Prospective Intraoperative Syndesmotic Evaluation During Ankle Fracture Fixation

Matuszewski, Paul E.; Dombroski, Derek; Lawrence, J. Todd R.; Esterhai, John L.; Mehta, Samir

doi:10.1097/bot.0000000000000247

Cited by 23 publications

(13 citation statements)

References 20 publications

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“…6,9,10,17,19 To date, there is a lack of consensus on the exact definition of syndesmotic instability and on the recommended treatment for these injuries. 11,13,20 An important distinction must be made between ligament injury and true instability. Although preoperative CT scans, MRI, and stress x-rays can help detect instability, intraoperative dynamic stress testing is still used to decide if operative fixation is needed.…”

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confidence: 99%

“…2,18,20 Unfortunately, both the LST and ERT radiographic parameters predominantly evaluate coronal fibular motion, which may explain why the sensitivity and specificity of these tests remain suboptimal. 2,6,13 Therefore, stressing the fibula in the sagittal and coronal plane would be more likely to improve the diagnostic accuracy of intraoperative syndesmosis instability assessment. In order to accomplish this, we developed a new intraoperative test, the torque test (TT), which stresses the fibula laterally and posteriorly under direct visualization.…”

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confidence: 99%

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Intraoperative Torque Test to Assess Syndesmosis Instability

Gosselin-Papadopoulos

Hébert‐Davies

Laflamme

et al. 2018

Foot Ankle Int.

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Background: In this cadaveric study, a new “torque test” (TT) stressing the fibula posterolaterally under direct visualization was compared with the classical external rotation stress test (ERT) and lateral stress test (LST). Methods: The anteroinferior tibiofibular ligament (AiTFL), the interosseous membrane (IOM), and the posteroinferior tibiofibular ligament (PiTFL) were sectioned sequentially on 10 fresh-frozen human ankles. At each stage of dissection, instability was assessed using the LST, ERT, and TT under direct visualization. Anatomical tibiofibular diastasis measurements were taken directly on cadavers and compared using the Wilcoxon signed rank test. Results: All 3 tests showed statistically significant motion in the syndesmosis when at least 2 ligaments were sectioned. The mean increase across diastasis with a 2-ligament section was 3.0 mm ( P = .005), 3.2 mm ( P = .005), and 4.8 mm ( P = .005) for the LST, ERT, and TT, respectively. The largest mean increase in diastasis was obtained with a complete injury using the TT and was 6.2 mm ( P = .008). With the TT, a 3.5-mm tibiofibular diastasis was 90% sensitive and 100% specific when 2 or more syndesmotic ligaments were sectioned. Conclusion: The TT was a more sensitive and specific tool for detecting syndesmosis instability than classic LST and ERT. Clinical relevance: Stressing the fibula in a posterolateral direction created a larger distal tibiofibular diastasis, which would be easier to detect in the intraoperative setting. The TT was more sensitive and specific to detecting a 2-ligament syndesmotic injury than the classic test and required less force to perform.

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confidence: 99%

mentioning

confidence: 99%

Intraoperative Torque Test to Assess Syndesmosis Instability

Gosselin-Papadopoulos

Hébert‐Davies

Laflamme

et al. 2018

Foot Ankle Int.

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“…Because of the anatomy and limited range of motion of the ankle joint, the epiphysis of the distal tibia, especially the medial malleolus, often suffers sprain and extrusion. When the foot is fixed, external forces causing varus or valgus movement, plantar flexion, dorsiflexion, or external rotation of the foot can all cause injury to the epiphysis of the distal tibia [18]. In children, the epiphyseal plate is particularly susceptible to injury during the skeletal developmental stages because the epiphyseal plate connection is a mechanically weak zone.…”

Section: Discussionmentioning

confidence: 99%

Cannulated screw and Kirschner fixation for the treatment of medial and lateral malleolar epiphyseal fractures in children: a retrospective study of 36 cases

Jiang

et al. 2019

J Orthop Surg Res

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Background Percutaneous fixation with cannulated screws is an effective method for treating medial malleolar epiphyseal fractures, which comprise a portion of bimalleolar and trimalleolar fractures. Lateral malleolar fractures also need to be fixed to achieve anatomical reduction and absolute stable fixation of the ankle. However, there are no individual studies in the literature on this topic. Methods Thirty-six children (22 boys and 14 girls) aged 8 to 15 years (average, 11.3 years) with medial and lateral epiphyseal fractures were treated by cannulated screw and Kirschner fixation after closed reduction from January 2010 to December 2015 in our hospital. The patients were examined each month postoperatively. Ankle function was assessed using the Baird-Jackson ankle score. Results The 36 patients were followed up for 18 to 29 months (average, 25 months). No cases of fracture non-union or secondary displacement were observed, and the healing time was 2.8 ± 1.1 months (range, 2–4 months). At the last follow-up visit, the Baird-Jackson ankle score ranged from 83 to 100 (average, 94), including an “excellent” score in 13 cases, a “good” score in 19 cases, a “fair” score in 4 cases, and a “poor” score in 0 cases. The ankle recovered to the pre-injury level of function within 3.5 ± 1.6 months (range, 2–5 months). Dysfunction, pain, instability, and premature epiphyseal closure were not observed during the follow-up of the 36 patients. Conclusions Cannulated screw and Kirschner fixation after closed reduction is an effective and readily available method for the treatment of medial and lateral malleolar epiphyseal fractures in children.

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“…The bone block was supplemented with a tetracortical syndesmotic screw. Follow-up demonstrated improved average AOFAS scores (75)(76)(77)(78)(79)(80)(81)(82)(83)(84)(85)(86)(87)(88)(89)(90)(91)(92) in 12 patients treated greater than 2 years after initial injury with an average follow-up of 25 months.…”

Section: Surgical Treatment Reconstructionmentioning

confidence: 95%

“…A prospective cohort study showed that widening with stress external rotation was significantly greater than with lateral fibular stress and appreciable on standard fluoroscopic views. 87 However, these results must be taken in the context of biomechanical evidence to suggest that the hook test with a 100 N force and visualization of widening of the TFCS is superior in differentiating syndesmotic disruption from isolated deltoid ligament injury in a Weber B ankle fracture model. 88 even if the external rotation stress may demonstrate significant widening, this may represent a deltoid ligament injury based on biomechanical data; this underlies the point that the clinician needs to use all available techniques to accurately diagnose a syndesmotic injury.…”

Section: Syndesmotic Injuries With Associated Fracturesmentioning

confidence: 95%