction is the most important independent predictor of clinical outcomes; therefore care should be taken to reduce the syndesmosis accurately

In 52 patients we compared the accuracy of standard anteroposterior (AP) radiography, mortise radiography and MRI with arthroscopy of the ankle for the diagnosis of a tear of the tibiofibular syndesmosis. In comparison with arthroscopy, the sensitivity, specificity and accuracy were 44.1%, 100% and 63.5% for standard AP radiography and 58.3%, 100% and 71.2% for mortise radiography. For MRI they were 100%, 93.1% and 96.2% for a tear of the anterior inferior tibiofibular ligament and 100%, 100% and 100% for a tear of the posterior inferior tibiofibular ligament. Standard AP and mortise radiography did not always provide a correct diagnosis. MRI was useful although there were two-false positive cases. We suggest that arthroscopy of the ankle is indispensable for the accurate diagnosis of a tear of the tibiofibular syndesmosis

Classical AO teaching recommends that a syndesmosis screw should be inserted at 25 to 30 degree angle to the coronal plane of the ankle. In practice accurately judging the 25/30 degree angle can be difficult, and there are several reports based on post operative CT scans demonstrating that a significant minority of patients have poorly operatively reduced syndesmotic injuries. The CT scans of 200 normal ankles in one hundred individuals which had been performed as part a CT angiogram were retrospectively examined. The centroid of the fibula and tibia in the axial plane 15mm proximal to the talar dome was calculated. Since a force vector between the centroid of the fibula and the tibia in the axial plane should not displace the fibula relative to the tibia, a line connecting the two centroids was therefore postulated to be the ideal syndesmosis line, and also the optimum position in which to place a compression clamp after reducing the syndesmosis. Where this ideal line passed through the lateral border of the fibula, and through the medial malleolus was then noted. The ideal syndesmosis line was shown to pass through the fibula with in 2mm of the lateral cortical apex of the fibula, and the anterior half of the medial malleolus in 100% of the ankles studied. The results support the concept that in the operatively reduced syndesmosis, the anterior half of the medial malleolus can be used as a reliable guide for aiming the syndesmosis drill hole, provided that the fibular entry point is at or adjacent the lateral fibular apex. The corollary of these findings is that a screw inserted through a plate on the standard antero-lateral border of the fibula, or a plate in the anti-glide position posteriorly, cannot lie in the centroidal axis of the ankle

Aims. The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes. Methods. Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)). Results. All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side. Conclusion. This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68–75

Background: Injuries to ankle joint consist 12% of visits to emergency departments. In spite of the common occurrence of ankle sprain, syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. Methods: Among 100 patients with ankle sprain we evaluated the incidence of syndesmosis sprain by MRI of the ankle. Adults who had acute ankle sprain with no fracture and examined on the same day that injury had took place were being included in the survey. Results: Out of 100 patients with ankle injury, four had syndesmosis sprain. Three patients had partial tear of syndesmotic complex and one had complete tear. All injuries occurred in sports except one which had happened in an accident, and two of the patients were athletes. Anterior inferior tibiofibular ligament was the most common ruptured ligament. Conclusions: We reported a four-percent incidence of this injury. Our high rate of this injury emphasized on the fact that all suspicious cases should go under more accurate investigation not to miss this diagnosis

Aims

In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years.

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Introduction. Early clinical examination combined with MRI following a high ankle sprain allows accurate diagnosis of syndesmosis instability. However, patients often present late, and for chronic injuries clinical assessment is less reliable. Furthermore, in many centres MRI may be not be readily available. The aims of the current study were to define MRI characteristics associated with syndesmosis instability, and to determine whether MRI patterns differed according to time from injury. Methods. Retrospectively, patients with an unstable ligamentous syndesmosis injury requiring fixation were identified from the logbooks of two fellowship trained foot and ankle surgeons over a five-year period. After exclusion criteria (fibula fracture or absence of an MRI report by a consultant radiologist), 164 patients (mean age 30.7) were available. Associations between MRI characteristics and time to MRI were examined using Pearson's chi-square tests or Fisher's exact tests (significance set at p< 0.05). Results. Overall, 100% of scans detected a syndesmosis injury if performed acutely (within 6 weeks of injury), falling to 83% if performed after 12 weeks (p=0.001). In the acute group, 93.5% of patients had evidence of at least one of either PITFL injury (78.7%), posterior malleolus bone oedema (60.2%), or a posterior malleolus fracture (15.7%). In 20% of patients with a posterior malleolus bone bruise or fracture, the PITFL was reported as normal. The incidence of posterior malleolus bone bruising and fracture did not significantly differ according to time. Conclusion. For unstable ligamentous syndesmosis injuries, MRI becomes less sensitive over time. Importantly, posterior malleolus bone oedema or fracture may be the only evidence of a posterior injury. Failure to recognise instability may lead to inappropriate management of the patient, long term pain and arthritis. We therefore advocate early MRI as it becomes more difficult to ‘grade’ the injury if delayed

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT. This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF. Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position. Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers

Abstract. Objectives. The syndesmosis joint, located between the tibia and fibula, is critical to maintaining the stability and function of the ankle joint. Damage to the ligaments that support this joint can lead to ankle instability, chronic pain, and a range of other debilitating conditions. Understanding the kinematics of a healthy joint is critical to better quantify the effects of instability and pathology. However, measuring this movement is challenging due to the anatomical structure of the syndesmosis joint. Biplane Video Xray (BVX) combined with Magnetic Resonance Imaging (MRI) allows direct measurement of the bones but the accuracy of this technique is unknown. The primary objective is to quantify this accuracy for measuring tibia and fibula bone poses by comparing with a gold standard implanted bead method. Methods. Written informed consent was given by one participant who had five tantalum beads implanted into their distal tibia and three into their distal fibula from a previous study. Three-dimensional (3D) models of the tibia and fibula were segmented (Simpleware Scan IP, Synopsis) from an MRI scan (Magnetom 3T Prisma, Siemens). The beads were segmented from a previous CT and co-registered with the MRI bone models to calculate their positions. BVX (125 FPS, 1.25ms pulse width) was recorded whilst the participant performed level gait across a raised platform. The beads were tracked, and the bone position of the tibia and fibula were calculated at each frame (DSX Suite, C-Motion Inc.). The beads were digitally removed from the X-rays (MATLAB, MathWorks) allowing for blinded image-registration of the MRI models to the radiographs. The mean difference and standard deviation (STD) between bead-generated and image-registered bone poses were calculated for all degrees of freedom (DOF) for both bones. Results. The absolute mean tibia and fibula bone position differences (Table 1) between the bead and BVX poses were found to be less than 0.5 mm for both bones. The bone rotation differences were found to be less than 1° for all axes except for the fibula Z axis rotation which was found to be 1.46°. One study. 1. has reported the kinematics of the syndesmosis joint and reported maximum ranges of motion of 9.3°and translations of 3.3mm for the fibula. The results show that the accuracy of the methodology is sufficient to quantify these small movements. Conclusions. BVX combined with MRI can be used to accurately measure the syndesmosis joint. Future work will look at quantifying the accuracy of the talus to provide further understanding of normal ankle kinematics and to quantify the kinematics across a healthy population to act as a comparator for future patient studies. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Flexible fixation techniques combined with anatomic (open) syndesmosis reduction have demonstrated improved functional outcomes and rates of malreduction. Suture-button devices allow physiologic motion of the syndesmosis without need for implant removal, which may lower the risk of recurrent syndesmotic diastasis. There is limited longer-term assessment of the maintenance of reduction between static and flexible syndesmotic fixation using bilateral ankle CT evaluation. This is an a priori planned subgroup analysis of a multi-centre, randomized clinical trial comparing static syndesmosis fixation (two 3.5 mm screws) with flexible fixation (single knotless Tightrope) for patients with AO- OTA 44-C injuries. Patients who completed bilateral ankle CT scans at 3- and 12-month follow-up were included. The primary outcome measure was syndesmotic malreduction based on bilateral ankle CT scans, using the uninjured, contralateral ankle as a control. Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance were calculated to measure syndesmosis reduction. Secondary outcomes included re-operation, adverse events and functional outcomes including the EQ5D, Olerud-Molander Ankle Score (OM), Foot and Ankle Disability Index (FADI), and Work Productivity Activity Impairment Questionnaire (WPAI). Paired samples t-tests were used to compare injured to control ankles (R, v 3.5.1). 42 patients (24 Group S, 18 Group T) were included. ASD for Group T was 5.22mm (95%CI 4.69–5.77) at 3 months compared to 4.26mm (95%CI 3.82–4.71; p=0.007) in controls and 5.38mm (95%CI 4.72–6.04) at 12 months compared to 4.44mm (95%CI 3.73–5.16; p=0.048) in controls. ASD for Group S was 4.63mm (95%CI 4.17– 5.10) at 3 months compared to 4.67mm (95%CI 4.24–5.10; p=0.61) in controls, but significantly increased to 5.73mm (95%CI 4.81–6.66) at 12 months compared to 4.65mm (95%CI 4.15–5.15; p=0.04) in controls. MSD results were similar; Group T had a larger MSD than control ankles at 3 months (p=0.03) and 12 months (p=0.01), while the MSD in Group S was not different at 3 months (p=0.80) but increased at 12 months (p=<0.01). 88% (21/24) of Group S had broken or removed screws by 12 months. Unplanned re-operation was 15% in Group S and 4% in Group T (p=0.02), with an overall re-operation rate of 30% in Group S. There was no significant difference between treatment groups for EQ-5D, OM, FADI or WPAI at 3- or 12-month follow-up. Tightrope fixation resulted in greater diastasis of the ASD and MSD compared to contralateral, uninjured ankles at 3- and 12-months post-fixation. Group S initially had syndesmotic reduction similar to control ankles, but between 3- and 12-months post-fixation, there was significantly increased syndesmosis diastasis compared to controls. The majority of Group S (88%) had either broken screws or scheduled screw removal, which may explain the increased tibio-fibular diastasis seen at 12-months

