A computed tomography evaluation of two hundred normal ankles, to ascertain what anatomical landmarks to use when compressing or placing an ankle syndesmosis screw

Kennedy, M.T.; Carmody, Olan; Leong, Sum; Kennedy, Ciara; Dolan, M.

doi:10.1016/j.foot.2014.07.001

Cited by 22 publications

(23 citation statements)

References 23 publications

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“…Studies have reported malreduction rates ranging from 16% to 52% of patients. 10–13 Off-axis clamping and screw trajectory, 14–16 along with difficult intra-operative radiographic reduction assessment, are commonly cited factors for such high malreduction rates. 3,17,18 The use of computed tomography (CT) scanning has been validated as a more reproducible and sensitive means of assessing the accuracy of syndesmotic reductions.…”

Section: Introductionmentioning

confidence: 99%

Medial Clamp Tine Positioning Affects Ankle Syndesmosis Malreduction

Cosgrove

Putnam

Cherney

et al. 2017

Journal of Orthopaedic Trauma

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Objectives The purpose of this study was to determine if the position of the medial clamp tine during syndesmotic reduction affected reduction accuracy. Design Prospective Cohort. Setting Urban level 1 trauma center. Patients Seventy-two patients with operatively treated syndesmotic injuries. Intervention Patients underwent operative fixation of their ankle syndesmotic injuries using reduction forceps. The position of the medial clamp tine was then recorded with intraoperative fluoroscopy. Malreduction rates were then assessed with bilateral ankle computerized tomography. Main Outcome Measurement Fibular position within the incisura was measured with respect to the uninjured side to determine if a malreduction had occured. Malreductions were then analyzed for associations with injury pattern, patient demographics and the location of the medial clamp tine. Results A statistically significant association was found between medial clamp position and sagittal plane syndesmosis malreduction. In reference to anterior fibular translation, there was a 0% malreduction rate in the 18 patients where the clamp tine was placed in the anterior third, a 19.4% malreduction rate in the middle third and 60% malreduction rate in the posterior third (p = 0.006). In reference to posterior fibular translation, there was a 11.1% malreduction when clamp placement was in the anterior third, a 16.1% malreduction rate in the middle third and 60% malreduction rate in the posterior third (p = 0.062). There were no significant associations between medial clamp position and coronal plane malreductions (over- or under-compression) (p = 1). Conclusions When using reduction forceps for syndesmotic reduction, the position of the medial clamp tine can be highly variable. The angle created with off-axis syndesmotic clamping is likely a major culprit in iatrogenic malreduction. Sagittal plane malreduction appears to be highly sensitive to clamp obliquity, which is directly related to the medial clamp tine placement. Based on these data, we recommend placing the medial clamp tine in the anterior third of the tibial line on the lateral view to minimize malreduction risk.

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Section: Introductionmentioning

confidence: 99%

Medial Clamp Tine Positioning Affects Ankle Syndesmosis Malreduction

Cosgrove

Putnam

Cherney

et al. 2017

Journal of Orthopaedic Trauma

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“…This information is crucial given prior studies that emphasize the importance of anatomic syndesmotic reduction. Classically, syndesmotic screws are placed at 30 degrees from the coronal plane [11, 30]. In this study, we determined the anatomic TSA in 45 uninjured adult ankles and found that the average syndesmotic angle was less than this historically accepted value, averaging 21±5 degrees anterior to the plane of a lateral radiograph.…”

Section: Discussionmentioning

confidence: 92%

“…In a study by Lepojarvi et al [12], 97% of the fibulas were positioned anteriorly or centrally. As such, any reduction vector that is not collinear with the true axis of the syndesmosis has the potential to malreduce the fibula within the incisura [11, 12, 16, 18, 20]. Coronal and sagittal alignment is readily measured on plain radiographs, and coronal malalignment has been the most frequently cited and measured in previous studies [16, 18, 20].…”

Section: Discussionmentioning

confidence: 99%

“…Ankle fractures are one of the most common operatively managed lower extremity injuries in orthopaedics, and 11 to 20% of unstable ankle fractures will have concomitant syndesmotic disruption [10, 11, 30]. Anatomic reduction of the syndesmosis and ankle mortise is critical to restore normal joint biomechanics and tibiotalar contact forces in order to optimize outcomes [2, 19, 22, 27, 29].…”

Section: Introductionmentioning

confidence: 99%

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Simulating clamp placement across the trans-syndesmotic angle of the ankle to minimize malreduction: A radiological study

Putnam

Linn²,

Spraggs-Hughes

et al. 2017

Injury

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Background Ankle fractures associated with syndesmotic injury have a poorer prognosis than those without such an injury. Anatomic reduction of the distal tibiofibular joint restores joint congruency and minimizes contact pressures, yet operative fixation of syndesmotic ankle injuries is frequently complicated by malreduction of the syndesmosis. Current methods of assessing reduction have been shown to be inadequate. As such, additional methods to judge the accuracy of syndesmotic reduction are required. Questions/Purposes The purposes of our study were (1) to determine the anatomic axis of the syndesmosis, or the trans-syndesmotic angle (TSA), and (2) to describe the intraoperative fluoroscopic appearance of syndesmotic clamp reduction oriented along the anatomic syndesmotic angle. Methods Computed tomography (CT) scans of 45 uninjured adult ankles were analyzed to measure the TSA, defined as the angle between the plane of a lateral ankle radiograph and a line drawn perpendicular to the fibular incisura. Three-dimensional reconstructions of CT scans were then used to demonstrate clamp placement collinear with the TSA as would be seen on an intraoperative lateral ankle radiograph. Results The average TSA measured 21±5 degrees anterior to the plane of a lateral radiograph. When a simulated reduction clamp tine was placed on the fibular ridge and the clamp oriented along the TSA, the medial tine, as seen on a lateral radiograph, was within the anterior one-third of the tibia 93% of the time. It was, on average, 23±7% of the distance from the anterior to the posterior tibial cortex, with tine placement occurring in this range in 73% of ankles. The medial tine rested 53±17% of the distance between the anterior cortices of the tibia and fibula, with 71% of tines placed in this range. Conclusions Reduction clamp placement oriented along the TSA has a predictable appearance on lateral ankle imaging and can guide clamp positioning during syndesmotic reduction. With one tine placed on the fibular ridge, placing the medial clamp tine in the anterior third of the tibia, or halfway between the anterior cortices of the tibia and fibula is the most accurate position for reduction in line with the TSA. Level of Evidence 2 (Retrospective diagnostic)

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“…149 This position corresponds to a line from the lateral cortical apex of the fibula to the anterior half of the medial malleolus. 150 Aberrant screw placement may cause malreduction. 100 Furthermore, the screw should be inserted parallel to the ankle joint in the coronal plane to prevent any proximal migration.…”

Section: Implant Placementmentioning

confidence: 99%