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The management of acute distal tibio-fibular syndesmotic injuries: Results of a nationwide survey
Injury, Int. J. Care Injured 43 (2012) 1718–1723
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The management of acute distal tibio-fibular syndesmotic injuries: Results of a nationwide survey Tim Schepers a,*, Wouter J. van Zuuren b, Michel P.J. van den Bekerom b, Lucas M.M. Vogels a, Esther M.M. van Lieshout a a b
Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Orthopedics, Spaarne Hospital, Hoofddorp, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 17 June 2012
Introduction: Ankle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands. Materials and methods: A postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw. Results: A total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the ‘Hook test’. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1–4.0 cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. Conclusion: Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Ankle fracture Syndesmotic injury Treatment Survey
Distal tibiofibular injury, resulting in syndesmotic instability occurs in over 10% of ankle fractures.1 Anatomical restoration and stabilisation of the disrupted distal tibiofibular syndesmosis is essential to prevent changes in contact load and posttraumatic degeneration, and for improving functional outcome.2–5 In general practice, it is advised to stabilise syndesmotic instability with one or more metallic trans-syndesmotic screws.6–8 Because several different methods of syndesmotic restoration have been described, the factual placement of the screw (i.e., the number, size and location) used, the postoperative management and the need for removal have all been subject to debate.9
* Corresponding author at: University Medical Center Rotterdam, Department of Surgery-Traumatology, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel.: +31 10 7031050; fax: +31 10 7032396. E-mail address: [email protected] (T. Schepers). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.06.015
The annual number of hospital admission after an ankle fracture in the Netherlands (16.73 million inhabitants) has increased from 6945 in 2008 and 8504 in 2009, to 9924 patients in 2010.10 It is estimated that 10% of all ankle fractures11 and 20% of operatively treated ankle fractures12 are accompanied by a syndesmotic injury necessitating fixation. This implies that an expected total of 992– 1985 acute syndesmotic injuries are treated annually in the Netherlands. The latter number is close to the incidence of 15 per 100,000 persons per year mentioned in the literature.1,13 Previous research revealed a significant variety in treatment of acute distal tibiofibular syndesmotic injuries. With the many different options for syndesmotic stabilisation, there appears to be a wide variety in management by different physicians and this variety tends to increase with new implants and insights. To investigate whether this variation is also present in the Dutch situation, where both trauma surgeons and orthopaedic surgeons treat this type of injury, we set up a survey in which the
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different aspects of the treatment of syndesmotic injury were assessed. Differences within and between these two disciplines were examined in the context of the currently available literature.
Materials and methods A postal survey was developed according to guidelines provided by a meta-analysis of randomised studies of postal surveys to optimise response rates.14 Attention was paid to the recommendations of the American Association for Public Opinion Research (AAPOR).15 Two trauma surgeons from a level-1 trauma centre and two orthopaedic surgeons from a level-2 trauma centre developed the questionnaire. The questions included in the survey are shown in Table 1. These questions were derived from recent literature and similar questionnaires from different countries. The goals of the survey were explained in a personally addressed accompanying letter. A stamped returning envelope was provided. After 4 weeks a reminder was sent, including a copy of the survey and a returning envelope. Depending upon the size of the hospital’s catchment area, the survey was sent to one or two trauma surgery staff members and one or two orthopaedic surgery staff members in each of the 86 hospitals in the Netherlands. Recipients with interest in fracture care or foot-and-ankle surgery were selected by contacting all hospitals prior to the survey. Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS, Chicago, IL, USA). Normality of data was assessed using the Kolmogorov–Smirnov test and by Table 1 Questions in the survey. Questions of the acute syndesmotic injury survey 1. 2. 3. 4a. 4b. 5. 6a. 6b. 7a. 7b 8a. 8b. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Are you a trauma surgeon or an orthopaedic surgeon? In what hospital are you currently employed? How many years of expertise do you have in fracture treatment? How do you pre-operatively identify the presence of syndesmotic injury? How do you per-operatively identify the presence of syndesmotic injury? At what time during the procedure do you test for syndesmotic disruption? What type of syndesmotic fixation do you prefer for an ankle fracture? What type of syndesmotic fixation do you prefer for a Maisonneuve ankle fracture? If you use a screw, what diameter do you prefer for an ankle fracture? If you use a screw, what diameter do you prefer for a Maisonneuve ankle fracture? Over how many cortices do you place the screw for an ankle fracture? Over how many cortices do you place the screw for a Maisonneuve ankle fracture? How do you reduce the syndesmosis? At what level do you place the syndesmotic screw? How do you determine the accuracy of your syndesmotic reduction? Do you allow weight-bearing with a syndesmotic screw? Do you routinely remove the syndesmotic screw? What is according to you the main reason for removal? What type of anaesthesia do you use at removal? After how many weeks do you remove the syndesmotic screw? Do you test for stability during the removal procedure? Do you allow immediate weight-bearing after removal of the syndesmotic screw? Would you consider participating in a RCT (routine removal versus on indication)?