Syndesmotic ankle injuries are present in one fourth of all ankle trauma and may lead to chronic syndesmotic instability as well as posttraumatic ankle osteoarthritis. The main challenge remains distinguishing them from other types of ankle trauma. Currently, the patient's injured and non-injured ankles are compared using plain radiographs to determine pathology. However, these try to quantify 3D displacement using 2D measurements techniques and it is unknown to what extent the 3D configuration of the normal ankle syndesmosis is symmetrical. We aimed to assess the 3D symmetry of the normal ankle syndesmosis between the right and left side in a non- and weightbearing CT. In this retrospective comparative cohort study, patients with a bilateral non-weightbearing CT (NWBCT; N=28; Mean age=44, SD=17.4) and weight-bearing CT (WBCT; N=33; Mean age=48 years; SD=16.3) were analyzed. Consecutive patients were included between January 2016 and December 2018 when having a bilateral non-weightbearing or weightbearing CT of the foot and ankle. Exclusion criteria were the presence of hindfoot pathology and age less than 18 years or greather than 75 years. CT images were segmented to obtain 3D models. Computer Aided Design (CAD) operations were used to fit the left ankle on top of the right ankle. The outermost point of the apex of the lateral malleolus (AML), anterior tubercle (ATF) and posterior tubercle (PTF) were computed. The difference in the coordinates attached to these anatomical landmarks of the left distal fibula in the ankle syndesmosis with respect to right were used to quantify symmetry. A Cartesian coordinate system was defined based on the tibia to obtain the direction of differences in all six degrees of freedom. Statistical analysis was performed using the Mann-Whitney U test to allow comparison between measurements from a NWBCT and WBCT. Reference values were determined for each 3D measurement in a NWBCT and WBCT based on their 2SD. The highest difference in translation could be detected in the anterior-posterior direction (Mean AP. NWBCT. = −0.01mm; 2SD=3.43/Mean AP. WBCT. =−0.1mm; 2SD=2.3) and amongst rotations in the external direction (Mean AP. NWBCT. =−0.3°; 2SD=6.7/Mean AP. WBCT. =-0,2°; 2SD=5.2). None of these differences were statistically significant in the normal ankle syndesmosis when obtained from a NWBCT compared to a WBCT (P>0.05). This study provides references values concerning the 3D symmetry of the normal ankle syndesmosis in weightbearing and non-weightbearing CT-scans. These novel data contribute relevantly to previous 2D radiographic quantifications. In clinical practice they will aid in distinguishing if a patient with a syndesmotic ankle lesion differs from normal variance in syndesmotic ankle symmetry

The incisura fibularis (IF) provides intrinsic stability to the ankle joint complex by interlocking the distal tibia and fibula. Despite a high frequency of ligamentous ankle injuries, scant attention has been given to the morphology of the IF morphology incisura fibularis in the onset and development of these lesions. Therefore, we systematically reviewed the relation between ligamentous ankle disorders and the morphometrics of the IF. A systematic literature search was conducted on following databases: PubMed, Embase and Web of Science. Search terms consisted of ‘ankle trauma’, ‘ankle injury’, ‘ankle sprain’, ‘ankle fracture’, ‘tibiofibular’, ‘fibular notch’, ‘fibular incisura’, ‘incisura fibularis’, ‘morphometric analysis’, ‘ankle syndesmosis’, ‘syndesmotic stability’. The evaluation instrument developed by Hawker et al. was used to assess the quality of the selected studies. This protocol was performed according to the PRISMA guidelines and is registered on PROSPERO (CRD42021282862). Nineteen studies were included and consisted of prospective cohort (n=1), retrospective comparative (n=10), and observational (n=8) study design. Comparative studies have found certain morphological characteristics in patients with ankle instability. Several studies (n=5) have correlated a shallow IF depth with a higher incidence of ankle injury. A significant difference has also been found concerning the incisura height and angle (n=3): a shorter incisura and more obtuse angle have been noted in patients with ankle sprains. The mean Hawker score was 28 out of 36 (range=24-31). A shallower IF is associated with ligamentous ankle lesions and might be due to a lower osseous resistance against tibiofibular displacement. However, these results should be interpreted in light of moderate methodological quality and should always be correlated with clinical findings. Further prospective studies are needed to further assess the relation between the incisura morphometrics and ligamentous disorders of the ankle joint. Keywords: ankle instability, ankle injury, incisura fibularis, fibular notch, tibiofibular morphometrics, ankle syndesmosis

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

Malreduction of the syndesmosis is a poor prognosticator following ankle fracture and has been documented in as many as 52% of patients following fracture fixation. The current standard for assessment of reduction of the syndesmosis is bilateral computed tomography (CT) scan of the ankle. Multiple radiographic parameters are utilized to define malreduction, however, there has been limited investigation into the accuracy of these measurements to differentiate malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles. Bilateral lower extremity CT scans including ankles were screened. Studies were excluded if the patient was skeletally immature, had pathology below the knee or if they had congenital neuromuscular syndromes. The resulting cohort consisted of 207 patients. The indication for bilateral CT scan was femoral acetabular impingement in 110 patients (53%), rotation assessment following arthroplasty in 32 patients (15%), rotation assessment following femoral fracture in 30 patients (14%), rotational assessment for patellar instability in 30 patients (14%) and five miscellaneous indications (2%). Fifty patients were reviewed by three observers independently and to determine inter-observer reliability. A single observer repeated the measurements within the same cohort four weeks later to evaluate intra-observer reliability. Three observers then measured the anterior syndesmotic distance, posterior syndesmotic distance, central syndesmotic distance, fibular rotation and sagittal fibular translation at 1cm from the distal tibial articular surface. Overall side to side variability between the left and right ankle were assessed. Previously studied malreduction standards were evaluated. These included: anterior to posterior syndesmotic distance > 2mm, central syndesmotic difference > 1.5mm, average syndesmotic distance > 2mm, fibular rotational difference > 10o and sagittal translational difference > 2mm. The inter- and intra-observer reliability was good to excellent for anterior, posterior and central syndesmotic distance, and fibular rotation measurements. Sagittal fibular translation had an ICC of 0.583, and thus was only of fair reliability. Side to side comparison revealed statistically significant difference in only anterior syndesmotic difference (p=0.038). A difference of anterior to posterior syndesmotic distance of greater than 2mm was observed in 43 patients (20.2%). Thirty eight patients (17.8%) had a central syndesmotic difference of greater than 1.5mm. A fibular rotational difference of greater than 10o was observed in 49 patients (23%). The average difference between the anterior and posterior syndesmosis was greater than 2mm in 17 patients (8.2%). Nine patients (4.2%) had sagittal translation of greater than 2mm. Eighty one patients (39%) demonstrated at least one parameter beyond previously set standards for malreduction. Only one parameters was anomalous in 54 patients (26%), 18 patients (8%) had two positive parameters, while eight patients (4%) had three. One patient was asymmetrical in all measured parameters. In this study there was no statistically significant asymmetry between ankles. However, 39% of native syndesmoses would be classified as malreduced on CT scan using previously studied malreduction limits. Current radiographic parameters are not sufficient to differentiate mild inherent anatomical asymmetry from malreduction of the syndesmosis

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Introduction. Injury to the syndesmosis is not always clearly demonstrated on radiographs and different tests have been described to assess for injury. In the presence of a significant injury to the syndesmosis, surgical fixation is often indicated and various fixation methods have been described. If the result of surgery is any mal-reduction of the fibula, this may result in ongoing ankle pain. Assessing how well the fibula has been reduced intra-operatively is currently limited to image intensifier views. We have previously developed a simple assessment, which has been shown to give accurate intra-operative demonstration of an injury to the syndesmosis. Our objective was to ascertain if the same test could demonstrate any malreduction of the fibular after repair of a syndesmosis injury. Methods. Seven fresh frozen cadavers had complete sydesmosis disruption performed before fixation using a well-recognised technique with a single 3.5 mm small fragment screw. Purposeful malreduction was performed in three ankles and standard reduction in the remaining four. 2–5mls of contrast medium was then injected into the ankle joint. Results. When there had been a malreduction, an obvious ‘blush’ of dye leaked superiorly into the surrounding soft tissues, whereas a normal ankle arthrogram was shown when the fibular had been anatomically reduced into the incisura and well fixed. Conclusion. This cadaveric study showed the test to be an easy and reliable adjuct to assess for acute malreduction of a syndesmosis injury

Aims. Involvement of the posterior malleolus in fractures of the ankle probably adversely affects the functional outcome and may be associated with the development of post-traumatic osteoarthritis. Anatomical reduction is a predictor of a successful outcome. The purpose of this study was to describe the technique and short-term outcome of patients with trimalleolar fractures, who were treated surgically using a posterolateral approach in our hospital between 2010 and 2014. Patients and Methods. The study involved 52 patients. Their mean age was 49 years (22 to 79). There were 41 (79%) AO 44B-type and 11 (21%) 44C-type fractures. The mean size of the posterior fragment was 27% (10% to 52%) of the tibiotalar joint surface. Results. Reduction was anatomical in all patients with a residual step in the articular surface of ≤ 1 mm. In nine of the C-type fractures (82%), the syndesmosis was stable after fixation of the posterior fragment and a syndesmosis screw was not required. Apart from one superficial wound infection, there were no wound healing problems. At a mean radiological follow-up of 34 weeks (seven to 131), one patient with a 44C-type fracture had widening of the syndesmosis which required further surgery. Conclusion. We conclude that the posterolateral surgical approach to the ankle gives adequate access to the posterior malleolus, allowing its anatomical reduction and stable fixation: it has few complications. Take home message: Fixation of the posterior malleolus in trimalleolar fractures can be easily done via the posterolateral approach whereby anatomical reduction and stable fixation can be reached due to adequate visualisation of the fracture. Cite this article: Bone Joint J 2016;98-B:812–17

Injury to the syndesmosis occurs in 10–13% of all operative ankle fractures and there is evidence that both incomplete treatment and malreduction of the syndesmosis can lead to poor clinical outcomes. Much attention has been given to post–operative malreduction documented by computer tomography (CT), however, there is limited data about the intact positioning and relative motion of the native syndesmosis. The aim of this study is to elucidate more detailed information on the position of the fibula in the syndesmosis during simulated weight–bearing in intact state, with sequential ligament sectioning and following two reconstructive techniques. Fourteen paired, fresh–frozen human cadaveric limbs were mounted in a weight–bearing simulation jig. CT scans were obtained under simulated foot–flat loading (75 N) and in single–legged stance (700 N), in five foot positions: neutral, 15° external rotation, 15° internal rotation, 20° dorsiflexion, and 20° plantarflexion. The elements of the syndesmosis and the deltoid ligament were sequentially sectioned. One limb of each pair was then reconstructed via one of two methods: Achilles autograft and peroneus longus ligamentoplasty. The specimens were rescanned in all 5 foot positions following each ligament resection and reconstruction. Measurements of fibular diastasis, rotation and anterior–posterior translation were performed on the axial cuts of the CT scans, 1 cm proximal to the roof of the plafond. Multiple measurements were made to define the position of the fibula in the incisura. Clinically relevant deformity patterns were produced. The deformity at the incisura was consistent with clinical injury, and the degree of displacement in all ligament states was dependent on the foot position. The most destructive state resulted in the most deformity at the syndesmosis. Differences between the intact and reconstructed states were found with all measurements, especially when the foot was in external rotation and dorsiflexion. There was no significant difference with direct comparison of the reconstructions. This study has detailed the motion of the fibula in the incisura and its variation with foot position. Neither reconstruction was clearly superior and both techniques had difficulty in the externally rotated and dorsiflexed foot positions. This study design can serve as a model for future ex–vivo testing of reconstructive techniques

