Limitations of Standard Fluoroscopy in Detecting Rotational Malreduction of the Syndesmosis in an Ankle Fracture Model

Abstract

In the setting of ankle fractures with syndesmosis disruption, fixing the fibula in as much as 30 degrees of external rotation may go undetected using intraoperative fluoroscopy alone.

Complications in ankle fracture surgery

“…Direct visualization and open reduction of the syndesmosis has been recommended (Miller et al 2009), since lateral translation and rotational malalignment of the fibula at the level of the syndesmosis may go underdetected (Marmor et al 2011). This is reflected in our findings, since the majority of reoperated cases were due to syndesmotic malreduction (III).…”

Anatomic Fixation of Supination External Rotation Type IV Equivalent Ankle Fractures

“…Despite the previous confirmation that plain radiographs provide an inaccurate assessment of syndesmotic reduction, plain radiographs provide the easiest, most cost-saving, method of longitudinal evaluation of implants and bone position. 20 Additionally, the clinical significance of the 1-mm difference between final MCS in the 2 groups may not be determined until 10-20 years of clinical follow-up. These radiographs provide a cheaper assessment of ankle congruency and the presence of postoperative arthritis with prolonged follow-up, as well as a decreased radiation burden.…”

Acute and Chronic Injuries to the Syndesmosis

“…The literature has shown syndesmotic malreductions to occur in as many as 25.5% to 52% of patients. 66,75,76,102,109,110 The malpositioning is often in the sagittal plane with anterior displacement and internal rotation. [108][109][110] Predictors of malreduction have been investigated, but no significant factors could be elucidated.…”

“…A cadaveric study suggested that a 30 external malrotation of the fibula may result when using TFCS, TFO, and posterior subluxation to assess reduction. 102 Because of these difficulties, surgeons have attempted to compare the injured side with a normal contralateral extremity. 103,104 Although substantial variation in ankle anatomy exists between individuals, there is little variation between contralateral ankles of a single individual.…”