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inspecting frequency histograms. The Levene’s test was applied to assess homogeneity of variance between data. Numeric data were found to be normally distributed and are expressed as mean with standard deviation (SD); categorical data are shown as numbers with percentages. A Student’s t-test (parametric, numeric data) or Chi-squared analysis (categorical data) was performed to assess statistical significance between groups with and without complications. A p-value < 0.05 was taken as the threshold of statistical significance. Results A total of 142 trauma surgeons in 86 hospitals and 139 orthopaedic surgeons in 84 hospitals in the Netherlands were addressed. The response rate, calculated by dividing the number of sent surveys by the number of surveys received, after 8 weeks was 85.2% for the trauma surgeons (representing 93% of the hospitals) and 61.9% of the orthopaedic surgeons (representing 81% of the hospitals). The results are shown in Tables 2–4, specified separately for the trauma and orthopaedic surgeons. A total of 24.6% of all respondents had less than 5 years of experience, 38.2% 6–15 years and 37.2% more than 15 years previous experience in the treatment of fractures. The presence of a syndesmotic injury was judged solely on conventional radiographs in 86.5%, 1% used stress radiographs and 5.3% reported the use of both. During the surgical procedure the techniques to identify a syndesmotic disruption are the ‘hook test’ in 49.8%, ‘Exorotation stress test’ in 8.7% and both in 36.2% (other or not available in 5.3%). The peroperative testing was performed prior to fixation of the fractured malleoli in 6.8%, and in 94.2% following the fixation (1% did both). The fixation of a ruptured syndesmosis in a (Weber-B) ankle fracture was performed with one screw in 81.2% and with two screws in 9.2%; another technique (i.e., suturing) was reported by 6.3%. In Maisonneuve injuries, these percentages were 28.0, 66.2 and 4.4, respectively. In distal ankle fracture cases where a screw was the preferred type of fixation, it was a 3.5-mm screw in 86.0% and a 4.5-mm screw in 11.1%; the rest (2.9%) did not specify the type of screw. In the Maisonneuve type injury, these percentages were 84.1, 14.5 and 1.4%, respectively. The number of cortices engaged in distal ankle fractures was three in 63.8%, four in 30.9% and an oblique placement or non-specified was reported in 5.3% of questionnaires. In Maisonneuve injuries, these percentages were 58.9, 37.2 and 3.8%, respectively. Reducing the fibula into the distal tibial notch was done by hand in 32.9%, by a large reduction (Weber) forceps in 55.1% and by the use of a lag-screw in 6.3% (different or unknown in 5.8%). The level of placement was between 0 and 2.0 cm in 5.3%, between 2.1 and 4.0 cm in 76.3% and between 4.1 and 6.0 cm in 16.4% (other or unknown 1.9%). The accuracy of the reduction was checked on peroperative fluoroscopy in 72.0%, open inspection of the syndesmosis in 8.7% and the standard use of a computed tomography (CT) scan was reported in 0.5% of questionnaires. The use of both fluoroscopy and open inspection was done by 10.1% and a different approach (including a peroperative three-dimensional (3D) scan) was reported by 7.2% of surgeons. Following placement, 58.9% of patients were not allowed to bear weight, 21.7% were allowed to bear weight after 4–6 weeks on average, or in a walking cast in 16.4%. The removal of the syndesmotic screw was routinely done by 87.0% of surgeons, infrequently by 2.4% and only in case of complaints in 9.2%. As the most important reason for removal, respondents choose limitations in range of motion in 25.6%, risk of breakage in 40.1, both in 30.4% and other (i.e., pain) in 3.9%. Removal was performed using local anaesthetics in 56.0%, regional
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Table 2 Pre- and peroperative evaluation of syndesmotic injury. Item
Years of experience 5 6–15 >15 Pre-operative evaluation X-ray standard X-ray stress Both Per-operative evaluation Hook test Exorotation stress test Both Timing of stability testing Before fixation of malleoli After fixation of malleoli
Trauma surgeons (N = 121)
Table 4 Postoperative management in syndesmotic injury repair.
Orthopaedic surgeons (N = 86)
p-Value
28 (23.1) 42 (34.7) 51 (42.1)
23 (26.7) 37 (43.0) 26 (30.2)
>0.05 >0.05 >0.05
107 (88.4) 1 (0.8) 5 (4.1)
72 (83.7) 1 (1.2) 6 (7.0)
>0.05 >0.05 >0.05
60 (49.6) 12 (9.9) 44 (36.4)
43 (50.0) 6 (7.0) 31 (36.0)
>0.05 >0.05 >0.05
5 (4.1) 115 (95.0)
9 (10.5) 80 (93.0)
>0.05 >0.05
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100%, in case of missing values.