This study investigated athletes presenting with grade II syndesmosis injuries and identified the clinical and radiological factors important in differentiating a stable from dynamically unstable injury and those findings associated with a longer recovery and return to sport. Sixty-four athletes were prospectively assessed with an average follow-up of 37 months (range 24–66 months). Athletes with an isolated distal syndesmosis (+/− medial deltoid ligament) injury were included. Those athletes with a concomitant ankle fracture were excluded. Those considered stable (grade IIa) were treated conservatively with a boot and progressive rehabilitation. Those with clinical signs of instability underwent arthroscopy and if instability was confirmed (grade IIb) the syndesmosis was stabilized surgically. The clinical assessment of injury to individual ligaments of the ankle and syndesmosis were recorded along with MRI findings, complications and time to return to play. All athletes returned to the same level of professional sport – 28 with IIa injuries returned at a mean of 45 days whereas the 36 with grade IIb injuries returned to play at a mean of 64 days (p< 0.001). Clinical assessment of injury to the ligaments of the syndesmosis correlated well with MRI findings. Those with a positive squeeze test were 9.5 times as likely and those with a deltoid injury 11 times more likely to have an unstable syndesmosis confirmed arthroscopically. The combination of injury to the AITFL and deltoid ligament was associated with a delay in return to sport. Concomitant injury to the ATFL indicated a different mechanism of injury with the syndesmosis less likely to be unstable and was associated with an earlier return to sport. Clinical and MRI findings may differentiate stable from dynamically unstable grade II injuries and identify which athletes may benefit from early arthroscopic assessment and stabilization. It also suggests the timeframe for expected return to play

Introduction. The treatment of posterior malleolar fractures is developing. Mason and Molloy (Foot Ankle Int. 2017 Nov;38(11):1229-1235) identified only 49% of posterior malleolar rotational pilon type fractures had syndesmotic instabilities. This was against general thinking that fixation of such a fragment would stabilize the syndesmosis. Methods. We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures on the posterior aspect of the ankle. To compare the size to the rotational pilon posterior malleolar fracture (Mason and Molloy 2A and B) we gathered information from our posterior malleolar fracture database. 3D CT imaging was analysed using our department PACS system. Results. The PITFL insertion on the posterior aspect of the tibia is very large. The average size of insertion was 54.9×47.1mm across the posterior aspect of the tibia. Medially the PITFL blends into the sheath of tibialis posterior and laterally into the peroneal tendon sheath. 78 posterior lateral and 35 posterior medial fragments were measured. On average, the lateral to medial size of the posteromalleolar fragment was 24.5mm in the posterolateral fragment, and 43mm if there is a posteromedial fragment present also. The average distal to proximal size of the posterolateral fragment was 24.5mm and 18.5mm for the posteromedial fragment. Conclusion. The PITFL insertion on the tibia is broad. In comparison to the average size of the posterior malleolar fragments, the PITFL insertion is significantly bigger. Therefore, for a posterior malleolar fracture to cause posterior syndesmotic instability, a ligamentous injury will also have to occur. This explains the finding by Mason and Molloy that only 49% of type 2 injuries had a syndesmotic injury on testing

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)

Aims. Tibial plateau fractures (TPFs) are complex injuries around the knee caused by high- or low-energy trauma. In the present study, we aimed to define the distribution and frequency of TPF lines using a 3D mapping technique and analyze the rationalization of divisions employed by frequently used classifications. Methods. In total, 759 adult patients with 766 affected knees were retrospectively reviewed. The TPF fragments on CT were multiplanar reconstructed, and virtually reduced to match a 3D model of the proximal tibia. 3D heat mapping was subsequently created by graphically superimposing all fracture lines onto a tibia template. Results. The cohort included 405 (53.4%) cases with left knee injuries, 347 (45.7%) cases with right knee injuries, and seven (0.9%) cases with bilateral injuries. On mapping, the hot zones of the fracture lines were mainly concentrated around the anterior cruciate ligament insertion, posterior cruciate ligament insertion, and the inner part of the lateral condyle that extended to the junctional zone between Gerdy’s tubercle and the tibial tubercle. Moreover, the cold zones were scattered in the posteromedial fragment, superior tibiofibular syndesmosis, Gerdy’s tubercle, and tibial tubercle. TPFs with different Orthopaedic Trauma Association/AO Foundation (OTA/AO) subtypes showed peculiar characteristics. Conclusion. TPFs occurred more frequently in the lateral and intermedial column than in the medial column. Fracture lines of tibial plateau occur frequently in the transition zone with marked changes in cortical thickness. According to 3D mapping, the four-column and nine-segment classification had a high degree of matching as compared to the frequently used classifications. Cite this article: Bone Joint Res 2020;9(6):258–267

Introduction:. Recent published studies have examined the normal dimensions of the syndesmosis on CT. However, previous anatomical studies have shown variations of the articulating facets within the tibialae fibularis and may contribute to the false appearance of increased spacing within the syndesmosis. In this study, we measured and compared anterior and posterior distances of the distal tibiofibular(DTF) syndesmosis on MRI and CT imaging. Methods:. We identified adult patients who had had both a CT scan and an MRI scan of their ipsilateral ankle to investigate symptoms unrelated to the DTF syndesmosis. The anterior and the posterior DTF dimensions were measured on CT and MRI axial images, at the level of the distal tibial physeal scar. This was taken from anterior tubercle of tibia and from the most anterior aspect of the posterior tibial tubercle to the nearest point of medial aspect of the fibula. The geometrical shapes of the syndesmosis and the anterior tibial tubercle were also recorded. Results:. 16 ankles in 15 patients were included. The mean age was 34.6+/−8.8 years. The mean (SD) for the anterior DTF distance was 2.0 mm (0.7 mm) on MRI and 2.9 mm (0.9 mm) on CT whilst the mean posterior DTF distance was 3.2 mm (1.1 mm) on MRI and 4.3 mm (1.0 mm) on CT. This difference reached statistical significance (p < 0.001, paired T-test). When examining the shape of the syndesmosis on MRI, 56% were crescent and 44% rectangular, this was compared to 69% and 31%, respectively, on CT. There was, however, no statistical difference in the shape of the syndesmosis between the two radiological modalities (p=0.625, McNemar test). Conclusion:. CT appears to over-estimate the distal tibiofibular separation and may lead to a false positive diagnosis. Further studies are needed to establish the reliability in the use of CT scans to investigate normal and abnormal syndesmosis

Approximately 20% of patients with ankle fracture sustain syndesmosis injury. This is most common in trans-syndesmotic (type B) and supra-syndesmotic (type C) fibula fractures. Intra-operative assessment of syndesmosis integrity is important because failure to treat these injuries can result in ankle instability and pain. Our aim was to audit the documentation of intra-operative testing of syndesmosis during ankle fracture open reduction and internal fixation (ORIF). All patients who had ankle fracture ORIF between 1/1/2010 and 21/11/2011 were included. Pre-operative radiographs were reviewed and fractures were classified according to AO classification. Operation notes were reviewed for documentation of assessment of syndesmosis integrity. 153 patients, of mean age 50 years (15–93) were included. 60% (n=92) were female. In 78% of cases (n=119), an assessment of syndesmosis integrity was documented in the operation note. Of the patients with no documented syndesmosis assessment (n=35), the majority had type B fractures (n=34). One patient had a type C fracture. We have shown that 22% of patients undergoing ankle ORIF for fracture do not have documented assessment of syndesmosis integrity. We suggest that all patients who have ankle ORIF should have intra-operative assessment and documentation of syndesmosis integrity so these injuries are identified and treated accordingly

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

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

Introduction. The assessment of the accuracy of reduction of the ankle syndesmosis has traditionally been made using plain radiographic measurements. Recent studies have shown that computerized tomography (CT) scan is more sensitive than radiographs in detecting diastasis. The ethos has now therefore shifted towards CT scan assessment of the syndesmosis. There is however no validated method to scan the syndesmosis and measure it on the CT scans. This exposes the patient to significant radiation risk and also to anxiety from inappropriate interpretation from these scans. The objectives of this research project are to investigate the current practice of CT scanning the syndesmosis at a University Hospital and to devise a new CT protocol to reduce radiation exposure to patients and to assist surgeons in interpreting the observations. Methods. Research Ethics Committee approval was obtained. Current practice was evaluated. A new 5 cut CT protocol was devised. Starting at the level of the distal tibial plafond, 5 cuts were made proximally 0.5 cm apart. Accuracy of the syndesmosis reduction was assessed just above the distal tibial plafond. Both the injured and the normal sides were scanned 12 weeks post surgery. The normal side served as a control. Results. Current practice revealed that patients had on an average 620 cuts CT scan with radiation exposure of 0.2 mSv. 25 patients were prospectively recruited for the new 5 cut CT protocol. The radiation exposure with the new protocol was only 0.002 mSv. Comparison with the normal side revealed that 5 (20%) of syndesmosis had residual diastasis. The only difficulty with the new protocol was getting both the ankle joint lines at the same level for the first CT cut. Discussion and Conclusion. Our CT scan protocol has insignificant radiation risk, even lower than a single chest radiograph. Comparing the measurements between the fractured and the normal sides provides an accurate assessment of the reduction of the syndesmosis. Significance of the measurements on the CT scan will be correlated with functional scores

