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Optimal management of ankle syndesmosis injuries.

Porter DA, Jaggers RR, Barnes AF, Rund AM - Open Access J Sports Med (2014)

Bottom Line: If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted.In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct.Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible.

View Article: PubMed Central - PubMed

Affiliation: Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA.

ABSTRACT
Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

No MeSH data available.


Related in: MedlinePlus

Postoperative left anterior-posterior ankle radiograph after open reduction and internal fixation of Weber C fibular shaft fracture with lag screws, one third tubular plate and two suture button fixation of the syndesmosis demonstrating anatomic alignment of the syndesmosis, medial clear space and fibular shaft. The deltoid ligament was also repaired in this athlete.
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f2-oajsm-5-173: Postoperative left anterior-posterior ankle radiograph after open reduction and internal fixation of Weber C fibular shaft fracture with lag screws, one third tubular plate and two suture button fixation of the syndesmosis demonstrating anatomic alignment of the syndesmosis, medial clear space and fibular shaft. The deltoid ligament was also repaired in this athlete.

Mentions: Fixation with trans-syndesmotic screws has long served as a reliable method of tibiofibular stabilization. A recent study by Lambers et al33 examined 21-year follow-up in patients who underwent treatment with two syndesmotic screws for Maisonneuve-type pronation-external rotation injuries. They found that while nearly half of the patients had radiographic evidence of arthritis, 92% had good or excellent functional outcomes.33 In cases using syndesmotic screws, no study has found statistical differences between quadricortical and tricortical screws or the number of screws used.25 A four-hole, one-third tubular plate can be positioned over the lateral fibula and secured with 3.5 mm screws in the most proximal and distal holes stabilizing the placement. Under fluoroscopic guidance, a partially threaded 4.5 mm screw is placed across the syndesmosis, 1 cm above the tibial plafond. A second 4.5 mm screw is drilled proximally (fully threaded) for additional stability. In the rare instance of a Weber B pattern with an unstable syndesmosis, the present authors use anterior-to-posterior lag screw fixation and a posterolateral one-third tubular antiglide plate. Weber type C fractures are stabilized by a lateral slide plate and occasionally a 2.7 mm or 3.5 mm lag screw. True bimalleolar (medial malleolus and lateral malleolus) and bimalleolar equivalent (lateral malleolus and deltoid rupture) fractures follow anatomic reduction as prescribed via Weber type B and type C procedures, with additional repair of the deltoid ligament. True bimalleolar and bimalleolar equivalent fractures are classified together because the prognosis, recovery, rehabilitation, and decision-making are similar.8 One or two plates may be used depending on the extent and location of fracture. If a Maisonneuve fracture is present, fibular fixation is not performed for the proximal fibula fracture component. The syndesmotic screws and plate are typically removed 2–4 months after surgery. Some advocate screw removal should be delayed in overweight patients to ensure adequate reduction is maintained.2 Currently, the present authors stabilize syndesmosis injuries associated with a Weber C fracture with a suture-button device through the same plate used for the fibula fracture fixation (Figure 2). With this technique, there is no planned hardware removal. We ensure medially that the endobutton is subperiosteally placed to decrease “creep” and decrease the risk of tissue necrosis under the button leading to osteomyelitis.


Optimal management of ankle syndesmosis injuries.

Porter DA, Jaggers RR, Barnes AF, Rund AM - Open Access J Sports Med (2014)

Postoperative left anterior-posterior ankle radiograph after open reduction and internal fixation of Weber C fibular shaft fracture with lag screws, one third tubular plate and two suture button fixation of the syndesmosis demonstrating anatomic alignment of the syndesmosis, medial clear space and fibular shaft. The deltoid ligament was also repaired in this athlete.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4128849&req=5

f2-oajsm-5-173: Postoperative left anterior-posterior ankle radiograph after open reduction and internal fixation of Weber C fibular shaft fracture with lag screws, one third tubular plate and two suture button fixation of the syndesmosis demonstrating anatomic alignment of the syndesmosis, medial clear space and fibular shaft. The deltoid ligament was also repaired in this athlete.
Mentions: Fixation with trans-syndesmotic screws has long served as a reliable method of tibiofibular stabilization. A recent study by Lambers et al33 examined 21-year follow-up in patients who underwent treatment with two syndesmotic screws for Maisonneuve-type pronation-external rotation injuries. They found that while nearly half of the patients had radiographic evidence of arthritis, 92% had good or excellent functional outcomes.33 In cases using syndesmotic screws, no study has found statistical differences between quadricortical and tricortical screws or the number of screws used.25 A four-hole, one-third tubular plate can be positioned over the lateral fibula and secured with 3.5 mm screws in the most proximal and distal holes stabilizing the placement. Under fluoroscopic guidance, a partially threaded 4.5 mm screw is placed across the syndesmosis, 1 cm above the tibial plafond. A second 4.5 mm screw is drilled proximally (fully threaded) for additional stability. In the rare instance of a Weber B pattern with an unstable syndesmosis, the present authors use anterior-to-posterior lag screw fixation and a posterolateral one-third tubular antiglide plate. Weber type C fractures are stabilized by a lateral slide plate and occasionally a 2.7 mm or 3.5 mm lag screw. True bimalleolar (medial malleolus and lateral malleolus) and bimalleolar equivalent (lateral malleolus and deltoid rupture) fractures follow anatomic reduction as prescribed via Weber type B and type C procedures, with additional repair of the deltoid ligament. True bimalleolar and bimalleolar equivalent fractures are classified together because the prognosis, recovery, rehabilitation, and decision-making are similar.8 One or two plates may be used depending on the extent and location of fracture. If a Maisonneuve fracture is present, fibular fixation is not performed for the proximal fibula fracture component. The syndesmotic screws and plate are typically removed 2–4 months after surgery. Some advocate screw removal should be delayed in overweight patients to ensure adequate reduction is maintained.2 Currently, the present authors stabilize syndesmosis injuries associated with a Weber C fracture with a suture-button device through the same plate used for the fibula fracture fixation (Figure 2). With this technique, there is no planned hardware removal. We ensure medially that the endobutton is subperiosteally placed to decrease “creep” and decrease the risk of tissue necrosis under the button leading to osteomyelitis.

Bottom Line: If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted.In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct.Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible.

View Article: PubMed Central - PubMed

Affiliation: Methodist Sports Medicine/The Orthopedic Specialists, Indianapolis, IN, USA.

ABSTRACT
Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

No MeSH data available.


Related in: MedlinePlus