ACUTE DISTAL TIBIOFIBULAR SYNDESMOTIC INJURIES IN ANKLE FRACTURES
Abstract
A stable tibiofibular syndesmosis articulation maintains the tibiofibular alignment and is necessary for normal ankle function. An ideal syndesmotic reduction and stabilization strategy should replicate the orientation and stabilizing forces of the syndesmotic ligaments. The aim of this study is to evaluate the outcomes of operative treatment for tibiofibular syndesmosis rupture associated with malleolar fractures.
This study presents patients with tibiofibular syndesmosis disruption treated at the Orthopedic Clinic of the Clinical Center in Niš from January 2017 to January 2019. The subjects included individuals with malleolarfractures accompanied by tibiofibular syndesmosis injuries. Treatment involved malleolar fixation and transfixation of the tibiofibular syndesmosis. Radiographic, clinical, operative and statistical methods were used to evaluate the study objectives.
In the group of 46 subjects with tibiofibular syndesmosis rupture, there were 28 (61%) men and 18 (39%) women, with age ranging from 18 to 79 years (mean age = 43.6 ± 9.6 years). The predominant cause of injury was slipping and falling in 32 patients (70%), followed by falls from a height in 9 patients (19%), and traffic accidents in 5 patients (11%). According to the Lauge‒Hansen classification, 27 (59%) patients sustained supination-external rotation type injuries. Based on the final functional treatment outcome assessed using the Olerud-Molander scoring system, the average ankle score was 87 points (range 55 to 100). Among the patients, 34 (74%) achieved excellent or good results: 24 (52%) had excellent outcomes (score from 90 to 100 points), and 10 (22%) had good outcomes (80 to 89 points). Satisfactory outcomes were observed in 7 (15%) patients, while poor outcomes were recorded in 5 patients (11%).
Our results indicate that stable and timely surgical reconstruction and fixation of the malleolus and tibiofibular syndesmosis enable functional restoration and recovery of the ankle joint with a low rate of complications.
References
Burns WC 2nd, Prakash K, Adelaar R, Beaudoin A, Krause W. Tibiotalar joint dynamics: indications for the syndesmotic screw--a cadaver study. Foot Ankle 1993;14(3):153-8. [CrossRef] [PubMed]
Danis R. Les fractures malleolaires. In: Danis R, ed. Theorie et Pratique de l’Osteosynthese. Paris, France: Masson et Cie; 1949:133–65.
Desouky O, Elseby A, Ghalab AH. Removal of Syndesmotic Screw After Fixation in Ankle Fractures: A Systematic Review. Cureus 2021;13(6):e15435. [CrossRef] [PubMed]
Gan K, Zhou K, Hu K, Lu L, Gu S, Shen Y. Dynamic Fixation Versus Static Fixation for Distal Tibiofibular Syndesmosis Injuries: A Meta-Analysis. Med Sci Monit 2019;18(25):1314-22. [CrossRef] [PubMed]
Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat 2010;217(6):633-45. [CrossRef] [PubMed]
Hovis WD, Kaiser BW, Watson JT, Bucholz RW. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg Am 2002;84(1):26-31. [CrossRef] [PubMed]
Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16(4):494-502. [CrossRef] [PubMed]
Khambete P, Harlow E, Ina J, Miskovsky S. Biomechanics of the Distal Tibiofibular Syndesmosis: A Systematic Review of Cadaveric Studies. Foot Ankle Orthop 2021; 6(2): 24730114211012701. [CrossRef] [PubMed]
Lampridis V, Gougoulias N, Sakellariou A. Stability in ankle fractures: Diagnosis and treatment. EFORT Open Rev 2018;3(5):294-303. [CrossRef] [PubMed]
Lauge Hansen N. Ligamentous ankle fractures.Diagnosis and treatment. Acta Chir Scand 1949; 97: 544 – 50. [PubMed]
Miller MA, McDonald TC, Graves ML, Spitler CA, Russell GV, Jones LC, Replogle W, Wise JA, Hydrick J, Bergin PF. Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation. Foot Ankle Int 2018;39(1):99-104. [CrossRef] [PubMed]
Mladenović M, Stojiljković P, Mladenović D, Krstić A, Anđelković V. Uloga i značaj fiksacije zadnjeg maleolusa kod trimaleolarnih preloma. Timočki medicinski glasnik 2021; 46(2):79-85. [CrossRef]
O'Daly AE, Kreulen RT, Thamyongkit S, Pisano A, Luksameearunothai K, Hasenboehler EA, Helgeson MD, Shafiq B. Biomechanical Evaluation of a New Suture Button Technique for Reduction and Stabilization of the Distal Tibiofibular Syndesmosis. Foot Ankle Orthop 2020;5(4):2473011420969140. [CrossRef] [PubMed]
Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 1994;10(5):558-60. [CrossRef] [PubMed]
Olerud C, Molander H. A scoring scale for symptom evaluation after ankle fracture. Arch Orthop Trauma Surg 1984; 103: 190 – 4. [CrossRef] [PubMed]
Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg 1985;104(5):299–302. [CrossRef] [PubMed]
Ovaska MT, Mäkinen TJ, Madanat R, Kiljunen V, Lindahl J. A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop 2014;38(1):83-8. [CrossRef] [PubMed]
Pretterklieber ML. Anatomie und Kinematik der Sprunggelenke des Menschen. Der Radiologe 1999;39:1–7. [CrossRef] [PubMed]
Regauer M, Mackay G, Nelson O, Böcker W, Ehrnthaller C. Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries. J Clin Med 2022;11(2):331. [CrossRef] [PubMed]
Sanders D, Schneider P, Taylor M, Tieszer C, Lawendy A R. Canadian Orthopaedic Trauma Society Improved Reduction of the Tibiofibular Syndesmosis With Tight Rope Compared with Screw Fixation: Results of a Randomized Controlled Study. J Orthop Trauma 2019;33:531–7. [CrossRef] [PubMed]
Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop 2012;36(6):1199-206. [CrossRef] [PubMed]
Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J 2017;99-B (11):1413-9. [CrossRef] [PubMed]
Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am 1997;79(12):1809-15. [CrossRef] [PubMed]
Wang Q, Liu S, Wang Z, Li A, Ding J. Meta-analysis of elastic versus rigid fixation in the treatment of acute tibiofibular syndesmosis injury. Syst Rev 2024;13,51. [CrossRef] [PubMed]
Weber AC, Hull MG, Johnson AJ, Henn RF 3rd. Cost analysis of ankle syndesmosis internal fixation. J Clin Orthop Trauma 2019;10(1):173-7. [CrossRef] [PubMed]
Xing W, Wang Y, Sun L, Wang L, Kong Z, Zhang C, et al. Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis. Medicine (Baltimore) 2018;97(37):e12079. [CrossRef] [PubMed]
Yablon IG, Heller FG, Shouse L. The key role of the lateral malleolus in displaced fractures of the ankle. J Bone Joint Surg Am 1977;59(2):169-73. [CrossRef] [PubMed]
Yuen CP, Lui TH. Distal Tibiofibular Syndesmosis: Anatomy, Biomechanics, Injury and Management. Open Orthop J 2017; 31(11):670-7. [CrossRef] [PubMed]