Table 3 Differences in syndesmotic screw related management. Item
Orthopaedic surgeons (N = 86)
p-Value
(79.3) (9.9) (6.6)
72 (83.7) 7 (8.1) 5 (5.9)
>0.05 >0.05 >0.05
(25.6) (71.1) (1.7)
27 (31.4) 51 (59.3) 7 (8.2)
>0.05 >0.05 >0.05
(89.3) (6.6)
70 (81.4) 15 (17.4)
0.027
(89.3) (9.1)
66 (76.7) 19 (22.1)
0.032
(62.8) (31.4) (1.7)
56 (65.1) 26 (30.2) 2 (2.3)
>0.05 >0.05 >0.05
(57.9) (38.8) (1.7)
52 (60.5) 30 (34.9) 2 (2.3)
>0.05 >0.05 >0.05
(28.1) (58.7) (5.8) (3.3)
34 43 6 1
(39.5) (50.0) (7.0) (1.2)
>0.05 >0.05 >0.05 >0.05
(5.8) (74.4) (17.4)
4 (4.7) 68 (79.1) 13 (15.1)
>0.05 >0.05 >0.05
(7.4) (74.4) (4.1) (15.7)
9 59 1 17
>0.05 >0.05 >0.05 >0.05
Trauma surgeons (N = 121)
Fixation in ankle fracture Single screw 96 Two screws 12 Other 8 Fixation in Maisonneuve fracture Single screw 31 Two screws 86 Other 2 Screw type in ankle fracture 3.5 mm screw 108 4.5 mm screw 8 Screw type in Maisonneuve fracture 3.5 mm screw 108 4.5 mm screw 11 Cortices (n) in ankle fracture 3 cortices 76 4 cortices 38 Oblique 2 Cortices (n) in Maisonneuve fracture 3 cortices 70 4 cortices 47 Oblique 2 Reduction of syndesmosis By hand 34 By reduction forceps 71 By lag screw 7 Temporary Kirschner wire 4 Level of syndesmotic screw <2.0 cm 7 2.1–4.0 cm 90 >4.1 cm 21 Accuracy of reduction Open inspection 9 Plain X-ray 90 CT-scan 5 Combination 19
(10.5) (68.6) (1.2) (19.7)
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100% in case of missing values.
in 28.5% and general in 2.9%; no preference was reported by 11.1% of surgeons. The timing of removal was between 6 and 8 weeks in 73.9%, between 8 and 10 weeks in 17.9% and between 10 and 12 weeks in 3.9% (other or unknown in 4.3%). During the removal procedure,
Item
Weight bearing post placement No After some weeks In walking cast Screw removal Standard practice Rarely In case of complaints Main reason for removal Expected limited ROM Risk of breakage Both Type of anaesthesia Local Regional General No preference Timing of screw removal 6–8 weeks 8–10 weeks 10–12 weeks Stability test post-removal No Yes Weight-bearing post-removal Immediate (if possible) NWB exercise Walking cast
Trauma surgeons (N = 121)
Orthopaedic surgeons (N = 86)
p-Value
45 (52.3) 24 (27.9) 15 (17.4)
>0.05 >0.05 >0.05
104 (86.0) 3 (2.5) 12 (9.9)
76 (88.4) 2 (2.3) 7 (8.1)
>0.05 >0.05 >0.05
35 (28.9) 42 (34.7) 40 (33.1)
18 (20.9) 41 (47.7) 23 (26.7)
>0.05 >0.05 >0.05
71 27 2 20
45 32 4 3
(52.3) (37.2) (4.7) (3.5)
>0.05 >0.05 >0.05 >0.05
97 (80.2) 18 (14.9) 1 (0.8)
56 (65.1) 19 (22.1) 7 (8.1)
>0.05 >0.05 >0.05
98 (81.0) 20 (16.5)
69 (80.2) 17 (19.8)
>0.05 >0.05
102 (84.3) 2 (1.7) 5 (4.1)
70 (81.4) 7 (8.1) 2 (2.3)
>0.05 >0.05 >0.05
77 (63.6) 21 (17.4) 19 (15.7%)
(58.7) (22.3) (1.7) (16.5)
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100%, in case of missing values. NWB, non-weight bearing.
17.9% tested the tibiofibular syndesmosis for stability and 83.1% of patients were allowed to start weight bearing as soon as possible. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. When comparing the answers of the trauma surgeons and orthopaedic surgeons, only the more frequent use of 4.5-mm screws by the orthopaedic surgeons was statistically significantly different. Discussion With over 200 respondents and an average response rate of 74% of the addressed surgeons and 87% of all Dutch hospitals, the current survey is the largest and most complete available in the literature. This gives a valuable insight into the current opinion on managing acute distal tibiofibular syndesmotic injuries. The pre-selection of (orthopaedic) surgeons with an interest in trauma might have biased the results of the current survey, in a way that there might be an underestimation in the variation of treatments. On the other hand, our data have almost national coverage, whereas previous studies by Wood and Feldman and by Monga et al. concern parts of the UK.16,17 The first survey to evaluate the use of the syndesmotic screw was by Wood and Feldman from 2004.16 The survey was held in Scotland and the Northwest region of England. Monga et al. used a postal survey administered to orthopaedic surgeons in a different region (West Midlands) in England to establish an overview of syndesmotic screw management.17 Although almost all consultants used syndesmotic screw(s) for stabilisation, there was great variety in the technical aspects of the placement and the postoperative management.17 In a more recent study by Bava et al., a survey was taken among orthopaedic trauma surgeons from the Orthopaedic
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Table 5 Comparison of the current survey with three previous postal questionnaires. Item
Schepers 2012 Trauma surgeons
Orthopaedic surgeons
N (response rate %) Included Weber type(s) Single:two screws (B-type) (%) Single:two screws (C-type) (%) 3.5 mm:4.5 mm screw (C-type) (%) Cortices engaged 3:4 (C-type) (%) Placed as lag screw (%) Routine removal (%) Timing removal <8 weeks (%) Timing removal >12 weeks (%)
121 (85) B and C (Maisonneuve) 79:10 26:71 89:9 58:39 6 86 80 0
86 (62) B and C (Maisonneuve) 84:8 31:59 77:22 61:35 7 88 65 0
Bava 201018
Monga 200817
Wood 200416
77 (50) C NA 44:44 43:19 29:67 NA 65 0 100
189 (61) NA NA NA 50:32 59:34 11 84 NA NA
116 (54) C NA NA 51:42 60:37 11 92 99 1
A total percentage of 100% per item is not reached in this table, as there were frequently more than two answering possibilities, or more than one answer was given. NA, not available.