We report on the first clinical cases of the Arthrex Ankle Syndesmosis TightRope (winner of 2003 BOA Technological Achievement Award and 2004 Cutlers' Prize), which has recently been licensed for use where classically a syndesmosis screw would be used. Twelve patients with Weber C ankle fractures treated with Arthrex TightRope syndesmosis fixation have a minimum of six months follow-up. The syndesmosis was fixed with the ankle in plantarflexion to aid reduction. Patient demographics, including fracture classification and mode of injury were obtained. Parameters measured at follow-up included ankle range of motion, maintenance of reduction and fibular length, and AOFAS ankle outcome score. The patient cohort showed a typical bimodal distribution of age. Age over 65 years was associated with a poorer outcome. Five patients had ankle fracture-dislocations, which was a factor for a poorer outcome. Nine patients had fibular plate fixation in addition to syndesmosis fixation, whilst three patients with Maisonneuve injuries had syndesmosis fixation only. There were no major complications, loss of reduction, wound problems, implant loosening or osteolysis. Ankle dorsiflexion was not restricted and mean total ankle range of motion was comparable to the uninjured side. No patient required secondary surgery for any reason, including hardware removal. Arthrex TightRope fixation is a simple, safe and effective method of ankle syndesmosis fixation, which allows physiological micromotion. Fixation in plantarflexion provides optimum syndesmosis compression for reduction, and does not compromise ankle range of motion. The Arthrex Ankle Syndesmosis TightRope may become the treatment of choice in Weber C ankle fractures

This study is designed to evaluate intra-operative stress testing on detection of syndesmosis injuries. We evaluated forty patients with ankle fractures requiring surgery. Their ankles were subjected to stress examinations after each stage of fixation. These were compared to the contralateral side. Biomechanical criteria were used to predict need for syndesmosis fixation. In 42% of the fractures, intra-operative fluoroscopy found an unpredicted syndesmosis injury. In 8% the syndesmosis was intact despite prediction. Medial malleolar fixation was not adequate for syndesmosis fixation as shown by stress testing. These findings may have implications for future diagnosis and treatment of syndesmosis injuries. This study is designed to evaluate the utility of intra-operative fluoroscopic stress testing in diagnosing tibio-fibular syndesmotic injuries. Forty skeletally mature patients with unilateral external rotation ankle fractures requiring open reduction and internal fixation were prospectively recruited. Intra-operatively the injured ankle was examined fluoroscopically using external rotation, valgus and anterior drawer stress tests, as well as static antero-posterior, mortise, and lateral ankle views. Stress testing was performed using a standardized force of 37.5 N. Stress testing was done after each stage of fixation (lateral, medial, and syndesmotic). The uninjured contralateral limb was examined as a control, and a 1 mm side to side difference was defined as a positive stress examination. Intra-operative fluoroscopy detected unpredicted syndesmotic injuries in 42 % of ankle injuries. In all cases, fixation of the medial malleolus did not restore syndesmotic stability. In 8 % of ankle injuries, a syndesmotic injury was predicted but stress testing revealed the syndesmosis intact. Intra-operative fluoroscopy is a more sensitive modality for detection of otherwise unpredicted syndesmotic injuries compared to criteria based upon static radiographs. Medial malleolar fixation did not add stability to syndesmotic injuries in this study. Injuries involving the distal tibio-fibular syndesmosis are difficult to detect. Previously, the decision to stabilize the syndesmosis in ankle fractures was based upon biomechanical criteria and static radiography. This and other recent studies challenge this, suggesting fluoroscopic stress testing is a better diagnostic method for these poorly tolerated injuries. Funding: Synthes Canada, Smith Nephew Richards Inc

Screw fixation of the injured syndesmosis restores stability, but may reduce ankle motion. We wished to determine whether functional and radiographic results are improved by removal of syndesmosis screws. In addition, we studied whether large fragment screws have an advantage compared to small fragment screws. We hypothesised that retained intact syndesmosis screws are detrimental to ankle function. One hundred and seven adults with ankle fractures requiring syndesmosis screw fixation between 2001 and 2005 were retrospectively studied. Indications for syndesmosis fixation were a positive intraoperative external rotation stress test or inadequate lateral column buttress. Weight bearing was encouraged six weeks postoperatively. Syndesmosis screws were only removed for tenderness, prominence or ankle dorsiflexion < 0.05. The LEM score for patients with intact screws was 70 ± 26 compared with 85 ± 20 for broken, loosened or removed screws (p=0.05). The OM score for patients with intact screws was 48 ± 36 compared with 63 ± 27 for broken, loosened or removed screws (p=0.12). There was no difference in outcome comparing broken, loosened, and removed screws. The tibiofibular clear space for intact screws was 3.3 ± 1.3 compared with 4.1 ± 1.7 for removed, broken or loosened screws (p=0.02). There was no difference in outcome comparing large and small fragment screws. Patients with broken, loosened or removed syndesmosis screws have better functional outcome compared to intact 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

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken. Method: Study type: Retrospective audit of radiographs and patient records. Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF. Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow). Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?. Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3). Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction. Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

Injury to the syndesmosis occurs in approximately 10% of all patients with ankle fractures. Anatomic restoration of the syndesmosis is the only significant predictor of functional outcome. Several techniques of syndesmosis fixation are currently used such as cortical screws, bioabsorbable screws and more recently introduced suture-button fixation. No single technique has been shown to be superior to the others. The objective of this research project is to investigate whether treatment with a tightrope (suture-button fixation) gives superior results than the use of a cortical screw in the treatment of acute syndesmotic ankle injuries with regards to function, pain, satisfaction and return to normal activities. Research Ethics Committee approval was obtained. 40 patients with syndesmotic ankle injuries associated with diastasis were prospectively recruited, 20 in each group. Patients were randomized to one of the 2 groups. At 12 weeks, American Orthopaedic Foot and Ankle Society (AOFAS) scores and a computerized tomography (CT) scan of both the ankles was obtained. At 1 year, AOFAS scores and satisfaction was assessed. 32 patients have been recruited so far, 20 in the tightrope group and 12 in the cortical screw group. Mean AOFAS scores at 3 months post-op were 90.67 in the Tightrope group and 84 in the screw group. The difference was not significant (p= 0.096). CT scans revealed that the quality of syndesmosis reduction was equally good with both the techniques. Metalwork prominence was common with both the devices. Discussion and Conclusion. Both the devices achieved good reduction of the syndesmosis. Our CT scan protocol has insignificant radiation risk and allows more accurate assessment of the syndesmosis. Early clinical results do not show a significant difference in the functional outcome with the use of either device. Long-term (1 year) follow-up has been planned

A new apparatus and technique of syndesmosis fixation is tested in a prospective clinical study. Buttons on both sides of the ankle anchor a strong suture under tension following syndesmosis reduction. This syndesmosis suture acts like a tightrope when under tension. Implantation is simple with a minimally invasive technique, as the medial side is not opened. It allows physiological micromotion whilst resisting diastasis, does not require routine removal, and allows patients to weight-bear earlier. Sixteen patients with Weber C ankle fractures with a syndesmosis diastasis underwent suture-button fixation and the results compared to 16 consecutive patients with syndesmosis screw fixation. Patients were, in effect, quasi-randomised according to surgeon preference. Mean A,O,F,A,S, ankle scores were significantly better in the suture-button group at three months post-op (91 vs 80, p=0.01, unpaired t-test) and at twelve months (93 vs 83, p=0.04, unpaired t-test). Return to work was also significantly faster (2.6 months vs 4.6 months, p=0.02, unpaired t-test). No suture-buttons required implant removal. Axial CT scanning at three months showed implants to be intact with maintenance of reduction, as compared to the uninjured contralateral side. Suture-button syndesmosis fixation is simple, safe and effective. It has shown improved outcomes and faster rehabilitation, without needing routine removal. Although the apparatus design may undergo further refinement, we believe this technique will become the treatment of choice in Weber C ankle fractures with a syndesmosis injury

Aims: A new technique of syndesmosis fixation is proposed; placing buttons on both sides of the ankle, without opening the medial side, connected by a strong non-absorbable suture. We tested this against syndesmosis screw fixation in a cadaver model of a Maisonneuve injury and subsequently in a prospective clinical study. Methods: 16 cadaver legs were randomised to have suture-button or syndesmosis screw fixation and tested under torque loading. In the clinical study, 16 patients with a syndesmosis diastasis underwent suturebutton fixation and the results compared to 16 patients with syndesmosis screw fixation. Results: In the cadaver study, both groups had similar rates of diastasis, although the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001). In the clinical study, mean A.O.F.A.S. scores at 3 months were significantly better in the suturebutton group (91 vs 82, p=0.01). No suture-button implants required removal, compared to 13/16 of the screw group (p=0.001). Conclusions: Suture-button syndesmosis fixation is simple, safe and physiological. Biomechanically it performs at least as well as screw fixation. Clinically it has shown improved outcomes, without needing routine removal. It may become the treatment of choice in syndesmosis injuries

Introduction. It is recommended that the ankle be held in dorsiflexion at the time of placement of syndesmosis screw. We assessed the validity of this recommendation. Materials and methods. A two-part roentgenographic and computerised analysis of distal tibiofibular syndesmosis. The first part involved recruitment of 30 healthy adult volunteers. The second part involved 15 ankle fractures with syndesmotic injury requiring syndesmosis screw placement. In the first part individuals maximally dorsiflexed and plantarflexed their ankles in a specialised jig for standardisation. Mortice views were taken and intermalleolar distance measured. In the second part mortice views were taken in plantarflexion and dorsiflexion before and after the placement of syndesmosis screw in theatre. The intermalleolar distance was then measured. Results. In both parts of the study we found the change in intermalleolar distance between the positions of plantarflexion and dorsiflexion was not more than 0.9 mm. This change is significantly less than the calculated difference between the anterior and posterior talar body width of 3-5 mm. Conclusion. This study shows that the width of ankle mortice is independent of the position of the talus occupying it and hence dorsiflexion of the ankle at the time of syndesmosis screw placement is totally unwarranted

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

Treatment of syndesmotic injuries is a subject of ongoing controversy. Locking plates have been shown to provide both angular and axial stability and therefore could potentially control both shear forces and resist widening of the syndesmosis. The aim of this study is to determine whether a two-hole locking plate has biomechanical advantages over conventional screw stabilisation of the syndesmosis in this pattern of injury. Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. The limbs were then mounted on a servo-hydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Each limb was compared with its pair; one receiving stabilisation of the syndesmosis with two 4.5mm quadricortical cortical screws, the other a two-hole locking plate with 3.2mm locking screws (Smith and Nephew). Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening or axial migration >2mm. Both constructs effectively stabilised the syndesmosis during the cyclical loading within 1mm of movement. However the locking plate group demonstrated superior resistance to torque compared to quadricortical screw fixation (40.6Nm vs 21.2Nm respectively, p value <0.03). Conclusion. A 2 hole locking plate (3.2mm screws) provides significantly greater stability of the syndesmosis to torque when compared with 4.5mm quadricortical fixation

