Evaluation of syndesmosis reduction after removal syndesmosis screw in ankle fracture with syndesmosis injury

Amouzadeh Omrani, Farzad; Kazemian, Gholamhosein; Salimi, Sohrab

Evaluation of syndesmosis reduction after removal syndesmosis screw in ankle fracture with syndesmosis injury

Document Type : Original Article

Authors

¹ Department of Orthopedics, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

² Department of Anesthesiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

Background: Ankle fracture–dislocation with a syndesmotic injury has been treated with syndesmotic screw fixation. There are little evidences about the safety and efficacy of syndesmotic screw removal on the syndesmotic malreduction. This study aimed to evaluate the effects of syndesmotic screw removal of distal attachment of the fibula and tibia bones on the syndesmotic reduction and also impact of syndesmotic screw removal on the final functional score of ankle joint. Materials and Methods: Patients who underwent syndesmotic screw fixation for diagnosed syndesmosis injury during internal fixation surgery for ankle fractures from April 2017 to March 2018 were assessed for enrollment in our study. During open reduction and internal fixation for ankle fracture, existence of syndesmosis injury was evaluated using the Cotton test and external rotation stress test. Appropriate rehabilitation including short leg cast and nonweight bearing have been accomplished for a duration 12 weeks before removing of syndesmotic screws. At 12 weeks, screws were removed. After 1-month weight bearing, bilateral axial computed tomography (CT) scan and single-leg weight-bearing X-ray for injured ankle were obtained. Results: Of all 60 participants, 42 cases (70%) were male and 18 cases (30%) were female. Postoperative ankle radiographies were normal except one case with increased medial clear space. It was interesting findings that from total 60 cases, 18 patients (30%) had evidence of syndesmosis malreduction on postoperative initial CT scan, and after removing of syndesmotic screws (12 weeks) and a period of weight bearing and rehabilitation (4 weeks), there is evidence of appropriate reduction in 13 cases (of 18 patients [72.2%]) on final CT scans.Conclusion: Syndesmotic screw removal and weight bearing may be advantageous to achieve final anatomic reduction of the syndesmosis. Syndesmotic screw removal at appropriate time could not improve foot functional outcomes; however, more studies with the larger sample size are required to confirm the results of the study.

Keywords

References

1.	Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: Investigation and treatment options. Dtsch Arztebl Int 2014;111:377-88.
2.	Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. J Bone Joint Surg Br 2008;90:405-10.
3.	Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: Implications for screw removal. J Orthop Trauma 2010;24:2-6.
4.	Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma 2012;26:439-43.
5.	Moore JA Jr., Shank JR, Morgan SJ, Smith WR. Syndesmosis fixation: A comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int 2006;27:567-72.
6.	Song DJ, Lanzi JT, Groth AT, Drake M, Orchowski JR, Shaha SH, et al. The effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint: A Prospective radiographic study. Foot Ankle Int 2014;35:543-8.
7.	Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970-2000 and projections for the future. Bone 2002;31:430-3.
8.	Zaghloul A, Haddad B, Barksfield R, Davis B. Early complications of surgery in operative treatment of ankle fractures in those over 60: A review of 186 cases. Injury 2014;45:780-3.
9.	Casillas MM. Operative treatment of acute syndesmotic injuries with screw fixation and without direct exposure or repair of the syndesmotic ligaments. Tech Foot Ankle Surg 2006;5:27-33.
10.	Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 2005;19:102-8.
11.	Walley KC, Hofmann KJ, Velasco BT, Kwon JY. Removal of hardware after syndesmotic screw fixation: A systematic literature review. Foot Ankle Spec 2017;10:252-7.
12.	Schepers T. To retain or remove the syndesmotic screw: A review of literature. Arch Orthop Trauma Surg 2011;131:879-83.
13.	Miller AN, Paul O, Boraiah S, Parker RJ, Helfet DL, Lorich DG. Functional outcomes after syndesmotic screw fixation and removal. J Orthop Trauma 2010;24:12-6.
14.	Baek JH, Kim TY, Kwon YB, Jeong BO. Radiographic Change of the Distal Tibiofibular Joint Following Removal of Transfixing Screw Fixation. Foot Ankle Int. 2018;39(3):318-325.
15.	Tucker A, Street J, Kealey D, McDonald S, Stevenson M. Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal-is it really necessary? Injury 2013;44:1880-4.
16.	Kaftandziev I, Spasov M, Trpeski S, Zafirova-Ivanovska B, Bakota B. Fate of the syndesmotic screw – Search for a prudent solution. Injury 2015;46 Suppl 6:S125-9.
17.	Schepers T, van der Linden H, van Lieshout EM, Niesten DD, van der Elst M. Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury. Injury 2014;45:775-9.

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