Trauma Association and the American Orthopaedic Foot and Ankle Society concerning specifically the Weber-C fractures (i.e., Pronation Exorotation IV injuries according to Lauge-Hansen).18 The number of participants and response rates in the current study were higher than in the previous ones (Table 5). Considering a few controversial items in the treatment of acute syndesmotic injuries, the findings of the current survey were compared with the available literature. Peroperative stability testing In a recent cadaver study by Stoffel et al., the lateral stress (i.e., hook or Cotton) test appeared to be superior to the external rotation stress test for the detection of syndesmotic instability in ankle fractures on radiographs.19 Leeds et al. used 2-mm diastasis of the tibiofibular clear space as a cut-off point. A total of 86% of surgeons using the hook test in the Netherlands is therefore not remarkable, although higher than in the UK (68.8% of surgeons).17,20 Candal-Couto et al. applied the hook test in a sagittal plane (with lateral imaging), resulting in a larger and thus more easily visible displacement.21 The direction of the force applied was not considered in the current study. Reduction and confirmation of accuracy Postoperative malreduction of the fibula in the tibial incisura occurs in 16–52% of cases.22–24 The occurrence of malreduction has been explained by the use of a large (Weber) reduction clamp25 and is likely to remain undetected in intra-operative fluoroscopy or postoperative conventional radiographs.23,26 Stabilisation of the syndesmosis with a screw with the fibula in up to 308 of external rotation might not be detected by intra-operative fluoroscopy alone.26 Our data indicate that over 50% of respondents use a large reduction clamp as common practice; however, this should be discouraged in light of the above-named literature. Open inspection of the syndesmosis is reported by only 8.7% of the respondents (compared with peroperative fluoroscopy in 72.0%), which could lead to lower rates of malreduction if performed more often.27 A simple aid in reducing the syndesmosis is the use of a temporary Kirschner-wire fixation, which has shown a significant reduction in the rate of malreduction of the syndesmosis.24 This is used only in about 2% in the Netherlands. Even though the use of a postoperative CT-scan or peroperative use of 3D-fluoroscopy is not standard practice in the Netherlands (0.5% of respondents), literature data imply that malreduction occurs far more frequently than previously thought. Syndesmotic malreduction has a clear association with less favourable outcome22 and can be avoided or corrected when detected. There should be a low threshold for the use of a postoperative CT scan from a literature point of view.
Number of screws Using a biomechanical model, Xenos et al. found a higher mechanical strength in two-screw fixation compared with onescrew fixation. In a randomised study in which one- and two-screw fixation was compared, no differences were found in functional outcome, dorsiflexion and pain.28 Suggestions for using two-screw fixation in obese patients, non-compliant patients or in case of complete diastasis have been made.29–31 In our data, this may explain the higher percentage of fixation with two screws in Maisonneuve fractures (66.2%) compared with Weber-B fractures requiring syndesmotic stabilisation (9.2%). Diameter of screws Biomechanical studies in which the strength of the stabilisation was tested suggest little advantage of 4.5-mm over 3.5-mm screws in withstanding axial shear and external rotation stress.32,33 Even though some studies have shown higher breakage rates with 3.5-mm screws,34 in clinical studies both the 3.5-mm and the 4.5-mm screws show adequate stabilising qualities.35–37 This might explain why the majority of surgeons in our survey used the 3.5-mm screw (86.0%) in distal fibular fractures and in Maisonneuve fractures (84.1%), which are higher percentages compared with data in previous literature where 4.5mm screws are predominantly used (Table 5). The larger screw head of a 4.5-mm screw might facilitate the percutaneous removal in an outpatient department setting.18 Three or four cortices From a biomechanical point of view, a four-cortical screw fixation might seem a more rigid method of stabilisation of the syndesmosis than a three-cortical fixation. This however reduces the physiological movement in the ankle mortise and may consequently lead to a higher hardware failure rate.36 In biomechanical research, no difference was found in fixation of the syndesmosis through three or four cortices.38,39 In a prospective randomised study by Moore et al., 127 people with syndesmotic disruptions were treated with 3.5-mm cortical screws placed through three or four cortices, with a mean follow-up of 150 days. No differences in loss of reduction, screw breakage or need for hardware removal were found.40–43 One advantage of a four-cortical screw might be the easier removal in case of a broken screw.18,44 The number of cortices engaged in distal ankle fractures in this survey was three in 63.8% and four in 30.9% of patients. In Maisonneuve injuries, these percentages were 58.9 and 37.2, respectively. These percentages are in line with other surveys (Table 5).