Introduction. Previous studies have demonstrated the need of accurate reduction of ankle syndesmosis. Measurement of syndesmosis is difficult on plain radiographs. Recently, a difference of 2mm in anterior and posterior measurements at incisura of the inferior tibio-fibular joint on CT has been described as a measure of malreduction (depicted as ‘G’ for ease of description). Our practice changed towards routine post operative bilateral CT following syndesmosis fixation to assess the reduction and identify potential problems at an early stage. The aim of this primarily radiological study was to determine if the use of bilateral cross sectional imaging brings additional benefit above the more conventional practice of unilateral imaging. Method. Between 2007 and 2009, nineteen patients with ankle fractures involving the syndesmosis were included in the study group who had bilateral CT post operatively. The values of ‘G’ and the mean diastasis (MD) were calculated, representing the average measurement between the fibula and the anterior and posterior incisura. Results. When compared to the normal side, eight out of nineteen (42%) cases were found to have a residual diastasis even after fixation across the syndesmosis, However, if a standard value of G(2mm) was used for the injured leg only, all of the nineteen cases would have abnormal values of ‘G’ following reduction. The value of G for the injured side was poorly correlated with the mean inter-limb diastasis (MD, R=0.23). Discussion. Our study has clearly demonstrated the need for individualising the assessment method to guide surgeons and radiologists prior to revision surgery. A standard value of ‘G’ of 2mm as the normal limit cannot be applied universally as apparent from the data presented in this study

There have been few reports with efficient treatments for neglected distal tibiofibular syndesmosis disruption. Here we will report four cases of successful anatomical reconstruction with autologous gracilis tendon, using the interference fit anchoring (IFA) system. All four cases were males between 20 and 58 years of age at the time of surgery (mean age 36 years). The post-injury period to surgery was between 7 and 59 months (mean 20.1 months), with the consultation period being from 5 to 19 months (mean 9.5 months). Radiographs at the time of injuries were all malleolar fractures of pronation-external rotation (PE) stage 3 in the Lauge-Hansen classification. Stress tests for distal tibiofibular syndesmosis were positive in all cases (dilation more than 2 mm). Arthroscopic drilling was conducted in two cases with a cartilaginous injury of trochlea of talus. Distal tibiofibular syndesmosis was anatomically repositioned and was fixed with screws after bony and soft tissues within the tibiofibular syndesmosis were removed and fibular adhesion was dissected. Ipsilateral autologous gracilis tendon was passed through foramen in the insertion of the anterior inferior tibiofibular tendon on tibia and fibula, and was fixated using the IFA system. The preoperative Japanese society for surgery of the foot (JSSF) score was from 26 to 74 points (mean 43.5) and postoperative JSSF score was from 67 to 100 (mean 89.5). In a case where there was a poor outcome, five years of post injury had passed before the surgery. Although the JSSF score improved to 67 points postoperatively (from the preoperative score of 26) in this case, arthroscopic arthrodesis was conducted 5 months postoperatively due to persistent pain. Anatomical reconstruction with autologous gracilis tendon using the IFA system showed a favorable functional prognosis overall. However, there was a case with progressive degenerated changes of injured distal tibiofibular syndesmosis due to a prolonged post-injury period resulted in a poor outcome

Introduction A new technique of ankle syndesmosis fixation is proposed. Buttons are placed on both sides of the ankle, connected by a strong non-absorbable suture. The technique is simple and minimally invasive: a medial incision is not required. It resists diastasis whilst allowing physiological micromotion and does not require routine removal. Methods The technique was tested on a cadaver model of a Maisonneuve injury under increasing torque loads. Sixteen embalmed cadaver legs were randomised to receive suture-button fixation or four-cortical 4.5 mm syndesmosis screw fixation. A prospective clinical study involving 16 patients with Weber C fractures and syndesmosis diastasis is presented. They underwent suture-button fixation and the results were compared to 16 consecutive patients with syndesmosis screw fixation. Results In the cadaver study, both groups had similar rates of diastasis following torque loading. However, the suture-button did give a more consistent performance: standard deviations were significantly lower (p=0.001) than the screw group. In the clinical study, both groups were evenly matched as regards patient age, male: female ratio, and fracture patterns. Mean AOFAS ankle outcome scores at three months were significantly better in the suture-button group (91 versus 82, p=0.01). No suture-button patients required implant removal. They had a faster return to work compared to the screw group (three months versus five months). Axial CT scanning performed at three months post-op showed all implants to be intact with no loss of reduction. Conclusions Suture-button syndesmosis fixation is simple, safe, effective and physiological. It has shown improved outcomes and faster rehabilitation, without needing routine removal. It may become the treatment of choice in Weber C ankle fractures with a syndesmosis diastasis. In relation to the conduct of this study, one or more the authors have received, or are likely to receive direct material benefits

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

Rotational instability is defined as combined medial and lateral ligament instability of the ankle joint. In the case of combined injury to the posterior syndesmosis and posterior joint portion the typical giving-away-symptoms and the therapy resistant complaints are accompanied. In the following prospective study 43 patients between the ages of 16 and 35 with the average age of 23.9 years with posttraumatic chronic joint-instability as well as posterior syndosmosis insufficiency were examined. The treatment of rotational instability was performed by an anchoring technique modified by Broström. The resulting insufficiency of the posterior syndesmosis was treated by a Tight Rope provided by Arthrex. The study was run over 14 months, where only 36 out of 43 patients were available for postoperative follow up. A preoperative baseline 2-view x-ray as well as an MRI was performed in all patients. The operation to establish the stability of the ligaments via anchoring-technique and the treatment of the posterior syndesmosis through Tight-Rope were performed via arthroscopy of the ankle joint with additional inspection of the posterior joint portion. At the same time existent impingements were recessed. In each patient the AOFAS score as an indicator for the treatement outcome and the VAS-score was used as the measurement for the level of pain developement were used. The first exam was performed in preoperative setting followed by subsequent 12 and 24 weeks as well as 12 and 14 months postoperatively. To ensure stability a preoperative x-ray in suppination stress was performed followed by the same type of x-ray 3 months postoperatively. A significant improvement in the above mentioned scores were noted already 3 months after the operation. An improvement in VAS-score of 5.1 points as well as in AOFAS-score of 79% was observed. The degree of Suppination and rotational movement as well as the extent of talus-forfall has reduced significantly. The already improvement of the above scores after 3-month-follow up were consistent even after 14 months. About 90% of patients were satisfied with the outcome of the operation with the “good” and “very good” scores. The complication rate was about 3%. In conclusion, the treatment of posttraumatic mechanical ankle joint instability with posterior syndesmosis injury via anatomic anchoring reconstructive technique and Tight-Rope is considered to be an operative modality with significantly satisfactory results. Keywords: Rotational instability, posterior syndesmosis, stabilisation, tight-rope

There is an increasing acceptance that the clinical outcomes following posterior malleolar fractures are less than satisfactory. Current ankle classification systems do not account for differences in fracture patterns or injury mechanisms, and as such, the clinical outcomes of these fractures are difficult to interpret. The aim of this study was to analyse our posterior malleolar fractures to better understand the anatomy of the fracture. In a series of 42 consecutive posterior malleolar, who all underwent CT imaging, we have described anatomically different fracture patterns dictated by the direction of the force and dependent on talus loading. We found 3 separate categories. Type 1 – a rotational injury in an unloaded talus resulted in an extraarticular posterior avulsion of the posterior ligaments. This occurred in 10 patients and was most commonly associated with either a high fibular spiral fracture or a low fibular fracture with Wagstaffe fragment avulsion. The syndesmosis was usually disrupted in these patients. Type 2 – a rotational injury in a loaded talus resulting in a posterolateral articular fracture, of the posterior incisura. This occurred in 16 patients and was most commonly associated with a posterior syndesmosis injury, low fibular spiral fracture and an anterior collicular fracture of the medial malleolus. Type 3 – axially loaded talus in plantarflexion causing a posterior pilon. This occurred in 16 patients and was most commonly associated with a long oblique fracture of the fibular and a Y shape fracture of the medial malleolus. The syndesmosis was usually intact in these patients. In conclusion, the anatomy of the posterior malleolar should not be underestimated and requires careful consideration during treatment and categorisation in outcome studies to prevent misinterpretation

We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis

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: Several methods for the management of syndesmosis disruption during ankle fracture fixation have been documented The Tightrope anchor is a relatively new technique consisting of two buttons and a strand of Fiber-wire which is looped twice though the buttons to create a pulley effect between the fibula and tibia, thereby stabilising the ankle syndesmosis. We have reviewed the outcomes in 38 patients treated with this technique. Materials and Methods: Data including nature of operation, complications and the need for subsequent surgery were recorded for all patients receiving a Tightrope from May 2006 to September 2008. Results: The mean patient age was 35 years, and 23 were male. 30/38 patients required no further surgery and had a good functional outcome. Two patients had prominent fibula plates removed but achieved good functional outcomes. For one patient a Tightrope was performed following diastasis screw failure: an improved but suboptimal outcome was achieved. A patient with fibromyalgia had a good range of movement but complained of discomfort. One patient with Poland sequence, who fell post operatively, needed tightrope removal and syndesmosis debridement resulting in a good but painful range of movement. Another patient developed a pulmonary embolus following surgery and prolonged swelling and discomfort limited her functional capacity. Two patients required tightrope removal and significant wound debridement following osteomyelitis of the fibula and tibia. Discussion and Conclusion: The Tightrope is an effective method of ankle syndesmosis repair, with a reduced need for subsequent diastasis related surgery (35/38) when compared to our diastasis screw method (100%). However, our significant rate of osteomyelitis is disturbing, warranting further investigation

