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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 anterior-posterior ankle radiograph after open reduction and internal fixation of unstable syndesmosis injury with five hole one third tubular plate, two suture buttons and one 4.5 mm cannulated screw demonstrating anatomic alignment of the syndesmosis and the medial clear space. The deltoid was also repaired.
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f3-oajsm-5-173: Postoperative anterior-posterior ankle radiograph after open reduction and internal fixation of unstable syndesmosis injury with five hole one third tubular plate, two suture buttons and one 4.5 mm cannulated screw demonstrating anatomic alignment of the syndesmosis and the medial clear space. The deltoid was also repaired.

Mentions: Recent years have seen the advent of suture-button devices, providing what has proven to be another viable option for syndesmosis stabilization. Suture-button fixation consists of a braided, nonabsorbable fiberwire suture that spans the distal tibiofibular articulation that is secured in place directly on the bone on each side by an endobutton (or over the plate in the setting of fibular fracture fixation). This provides for potential advantages over screw fixation, including greater, more anatomic mobility of the joint, quicker return to weight bearing and sports, no osteolysis, and no need for hardware removal.17,21,36,37 The procedure is performed with the same basic principles as screw fixation. After anatomic restoration of the syndesmosis and placement of a tibiofibular clamp, a 2.7 mm drill is used to create the intraosseous pathway. A guidewire is then used to pull one endobutton and the suture through to the medial side. The endobutton is toggled and flipped, and the suture is tensioned and secured laterally over a second endobutton, which is placed over a lateral fibular plate. Newer designs with knotless tightrope systems have helped to minimize the risk of soft tissue irritation over the lateral knot.38 In the setting of purely ligamentous injuries, the present authors have recently moved to a combination of screw and suture-button fixation (Figure 3). This allows for initial rigid fixation until screw removal, which can be performed in the office. The suture-buttons then remain for longer-term stabilization.


Optimal management of ankle syndesmosis injuries.

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

Postoperative anterior-posterior ankle radiograph after open reduction and internal fixation of unstable syndesmosis injury with five hole one third tubular plate, two suture buttons and one 4.5 mm cannulated screw demonstrating anatomic alignment of the syndesmosis and the medial clear space. The deltoid was also repaired.
© Copyright Policy
Related In: Results  -  Collection

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

f3-oajsm-5-173: Postoperative anterior-posterior ankle radiograph after open reduction and internal fixation of unstable syndesmosis injury with five hole one third tubular plate, two suture buttons and one 4.5 mm cannulated screw demonstrating anatomic alignment of the syndesmosis and the medial clear space. The deltoid was also repaired.
Mentions: Recent years have seen the advent of suture-button devices, providing what has proven to be another viable option for syndesmosis stabilization. Suture-button fixation consists of a braided, nonabsorbable fiberwire suture that spans the distal tibiofibular articulation that is secured in place directly on the bone on each side by an endobutton (or over the plate in the setting of fibular fracture fixation). This provides for potential advantages over screw fixation, including greater, more anatomic mobility of the joint, quicker return to weight bearing and sports, no osteolysis, and no need for hardware removal.17,21,36,37 The procedure is performed with the same basic principles as screw fixation. After anatomic restoration of the syndesmosis and placement of a tibiofibular clamp, a 2.7 mm drill is used to create the intraosseous pathway. A guidewire is then used to pull one endobutton and the suture through to the medial side. The endobutton is toggled and flipped, and the suture is tensioned and secured laterally over a second endobutton, which is placed over a lateral fibular plate. Newer designs with knotless tightrope systems have helped to minimize the risk of soft tissue irritation over the lateral knot.38 In the setting of purely ligamentous injuries, the present authors have recently moved to a combination of screw and suture-button fixation (Figure 3). This allows for initial rigid fixation until screw removal, which can be performed in the office. The suture-buttons then remain for longer-term stabilization.

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