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Position of the screw Available literature regarding the position of the screw is not conclusive. McBryde et al. advised placement 2 cm above the tibiotalar joint. They found less syndesmotic widening in external rotation with screw placed at 2 cm compared with 3.5 cm proximal to the tibial plafond.45 Sproule et al. recommended placement of the screw at 4 cm above the tibiotalar joint in Maisonneuve fractures.46 Kukreti et al. however found no significant difference in clinical and radiological outcome between placement of the screw through or above the syndesmosis.47 The vast majority (76.3%) of surgeons in the current survey placed the screw according to the advised position in literature, that is, between 2.1 and 4.0 cm above the tibial plafond just above the tibiofibular joint.48,49 Routine removal In a recent overview of the literature, in which data of seven clinical studies were reviewed, no differences in outcome between retained or removed screws were found.50 Patients with broken or loosened screws had at least similar outcome compared with patients in whom the screws had been removed. Besides the additional costs of secondary surgery and associated work absence, the routine removal of syndesmotic screws exposes patients to an avoidable complication rate of more than 20%, including mainly recurrent diastasis and wound infections.51 In addition, in previous surveys a trend was noted towards decreased routine syndesmotic screw removal over time16–18 (Table 5). Despite the above, most screws (87%) are still removed routinely in the Netherlands because of expected complaints of pain and diminished motion and because of the change of breakage. Alternatives (suture-button device, primary suture or bioabsorbable screws) were on average reported in less than 1% in the current study. A total of 73.9% of surgeons remove the syndesmotic screws between 6 and 8 weeks after placement, even though early removal harbours a high rate of recurrent syndesmotic diastasis of 8.9%51 to 11.5%.52 In conclusion, the current survey study gives a valuable insight into the current practice on the treatment of acute distal tibiofibular syndesmotic injuries. Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication. The majority of respondents pledged interest in participation in such a trial. Conflicts of interest and source of funding No conflict of interest or funding is declared by any of the authors. References 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures – an increasing problem? Acta Orthopaedica Scandinavica 1998;69:43–7. 2. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. Journal of Bone and Joint Surgery 1984;66-A:490–503. 3. Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar shift in ankle fractures. Foot and Ankle International 2006;27:793–6. 4. Pettrone FA, Gail M, Pee D, et al. Quantitative criteria for prediction of the results after displaced fracture of the ankle. Journal of Bone and Joint Surgery 1983;65A:667–77. 5. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. Journal of Bone and Joint Surgery 1976;58-A:356–7.
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Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthopaedica Scandinavica 1998;69:48–50. 14. Edwards P, Roberts I, Clarke M, et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324:1183. 15. Johnson T, Owens L. Survey response rate reporting in the professional literature. Presented at the 58th annual meeting of the American association for public opinion research. 2003. 16. Wood GCA, Feldman YA. Indications and use of the ankle syndesmosis screw: a multi-regional survey. Foot and Ankle Surgery 2004;10:65–9. 17. Monga P, Kumar A, Simons A, Panikker V. Management of distal tibio-fibular syndesmotic injuries: a snapshot of current practice. Acta Orthopaedica Belgica 2008;74:365–9. 18. Bava E, Charlton T, Thordarson D. Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons. The American Journal of Orthopedics (Belle Mead NJ) 2010;39:242–6. 19. Stoffel K, Wysocki D, Baddour E, et al. Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. Journal of Bone and Joint Surgery 2009;91-A:2646–52. 20. van den Bekerom MP, Haverkamp D, Kerkhoffs GM, van Dijk CN. Syndesmotic stabilization in pronation external rotation ankle fractures. Clinical Orthopaedics and Related Research 2010;468:991–5. 21. Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ. Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction? Injury 2004;35:814–8. 22. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. Journal of Orthopaedic Trauma 2012;26:439–43. 23. Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot and Ankle International 2006;27:788–92. 24. Schwarz N, Ko¨fer E. Postoperative computed tomography-based control of syndesmotic screws. European Journal of Trauma 2005;31:266–70. 25. Miller AN, Barei DP, Iaquinto JM, et al. Iatrogenic syndesmosis malreduction via clamp and screw placement. Journal of Orthopaedic Trauma 2012. 26. Marmor M, Hansen E, Han HK, et al. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot and Ankle International 2011;32:616–22. 27. Miller AN, Carroll EA, Parker RJ, et al. Direct visualization for syndesmotic stabilization of ankle fractures. Foot and Ankle International 2009;30:419–26. 28. Xenos JS, Hopkinson WJ, Mulligan ME, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. Journal of Bone and Joint Surgery 1995;77-A:847–56. 29. Thordarson DB. Ankle fractures in diabetics. Techniques in Foot and Ankle Surgery 2004;3:192–7. 30. Vander Griend R, Michelson JD, Bone LB. Fractures of the ankle and the distal part of the tibia. Instructional Course Lectures 1997;46:311–21. 31. Duchesneau S, Fallat LM. The Maisonneuve fracture. Journal of Foot and Ankle Surgery 1995;34:422–8. 32. Hansen M, Le L, Wertheimer S, et al. Syndesmosis fixation: analysis of shear stress via axial load on 3.5-mm and 4.5-mm quadricortical syndesmotic screws. Journal of Foot and Ankle Surgery 2006;45:65–9. 33. Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws. Foot and Ankle International 2000;21:736–41. 34. Stuart K, Panchbhavi VK. The fate of syndesmotic screws. Foot and Ankle International 2011;32:S519–25. 35. Ebraheim NA, Mekhail AO, Gargasz SS. Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. Foot and Ankle International 1997;18:513–21. 36. Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot and Ankle 1989;9:290–3. 37. Mast JW, Teipner WA. A reproducible approach to the internal fixation of adult ankle fractures: rationale, technique, and early results. Orthopedic Clinics of North America 1980;11:661–79. 38. Beumer A, Campo MM, Niesing R, et al. Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury 2005;36:60–4. 39. Nousiainen MT, McConnell AJ, Zdero R, et al. The influence of the number of cortices of screw purchase and ankle position in Weber C ankle fracture fixation. Journal of Orthopaedic Trauma 2008;22:473–8.