Purpose. The anterior inferior tibiofibular ligament (AiTFL) is the primary lateral ligamentous stabilizer of the ankle syndesmosis. Current syndesmosis repair techniques traverse the tibia and fibula, but do not anatomically reconstruct the AiTFL. We compared a novel AiTFL anatomic repair technique (ART) to rigid syndesmosis screw fixation (SCREW). Method. Twelve cadaveric below knee specimens were compared radiographically and using a biomechanical testing protocol. All specimens underwent a CT scan of the ankle joint prior to testing. Next, the AiTFL, interosseous membrane and deltoid ligament were sectioned, and the posterior malleolus osteotomized, to recreate a trimalleolar-equivalent ankle fracture. The posterior malleolus was repaired with the posterior ligamentous insertions intact and functional (PMALL). Ankles were examined under fluoroscopy with an external rotation stress exam and the medial clear space (MCS) measured. Specimens were then randomized to receive either a conventional syndesmosis screw (SCREW), or the novel anatomic repair technique (ART). External rotation stress fluoroscopy was repeated. A second CT was completed and the fibular position compared to the pre-injury CT. Each specimen was then loaded in external rotation until failure using a custom biomechanical jig. Results. The MCS during stress examination increased by 1.04 0.31mm in the PMALL group. MCS increased significantly less at only 0.300.07mm (p=0.002) in the ART group. The SCREW fixation method demonstrated a delta MCS of 0.280.16mm (p=0.008). Post repair CT showed that 33% of specimens were subluxed from the SCREW group compared to 0% for the ART. Mean torque at failure for ART was 24.85.5Nm compared to 16.85.8Nm for SCREW (p=0.01). Conclusion. Repair of the posterior malleolus alone demonstrated a greater than 1mm of medial clear space widening and is not sufficient to re-establish syndesmotic stability. Addition of the ART or SCREW technique restored syndesmotic stability. None of the ART specimens demonstrated fibular subluxation, while 33% of SCREW specimens were subluxed anteriorly on CT. Biomechanical strength of the ART was found to be greater than that of rigid screw fixation

Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management. Treatment. Because of the spectrum of injury, there is a spectrum of treatment. if there is mortise widening, operative stabilization is required. if the mortise is normal, even with external rotation stress test positive, conservative treatment has been employed. staged conservative regimen directed at reducing pain and swelling acutely, at regaining range of motion and strength subacutely, and then progressed to functional training and finally return to sport. The timeframe for these was in the range of 2 to 6 weeks without very specific progression criteria. In the athlete, pain with rotational stress, greater severity of sprain, may treat operatively to stabilize the syndesmosis and aggressive rehab with earlier return to sport. Tightrope vs screw fixation vs both. Use of arthroscopy. Chronic sprains with recalcitrant pain and functional instability usually require operative treatment. very poor evidence exists as to the timing or type of procedure. Arthroscopy is required to confirm the diagnosis, treat intraarticular problems, and provide fixation of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the same as the one used when treating an acute syndesmosis disruption. Tight rope vs Screw Fixation. clinical studies tightrope fixation has been acceptable and comparable to screw fixation. laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting. indications for tightrope fixation are becoming more clear with more experience. my indications:. syndesmotic sprains with complete or incomplete disruption. fractures with syndesmotic disruption augment with screws, leave in place following screw removal. Summary and Controversies. Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost from sport. The conclusion that can be drawn from the current evidence is that the current diagnostic process probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately predicting the time lost from sport. Syndesmosis sprains can be a significant injuries that result in an inability to play sports for significant periods of time(up to 137 days). We need to be able to identify the more severe ones earlier in order to improve their treatment, perhaps lead to operative stabilization. Tightrope fixation avoids screw removal, minimally invasive, permanent stabilization

Introduction:. Fibular malreduction is a common and important cause of pain after surgical fixation following a syndesmosis injury, but it is unclear which components of malreduction correspond to clinical outcome. Plain radiographs have been shown to be unreliable at measuring malreduction when compared to CT scans. A number of published methods for measuring fibular position rely on finding the axis of the fibula. Elgafy demonstrated that fibular morphology varies greatly, and some studies have demonstrated difficulty finding the fibular axis. Methods:. We developed a new method of measuring the distal fibular position on CT images. We used CT studies in 16 normal subjects. Two assessors independently measured the ankle syndesmosis using the Davidovitch method, and our new protocol for fibular AP position, diastasis and fibular length. Results:. We demonstrated that after statistical analysis (Pearson Product Moment Correlation) our method showed improved inter-observer reliability (r = 0.99 and 0.95 vs 0.59 and 0.78 respectively) for diastasis and AP translation, and improved intra-observer reliability (r = 0.99 and 0.99 vs 0.91 and 0.97 respectively). We found inter and intra observer reliability of 0.80 and 0.91 respectively for fibular length, but were unable to find a novel, accurate method for measuring fibular rotation. Conclusions:. Our method is a new, simple, accurate and reproducible system for measuring the ankle syndesmosis. We believe that this method could be used to assess fibular reduction after obtaining CT images of the uninjured side for comparison

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

The February 2015 Trauma Roundup. 360 . looks at: Evaluating the syndesmosis in ankle fractures; Calcaneal fracture management an ongoing problem; Angular stable locking in low tibial fractures did not improve results; Open fractures: do the seconds really count?; Long-term outcomes of tibial fractures; Targeted performance improvements in pelvic fractures

Aims. In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery. Materials and Methods. A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied. Results. A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws. Conclusions. The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497–1504

Background. Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis, the deltoid ligament and are predictive of ankle instability, early joint degeneration and long-term ankle dysfunction. Detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in the absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the fibula in fractures up to 4.5mm above the ankle joint. Generally, syndesmotic ligamentous injuries are treated operatively by temporary fixation performed with positioning screws. But do syndesmotic injuries need to be treated operatively at all?. Methods. The purpose of this biomechanical cadaveric study was to investigate the relative movements of the tibia and fibula, under normal physiological conditions and after sequential sectioning of the syndesmotic ligaments. Ten fresh-frozen below-knee human cadaveric specimens were tested under normal physiological loading conditions. Axial loads of 50 Newton (N) and 700N were provided in an intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular (AITFL), posterior-inferior tibiofibular (PITFL), interosseous (IOL), and whole deltoid (DL). In each condition the specimens were tested in neutral position, 10 degrees of dorsiflexion, 30 degrees of plantar flexion, 10 degrees of inversion, 5 degrees of eversion, and externally rotated up to 10Nm torque. Finally, after sectioning of the deltoid ligament, we triangulated Boden's classic findings with modern instruments. We hypothesized that only after sectioning of the deltoid ligament; the lateralization of the talus will push the fibula away from the tibia. Results. During dorsiflexion and external rotation the ankle syndesmosis widened, and the fibula externally rotated after sequential sectioning of the syndesmotic ligaments. After the AITFL was sectioned the fibula starts rotating externally. However, the external rotation of the fibula significantly reduced when the external rotation torque was combined with axial loading up to 700N as compared to the external rotation torque alone. The most relative moments between the tibia and fibula were observed after the deltoid ligament was sectioned. Conclusion. Significant increases in movements of the fibula relative to the tibia occur when an external rotation torque is provided. However, axial pressure seemed to limit external rotation because of the bony congruence of the tibiotalar surface. The AITFL is necessary to prevent the fibula to rotate externally when the foot is rotating externally. The deltoid ligament is the main stabilizer of the ankle mortise

Percutaneous fixation of syndesmosis is an accepted treatment of isolated Weber C fractures of the ankle. However, the status of syndesmosis after removal of the screws has never been studied to our knowledge. We studied eight patients for any residual diastasis and its clinical significance. CT scan was used to study the residual diastasis of syndesmosis after the removal of screws by comparing with the normal side. Patients were clinically assessed using Maryland and International Foot Scoring systems. The talocrural angles were measured and were compared with the normal side. Ten patients of isolated Weber C fractures were treated with percutaneous application of syndesmotic position scres from November ’97 to July ’99. Eight were available for follow up and two were lost to follow up. The average follow up was 427.9 days (14.26 months) with a range 167–744 days. There were 7 males and 3 females. The average age was 32.2 years (range 17–66). Left side was involved in 6 cases and right side in 4. The scres were removed after an average period of 78.3 days (11.8 weeks) with a range of 45–189 days. All patients were found to be having diastasis ranging from 1 mm to 3 mm with an average of 2.06 mm. The Maryland score ranged from 76 to 100 with an average of 90. The international score ranged from 78 to 100 with an average of 87.62. The diastasis roughly paralleled with the Foot scores. All patients who had percutaneous fixation of syndesmosis had residual diastasis following removal of the screws and this may be clinically significant

Is to present our clinical experience in how we evaluate ankle fractures as unstable and the use of syndesmosis screw in their treatment. Since 2004–2008, 85 ankle fractures treated surgically. Of them 31 were evaluated as unstable according to:. preoperative x-rays findings. intraoperative tests, and syndesmosis screw was used. We used AO-Weber classification: 14 cases type B(7 cases of B2 and 7B3), 16 cases type C(4 cases of C1 and 12 C2). Twenty-one of them were females and 10 were males. Their age rage was from 17–61 years old (Mean 42,5).The follow-up was from 6 months to 4 years(Mean 2,5 years). Syndesmosis screw was removed afters six weeks. Postoperative results were evaluated according the scoring system of Olerud and Malander. Postoperative there were 2 ankle O.A.(6,45%) due to false surgical technique. They treated by arthrodesis. The proper evaluation of the first x-ray findings of the fracture is of great importance for the proper treatmet. The syndesmosis screw is obligatory in unstable ankle fractures, in which, in combination with proper osteosynthesis preserves the ankle’s stability and viability. Ligament and bone lesions are responsible for ankle stability

The April 2012 Foot & Ankle Roundup. 360 . looks at injecting the tendon sheath, total ankle replacement, heterotopic ossification, replacement or arthrodesis, achilles tendinopathy, healing of the torn Achilles, grafting of the calcaneal bone cyst, avulsion fractures in athletes, percutaneous distal osteotomy for bunionette formation, and repairing the torn tibiofibular syndesmosis