T. Schepers et al. / Injury, Int. J. Care Injured 43 (2012) 1718–1723 40. Moore Jr JA, Shank JR, Morgan SJ, Smith WR. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot and Ankle International 2006;27:567–72. 41. Hoiness P, Stromsoe K. Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation. Journal of Orthopaedic Trauma 2004;18: 331–7. 42. Wikeroy AK, Hoiness PR, Andreassen GS, et al. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. Journal of Orthopaedic Trauma 2010;24:17–23. 43. Jordan TH, Talarico RH, Schuberth JM. The radiographic fate of the syndesmosis after trans-syndesmotic screw removal in displaced ankle fractures. Journal of Foot and Ankle Surgery 2011;50:407–12. 44. Thordarson DB, Hedman TP, Gross D, Magre G. Biomechanical evaluation of polylactide absorbable screws used for syndesmosis injury repair. Foot and Ankle International 1997;18:622–7.
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45. McBryde A, Chiasson B, Wilhelm A, et al. Syndesmotic screw placement: a biomechanical analysis. Foot and Ankle International 1997;18:262–6. 46. Sproule JA, Khalid M, O’Sullivan M, McCabe JP. Outcome after surgery for Maisonneuve fracture of the fibula. Injury 2004;35:791–8. 47. Kukreti S, Faraj A, Miles JN. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury 2005;36:1121–4. 48. Hahn DM, Colton CL. Malleolar fractures. In: Ru¨edi TP, Murphy WM, editors. AO principles of fracture management. New York: Thieme; 2001. p. 583–4. 49. Tile M. Fractures of the ankle. In: Schatzker J, Tile M, editors. The rationale of operative fracture care. New York: Springer-Verlag; 2005. p. 580–1. 50. Schepers T. To retain or remove the syndesmotic screw: a review of literature. Archives of Orthopaedic and Trauma Surgery 2011;131:879–83. 51. Schepers T, Van Lieshout EMM, De Vries MR, Van der Elst M. Complications of syndesmotic screw removal. Foot and Ankle International 2011;32:1040–4. 52. Hsu YT, Wu CC, Lee WC, et al. Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function. International Orthopaedics 2011;35:359–64.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The management of acute distal tibio-fibular syndesmotic injuries: Results of a nationwide survey Tim Schepers a,*, Wouter J. van Zuuren b, Michel P.J. van den Bekerom b, Lucas M.M. Vogels a, Esther M.M. van Lieshout a a b
Department of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Orthopedics, Spaarne Hospital, Hoofddorp, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 17 June 2012
Introduction: Ankle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands. Materials and methods: A postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw. Results: A total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the ‘Hook test’. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1–4.0 cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. Conclusion: Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication. ß 2012 Elsevier Ltd. All rights reserved.
Keywords: Ankle fracture Syndesmotic injury Treatment Survey
Distal tibiofibular injury, resulting in syndesmotic instability occurs in over 10% of ankle fractures.1 Anatomical restoration and stabilisation of the disrupted distal tibiofibular syndesmosis is essential to prevent changes in contact load and posttraumatic degeneration, and for improving functional outcome.2–5 In general practice, it is advised to stabilise syndesmotic instability with one or more metallic trans-syndesmotic screws.6–8 Because several different methods of syndesmotic restoration have been described, the factual placement of the screw (i.e., the number, size and location) used, the postoperative management and the need for removal have all been subject to debate.9
* Corresponding author at: University Medical Center Rotterdam, Department of Surgery-Traumatology, Room H-822k, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands. Tel.: +31 10 7031050; fax: +31 10 7032396. E-mail address: [email protected] (T. Schepers). 0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.06.015
The annual number of hospital admission after an ankle fracture in the Netherlands (16.73 million inhabitants) has increased from 6945 in 2008 and 8504 in 2009, to 9924 patients in 2010.10 It is estimated that 10% of all ankle fractures11 and 20% of operatively treated ankle fractures12 are accompanied by a syndesmotic injury necessitating fixation. This implies that an expected total of 992– 1985 acute syndesmotic injuries are treated annually in the Netherlands. The latter number is close to the incidence of 15 per 100,000 persons per year mentioned in the literature.1,13 Previous research revealed a significant variety in treatment of acute distal tibiofibular syndesmotic injuries. With the many different options for syndesmotic stabilisation, there appears to be a wide variety in management by different physicians and this variety tends to increase with new implants and insights. To investigate whether this variation is also present in the Dutch situation, where both trauma surgeons and orthopaedic surgeons treat this type of injury, we set up a survey in which the
T. Schepers et al. / Injury, Int. J. Care Injured 43 (2012) 1718–1723
different aspects of the treatment of syndesmotic injury were assessed. Differences within and between these two disciplines were examined in the context of the currently available literature.
Materials and methods A postal survey was developed according to guidelines provided by a meta-analysis of randomised studies of postal surveys to optimise response rates.14 Attention was paid to the recommendations of the American Association for Public Opinion Research (AAPOR).15 Two trauma surgeons from a level-1 trauma centre and two orthopaedic surgeons from a level-2 trauma centre developed the questionnaire. The questions included in the survey are shown in Table 1. These questions were derived from recent literature and similar questionnaires from different countries. The goals of the survey were explained in a personally addressed accompanying letter. A stamped returning envelope was provided. After 4 weeks a reminder was sent, including a copy of the survey and a returning envelope. Depending upon the size of the hospital’s catchment area, the survey was sent to one or two trauma surgery staff members and one or two orthopaedic surgery staff members in each of the 86 hospitals in the Netherlands. Recipients with interest in fracture care or foot-and-ankle surgery were selected by contacting all hospitals prior to the survey. Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS, Chicago, IL, USA). Normality of data was assessed using the Kolmogorov–Smirnov test and by Table 1 Questions in the survey. Questions of the acute syndesmotic injury survey 1. 2. 3. 4a. 4b. 5. 6a. 6b. 7a. 7b 8a. 8b. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
Are you a trauma surgeon or an orthopaedic surgeon? In what hospital are you currently employed? How many years of expertise do you have in fracture treatment? How do you pre-operatively identify the presence of syndesmotic injury? How do you per-operatively identify the presence of syndesmotic injury? At what time during the procedure do you test for syndesmotic disruption? What type of syndesmotic fixation do you prefer for an ankle fracture? What type of syndesmotic fixation do you prefer for a Maisonneuve ankle fracture? If you use a screw, what diameter do you prefer for an ankle fracture? If you use a screw, what diameter do you prefer for a Maisonneuve ankle fracture? Over how many cortices do you place the screw for an ankle fracture? Over how many cortices do you place the screw for a Maisonneuve ankle fracture? How do you reduce the syndesmosis? At what level do you place the syndesmotic screw? How do you determine the accuracy of your syndesmotic reduction? Do you allow weight-bearing with a syndesmotic screw? Do you routinely remove the syndesmotic screw? What is according to you the main reason for removal? What type of anaesthesia do you use at removal? After how many weeks do you remove the syndesmotic screw? Do you test for stability during the removal procedure? Do you allow immediate weight-bearing after removal of the syndesmotic screw? Would you consider participating in a RCT (routine removal versus on indication)?