During surgical reduction of ankle injuries with syndesmotic instability surgeons often use the anteroposterior (AP) and mortise radiographs to assess reduction. Current literature predicts 50% are malreduced mainly in the sagittal plane. Our aim was to develop a radiographic measure based on the lateral view to assess both the normal and abnormal fibula/tibia relationship after simulated syndesmotic malreduction and to evaluate the effect on commonly used AP and mortise measurements. Nine fresh-frozen cadaveric specimens were dissected to the level of the syndesmosis. AP, mortise and talar dome lateral radiographs were obtained before and following syndesmosis division and posterior fibula displacement. On the lateral radiograph a line was drawn (Orthoview) from the anterior border of the fibula bisecting a line drawn from the anterior to posterior lips of the distal tibia. The ratio of the anterior-posterior segments was calculated. Also a line was drawn from the posterior border of the fibula and the distance was measured to the posterior lip of the tibia. At 0, 2, 4 and 6mm of displacement the ratio measured 1.3±0.2, 1.1±0.2, 0.9±0.2 and 0.7±0.2 respectively with all pairwise comparisons being significantly different. Inter- and intra-observer variability varied from substantial to perfect. The only significant medial clear space (MCS) difference was on the mortise view between 0mm (2.0±0.3mm) and 6mm (2.4±0.4mm) displacement. Our new measure of syndesmotic reduction is reproducible and can detect from 2mm of saggital fibular displacement. At maximum fibular displacement the increase in MCS was less than 1mm. This demonstrates standard mortise radiographs are poor at detecting syndesmotic reduction. An interesting observation was in all specimens prior to any displacement, the posterior fibular line always bisected the posterior lip of the tibia or lay just anterior to it, never posterior. This could serve as a useful adjunct for surgeons when assessing syndesmotic reduction intra-operatively

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

The June 2014 Foot & Ankle Roundup. 360 . looks at: peroneal tendon tears associated with calcaneal fractures; syndesmosis procedure for first ray deformities; thromboprophylaxis not necessary in elective Ilizarov surgery; ankle replacement gaining traction in academic centres; some evidence for PRP and; fusion nailing and osteotomy an effective treatment for symptomatic tibial malunion

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

The best method of stabilisation of the ankle syndesmosis remains a topic of debate; a relatively recent development is the ankle tightrope – a tensionable fibrewire suture device. Despite over 30,000 successful surgeries reported, evidence supporting its use when compared with screw fixation remains extremely limited. We retrospectively compared two consecutive groups of patients whose syndesmotic injuries were stabilised either with a tightrope or screws. The aim of our study was to compare complications arising after insertion of these devices. All patients undergoing tightrope stabilisation of the syndesmosis between January 2006 and February 2009 were included as the treatment group. The control group was made up of a similar number of consecutive patients who underwent screw stabilisation between November 2010 and January 2011. Data was obtained through theatre records, case notes and from the local PACS X-ray system. Eighteen eligible cases were identified in the tightrope group compared with sixteen eligible cases treated with screws. Both groups had similar baseline demographics with respect to distribution of age and gender. Twenty two percent (n = 4) of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included persistent syndesmotic widening (n = 2, 11%), knot prominence without removal (n = 1, 5.5%) and synostosis (n = 1, 5.5%). In comparison, only 1 patient (6.3%) experienced a complication (pain and decreased RoM) in the control group. A total of 14 screws were removed. Thirteen screws were removed uneventfully. One patient was discharged to another hospital for a planned removal of screw, but was lost to follow-up. The remaining two patients elected not to have their screws removed. Discussion. Our study demonstrates that in our hands a relatively high complication rate exists with tightrope stabilisation, whereas few problems are seen with screw fixation

Stabilisation of the ankle syndesmosis remains a topic of debate regarding the best method of fixation; the most recent development is the ankle tightrope - a tensionable fibrewire suture. Despite over thirty thousand successful surgeries(1) reported, evidence supporting its use remains extremely limited. The aim of our study was to identify complications arising after insertion of this device for syndesmotic instability. All patients undergoing tightrope stabilisation of the ankle syndesmosis in Aberdeen Royal Infirmary between January 2006 and February 2009 inclusive were incorporated in our study. Patient identifier data was collated at the time of operation by a research nurse with case records collected and analysed by the authors at the end of the study period. Nineteen cases were identified with one subsequently excluded due to death. Of the remaining patients thirteen were male and five female. Age ranged from sixteen to fifty-eight years. Five patients required tightrope fixation alone, the remainder necessitating bony fixation according to AO recommendations. Time in cast immobilisation ranged from five to eight weeks, time to full weight bearing six to ten weeks and time to discharge eight weeks to fifteen months. In this series, 22% of tightropes were removed secondary to wound breakdown or knot prominence. Other complications included syndesmotic widening(11%), knot prominence without removal(5.5%) and synostosis(5.5%). Incontrast to previously published literature (2,3,4,5,6) this, the second largest series to date, demonstrates a high complication rate(44%) - perhaps the tightrope is not as advantageous as initially thought

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

It has been suggested that a supramalleolar osteotomy can return the load distribution in the ankle joint to normal. However, due to the lack of biomechanical data, this supposition remains empirical. The purpose of this biomechanical study was to determine the effect of simulated supramalleolar varus and valgus alignment on the tibiotalar joint pressure, in order to investigate its relationship to the development of osteoarthritis. We also wished to establish the rationale behind corrective osteotomy of the distal tibia. We studied 17 cadaveric lower legs and quantified the changes in pressure and force transfer across the tibiotalar joint for various degrees of varus and valgus deformity in the supramalleolar area. We assumed that a supramalleolar osteotomy which created a varus deformity of the ankle would result in medial overload of the tibiotalar joint. Similarly, we thought that creating a supramalleolar valgus deformity would cause a shift in contact towards the lateral side of the tibiotalar joint. The opposite was observed. The restricting role of the fibula was revealed by carrying out an osteotomy directly above the syndesmosis. In end-stage ankle osteoarthritis with either a valgus or varus deformity, the role of the fibula should be appreciated and its effect addressed where appropriate

Aims

The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques.

Syndesmotic stability in ankle fractures is usually assessed by pulling on the fibula with a bone hook in the coronal plane (“hook test”). Our clinical observations have suggested that instability may be more marked in the sagittal plane. Our aim was to compare movement at the tibio-fibular syndesmosis in the sagittal and coronal planes after sequential ligament division in a cadaver model. Seven specimens were used. A blinded subject was asked to perform the hook test both in the sagittal and coronal planes. Movement was assessed by measuring the displacement of parallel k-wires three consecutive times. In all specimens, the anterior tibio-fibular, interosseous and posterior tibio-fibular ligaments were sequentially divided and movement tested. In three specimens the deltoid ligament was then divided and the interosseous membrane in another three. After division of all three syndesmosis ligaments the mean displacement was 8.8mm (±3.9) in the sagittal plane and 1.5mm (±0.4) in the coronal plane. When the deltoid ligament was then divided, the displacement increased to 11.7mm (±2.4) and 3.2mm (±0.5) respectively. When the interosseous membrane was divided the measurements were 12.7mm (±4) and 3.1mm (±1.5). We conclude that distal tibio-fibular instability should be assessed in the sagittal plane

Introduction: Ankle Arthroplasty is an alternative to arthrodesis for patients with disabling ankle arthritis. It aims to remove pain and preserve joint motion. We aimed to review the outcome of all total ankle replacements carried out in our institution between 2002 and 2006. Materials and Methods: We retrospectively reviewed the results of all patients who underwent the Agility ankle replacement performed by a single surgeon. Case notes and radiographs were reviewed and outcome assessment included standardised questionnaires. Results: 30 arthroplasties were performed in 30 consecutive patient. 11 males, 19 females, Pre operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2) with a mean age of 61.8 yrs. 8 patients required an additional procedure at the time of arthroplasty : tendoachilles lengthening (6); Calcaneal osteotomy (2); triple arthrodesis (2); tip post reconstruction (1). Intra operative technical complications included: Fracture of medial malleolus (3); nerve injury (3); tendon injury (1). 8 patients had wound problems: Delayed healing > 3/52 (8); Superficial infection (2); Deep infection (2). 1 patient had delayed union of the syndesmosis (> 6 months) and 6 had non-union (> 12 months). After a mean follow up of 3.2 years 2 patients had died and 9 patients had required further surgery: Implant removal for infection (1); Talar revision for loosening (1); Re-fusion of the syndemosis (4); Removal of syndesmosis screws (3); Calcaneal osteotomy for valgus hindfoot (1). Discussion: We found a high rate of complications which may be related to the surgeons learning curve, although some are specific to the design of implant which requires a tibio-fibular fusion. Conclusion: The first 30 agility ankle replacements performed in our centre demonstrates several potential complications and shows that there is often a need for subsequent surgery. Short term survivorship of the implant is acceptable and long term review is required

Aims: We aimed to evaluate diagnostic contribution of MRI-Arthrography in syndesmosis disruption at ankle fractures. Methods: 18 patient who had Denis Weber type B-C fractures and are suspected to have syndesmotic diastasis considering tibiofibular clear space and tibiofibular overlap measurments in conventional radiographs are assesed with MRI followed by MRI-Arthrography. Because joint fluid was already seen in tibiofibular space in 3 patients at MRI, MRI-Arthrography was performed for the remaining 15 patients. If there was a changes between the results obtained from MRI and the results obtained after MRI-arthrography was tested istatistically. Convantional radiographs, MRIs and MRI-Arthrographies were analysed by 2 independent observers and interobserver concordance was assesed. Following intraoperative observation and asssesment syndesmotic diastasis was treated considering radiographic and MRI-arthrographic results. Results: In 15 cases who were regarded to have syndesmotic diastasis according to conventional radiographies, 8 (53.3%) diastasis were confirmed with only MRI and 12 (80%) diastasis were confirmed with MRI arthrography. Following intraoperative assesment 13 (86.6%) cases were regarded to have diastasis and surgical intervention was performed for diastasis repair. In 2 (13.3%) cases surgical intervention for diastasis repair was not performed. If there was a change in decission after MRI and after MRI-arthrography is analysed with chi-square test between related groups. There were statistically significiant difference (p< 0.05) in these means. There is interobserver concordance in conventional radiographic, MRI-arthrographic assesments and in assesments for ATIF and PTIF seperately inMRI.(p< 0.001). Conclusion: These results suggest that conventional radiography and MRI is not sufficient in assesing syndesmosis and MRI-arthrography is important for diagnosis

Generally ankle fractures in the very elderly are treated by non-operative methods but some fractures can be highly unstable and are difficult to treat in a plaster. During a 10-year period, 74 patients over the age of 70 years were retrospectively studied to identify the early complications, length of stay, return to pre-injury mobility and residential status. There were 58 females and 16 males with an average age of 76 years (70–91years). 57(77%) fractures were at the level of the syndesmosis (Type B) and 17(33%) were above the level of the syndesmosis (Type C). All but one injury was due to a simple fall. All patients had initial manipulation and plaster immobilisation. They underwent ORIF after the reduction in the plaster was lost. Plate and screws were used in 53 patients (72%), rush pins in 12 patients (16%) and external fixation was used in 2 patients. All patients were immobilised in a below knee plaster after surgery for 6–8 weeks. Following surgery, 1% deep infection, 9% delayed wound healing, 5% malunion, and 3% mortality were recorded. In 12% of patients, soft bone and communition precluded fixation of one malleolus. The average length of stay for patients who walked with a Zimmer frame before injury was significantly longer than for those who walked independently or with sticks. However, the majority (85%) of patients regained their pre-injury mobility and residential status. We conclude that ORIF of ankle fractures in the elderly carries a significant risk of wound edge necrosis with delayed wound healing but the incidence of deep infection is relatively low. ORIF should be reserved for patients where non-operative management has failed. Poor bone quality presents technical difficulties but the majority of patients can expect a good outcome

Purpose of the study: Ankle sprains constitute a serious public health problem with nearly 6000 consultations daily in France. The prognosis is generally good if a precise clinical diagnosis can be established and appropriate treatment undertaken. The purpose of this study was to ascertain the pertinence of the initial physical examination which determines the treatment by correlating it with the results of a high-resolution ultrasound examination. Material and methods: This prospective study included 23 patients, mean age 30.7 years, who were followed regularly for three months. A total of 154 ultrasound explorations were performed. The initial treatment for these patients who consulted a hospital emergency room for ankle trauma was established on the basis of the Ottawa criteria. The ankles were examined by a senior physician and an ultrasonographic exploration was performed 3.9 days on average after the first consultation in the emergency room. Standard protocols were used for the physical examination and for the ultrasonography. Results: The initial results confirmed a lesion of the lateral collateral ligament in 91% of cases with an initial tear of the anterior talofibular ligament in half of the cases and a injury to the calcaneofibular ligament in one out of five cases. One quarter of the patients had an isolated lesion. One out of ten presented a lesion of the syndesmosis and one out of three lesions of the fibular tendons. The standard ankle examination performed by the senior physician established correct diagnosis of the precise lesion in 80% of the cases. Discussion: Lesions of the mid food and of the syndesmosis are diagnosed clinically, ultrasonography is not contributive. The stage of the initial lesion was compared with the stage at three months: in 7 out of 10 cases, the anterior talofibular and the calcaneofibular ligaments had healed correctly. Physical examination is essential but ultrasonography provides certain complementary information at a time when the physical examination can be hindered by the pain and potentially the lesser experience of emergency room examinators. Conclusion: In light of the evidence provided by this study, it can be confirmed that the initial diagnosis of ankle sprain established in an emergency room setting can be corrected by a physical examination performed by an experienced clinician. At the present time, it is not possible to demonstrate the specific contribution of ultrasonography for the management of ankle sprains. This would require a prospective study over a longer period and should be designed to demonstrate the relationship between injury of the fibular tendons and ankle stability

Introduction: Conventional metal ankle plates often require secondary removal due to problems such as discomfort or pain. Biodegradable ankle plates and screws have been developed to avoid the need for hardware removal. However, only limited clinical data exists with these new devices. The aim of this study was to retrospectively followup ankle fracture patients treated with biodegradable ankle plates and screws at the Seinäjoki Central Hospital (Finland), and to evaluate clinical outcome and occurrence of postoperative complications in these patients. Materials and Methods: After ethical committee approval, 57 ankle fracture patients treated with the biodegradable ankle plates and screws (Inion OTPS™, Inion Oy, Tampere, Finland) at the Seinäjoki Central Hospital between March 2004 and September 2006 were invited for a follow-up visit at a private outpatient clinic. Totally 50 patients participated (21 female, 29 male) in the study. There were 36 lateral malleolar fractures (2 with syndesmosis rupture) and 14 bimalleolar fractures (3 with syndesmosis rupture). The average age of the patients was 45 years (SD ± 14, range 18–65) and average weight was 80 kg (SD ± 18, range 45–150). Postoperatively, a cast was applied for 6 weeks. The patients were instructed as follows: First no weight bearing for 2 weeks, then half body weight bearing for 2 weeks, and thereafter gradually towards full weight bearing (with pain restriction). The follow-up included review of each patient’s medical records, evaluation of radiographs (preoperative, postoperative, and the ones taken at the follow-up visit) and fracture reduction classification according to Cedell (anatomic, good, poor), and functional scoring according to Olerud and Molander (0–100). All complications were recorded. In addition, duration of return to work and normal daily activities were asked from each patient. Results: Average follow-up time was 17 months (SD ± 6.2, range 7–36). No perioperative complications occurred. All fractures healed. Fracture alignment was classified as anatomic in 49 patients and good in 1 case. Average Olerud and Molander ankle score was 86 (SD ± 20, range 15–100). Average duration of return to work was 2.8 months (SD ± 1.3, range 1.5–6), and average duration of return to normal daily activities 3.1 months (SD ± 1.3, range 1.5–6). Postoperative complications: 1 delayed wound healing, 3 cases of deep venous thrombosis, and 4 soft tissue reactions. Discussion and Conclusions: According to the results of this retrospective study, biodegradable ankle plates and screws provide comparable fracture healing and functional results as those previously reported after use of conventional metal fixation (Lehtonen et al. 2003). Also postoperative complications and their occurrence rates are similar to those seen with metal

Aims

The aim of this retrospective cohort study was to assess and investigate the safety and efficacy of using a distal tibial osteotomy compared to proximal osteotomy for limb lengthening in children.

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).

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.

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

The June 2023 Foot & Ankle Roundup³⁶⁰ looks at: Nail versus plate fixation for ankle fractures; Outcomes of first ray amputation in diabetic patients; Vascular calcification on plain radiographs of the ankle to diagnose diabetes mellitus; Elderly patients with ankle fracture: the case for early weight-bearing; Active treatment for Frieberg’s disease: does it work?; Survival of ankle arthroplasty; Complications following ankle arthroscopy.

Introduction. Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications, and many of these secondary procedures may be preventable. Method. A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of X rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. Results. 236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, 7 (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, 3 (23%) for complete failure of fixation, 2 (15%) with wound problems and 1 (8%) for medial malleoulus mal-reduction. Of the patient group, 5 (38%) were known type 2 diabetics. Consultants performed 2 (15%) of procedures, supervised registrars 5 (39%) and unsupervised registrars 6 (46%) operations. Conclusion. Errors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures

Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

The April 2014 Trauma Roundup. 360 . looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture

Weber A fractures are a sub-group of ankle fractures parallel or distal to the joint line, below the level of the syndesmosis. Most stable Weber A fractures are managed conservatively with no significant difference in outcome vs. surgical intervention. 1,2. In an effort to ensure staff time was being used as efficiently as possible, a consultant-led virtual fracture clinic (VFC) was introduced to manage Weber A fractures. Patients not requiring immediate surgery were reviewed remotely and, wherever possible, were ‘virtually discharged’ to a nurse-led telephone line. Those with diagnostic uncertainty, unusual features or delayed recovery received a face to face review from a nurse or surgeon. To examine how patients were allocated under this protocol, along with overall patient satisfaction and functional outcome. An audit of satisfaction and outcome was performed of all patients who presented with a Weber A fracture to the ED between October 2011 and October 2012. The minimum follow-up period was two years. A satisfaction and patient reported outcome (5-level-likert-scale, EQ-5D, MOXFQ) measure was conducted via telephone. 3,4. After exclusions, 79 patients were left, of which 63 were successfully contacted (80%). Of the 79 patients included, 33 (42%) required early face-to-face review while 46 (58%) were discharged with advice following discussion at the VFC. Of the 63 successfully contacted, receipt of the information leaflet was recalled by 61 (97%) and 54 (86%) were satisfied with the information they had received. There was no difference in patient satisfaction regarding recovery (p=0.079) or treatment information (p=0.236) provided between avulsion and transverse fractures or in functional outcome according to MOXFQ (p=0.626) or EQ-Vas (p=0.915) scores. Patient satisfaction can remain high without face-to-face consultations following injury. This was demonstrated by the high satisfaction with recovery (83%) and with information provided (86%) and is consistent with current published literature and similar to what would have been achieved with traditional fracture clinic review. 5. The new protocol reduces unnecessary hospital attendances for patients and reduces the burden of unnecessary review in orthopaedic departments. Only 15% of patients required review at a traditional fracture clinic and 27% at a nurse-led clinic, freeing resources for more complex cases

Introduction. Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre. Methods. We reviewed the results of 40 ankle fractures (14 open and 26 closed) with significant soft tissue injuries and open fractures that were treated with a fibula rod between 2012 and 2015. The median age of patients was 60 (17–98 years). Results. Satisfactory fracture reduction was achieved in all of these patients Two patients had loss of syndesmosis fixation. All fibula fractures healed but 3 medial malleolus non unions occurred which did not need further surgery. 1 patient developed post-operative deep infection and had removal of metalwork. The median physical component Short-Form 12 (PSF12), Olerud and Molander score (OMS), and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores (AOFAS) were 40 (19 to 52), 57 (0 to 85) and 75 (20 to 95), respectively. The median PSF12, OMS and AOFAS were 33, 35 and 47 for open fractures and 42, 60 and 78 for closed fractures respectively. Conclusion. Using the fibula rod resulted in good radiological and satisfactory functional outcomes with minimal complications. In spite of lower scores in the open fracture group, only one patient needed removal of metal work for deep infection. We recommend using the fibula rod in unstable ankle fracture in patients with significant soft tissue injuries and consider its use in open injuries

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.

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

Introduction:. Failure to adequately treat an injury of the syndesmosis leads to poor functional outcomes and posttraumatic arthritis. Many techniques have been proposed to salvage chronic instability. We report on the largest series of chronic syndesmotic injuries to be managed by syndesmotic arthrodesis from Europe to date. Aim:. To determine the radiographic and clinical outcomes for this technique at our institute. Methods:. Patients were followed-up prospectively. Relevant radiological and clinical data were obtained from electronic and case note review. The AOFAS score was utilised. Results:. A total of 6 patients were found. The average age was 33 years and the mean length of follow-up was 20 months. Arthrodesis was radiologically successful in all cases. Mean pre-operative and post-operative AOFAS scores were 70 and 82 respectively. All patients had some persistent ankle pain. One third had radiological progression of ankle osteoarthritis. Complications consisted of one patient with scar sensitivity. Conclusions:. This technique has a role in the salvage of chronic ankle syndesmotic instability. However patients must be counselled to the likelihood of ongoing symptoms