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inspecting frequency histograms. The Levene’s test was applied to assess homogeneity of variance between data. Numeric data were found to be normally distributed and are expressed as mean with standard deviation (SD); categorical data are shown as numbers with percentages. A Student’s t-test (parametric, numeric data) or Chi-squared analysis (categorical data) was performed to assess statistical significance between groups with and without complications. A p-value < 0.05 was taken as the threshold of statistical significance. Results A total of 142 trauma surgeons in 86 hospitals and 139 orthopaedic surgeons in 84 hospitals in the Netherlands were addressed. The response rate, calculated by dividing the number of sent surveys by the number of surveys received, after 8 weeks was 85.2% for the trauma surgeons (representing 93% of the hospitals) and 61.9% of the orthopaedic surgeons (representing 81% of the hospitals). The results are shown in Tables 2–4, specified separately for the trauma and orthopaedic surgeons. A total of 24.6% of all respondents had less than 5 years of experience, 38.2% 6–15 years and 37.2% more than 15 years previous experience in the treatment of fractures. The presence of a syndesmotic injury was judged solely on conventional radiographs in 86.5%, 1% used stress radiographs and 5.3% reported the use of both. During the surgical procedure the techniques to identify a syndesmotic disruption are the ‘hook test’ in 49.8%, ‘Exorotation stress test’ in 8.7% and both in 36.2% (other or not available in 5.3%). The peroperative testing was performed prior to fixation of the fractured malleoli in 6.8%, and in 94.2% following the fixation (1% did both). The fixation of a ruptured syndesmosis in a (Weber-B) ankle fracture was performed with one screw in 81.2% and with two screws in 9.2%; another technique (i.e., suturing) was reported by 6.3%. In Maisonneuve injuries, these percentages were 28.0, 66.2 and 4.4, respectively. In distal ankle fracture cases where a screw was the preferred type of fixation, it was a 3.5-mm screw in 86.0% and a 4.5-mm screw in 11.1%; the rest (2.9%) did not specify the type of screw. In the Maisonneuve type injury, these percentages were 84.1, 14.5 and 1.4%, respectively. The number of cortices engaged in distal ankle fractures was three in 63.8%, four in 30.9% and an oblique placement or non-specified was reported in 5.3% of questionnaires. In Maisonneuve injuries, these percentages were 58.9, 37.2 and 3.8%, respectively. Reducing the fibula into the distal tibial notch was done by hand in 32.9%, by a large reduction (Weber) forceps in 55.1% and by the use of a lag-screw in 6.3% (different or unknown in 5.8%). The level of placement was between 0 and 2.0 cm in 5.3%, between 2.1 and 4.0 cm in 76.3% and between 4.1 and 6.0 cm in 16.4% (other or unknown 1.9%). The accuracy of the reduction was checked on peroperative fluoroscopy in 72.0%, open inspection of the syndesmosis in 8.7% and the standard use of a computed tomography (CT) scan was reported in 0.5% of questionnaires. The use of both fluoroscopy and open inspection was done by 10.1% and a different approach (including a peroperative three-dimensional (3D) scan) was reported by 7.2% of surgeons. Following placement, 58.9% of patients were not allowed to bear weight, 21.7% were allowed to bear weight after 4–6 weeks on average, or in a walking cast in 16.4%. The removal of the syndesmotic screw was routinely done by 87.0% of surgeons, infrequently by 2.4% and only in case of complaints in 9.2%. As the most important reason for removal, respondents choose limitations in range of motion in 25.6%, risk of breakage in 40.1, both in 30.4% and other (i.e., pain) in 3.9%. Removal was performed using local anaesthetics in 56.0%, regional
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Table 2 Pre- and peroperative evaluation of syndesmotic injury. Item
Years of experience 5 6–15 >15 Pre-operative evaluation X-ray standard X-ray stress Both Per-operative evaluation Hook test Exorotation stress test Both Timing of stability testing Before fixation of malleoli After fixation of malleoli
Trauma surgeons (N = 121)
Table 4 Postoperative management in syndesmotic injury repair.
Orthopaedic surgeons (N = 86)
p-Value
28 (23.1) 42 (34.7) 51 (42.1)
23 (26.7) 37 (43.0) 26 (30.2)
>0.05 >0.05 >0.05
107 (88.4) 1 (0.8) 5 (4.1)
72 (83.7) 1 (1.2) 6 (7.0)
>0.05 >0.05 >0.05
60 (49.6) 12 (9.9) 44 (36.4)
43 (50.0) 6 (7.0) 31 (36.0)
>0.05 >0.05 >0.05
5 (4.1) 115 (95.0)
9 (10.5) 80 (93.0)
>0.05 >0.05
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100%, in case of missing values.
Table 3 Differences in syndesmotic screw related management. Item
Orthopaedic surgeons (N = 86)
p-Value
(79.3) (9.9) (6.6)
72 (83.7) 7 (8.1) 5 (5.9)
>0.05 >0.05 >0.05
(25.6) (71.1) (1.7)
27 (31.4) 51 (59.3) 7 (8.2)
>0.05 >0.05 >0.05
(89.3) (6.6)
70 (81.4) 15 (17.4)
0.027
(89.3) (9.1)
66 (76.7) 19 (22.1)
0.032
(62.8) (31.4) (1.7)
56 (65.1) 26 (30.2) 2 (2.3)
>0.05 >0.05 >0.05
(57.9) (38.8) (1.7)
52 (60.5) 30 (34.9) 2 (2.3)
>0.05 >0.05 >0.05
(28.1) (58.7) (5.8) (3.3)
34 43 6 1
(39.5) (50.0) (7.0) (1.2)
>0.05 >0.05 >0.05 >0.05
(5.8) (74.4) (17.4)
4 (4.7) 68 (79.1) 13 (15.1)
>0.05 >0.05 >0.05
(7.4) (74.4) (4.1) (15.7)
9 59 1 17
>0.05 >0.05 >0.05 >0.05
Trauma surgeons (N = 121)
Fixation in ankle fracture Single screw 96 Two screws 12 Other 8 Fixation in Maisonneuve fracture Single screw 31 Two screws 86 Other 2 Screw type in ankle fracture 3.5 mm screw 108 4.5 mm screw 8 Screw type in Maisonneuve fracture 3.5 mm screw 108 4.5 mm screw 11 Cortices (n) in ankle fracture 3 cortices 76 4 cortices 38 Oblique 2 Cortices (n) in Maisonneuve fracture 3 cortices 70 4 cortices 47 Oblique 2 Reduction of syndesmosis By hand 34 By reduction forceps 71 By lag screw 7 Temporary Kirschner wire 4 Level of syndesmotic screw <2.0 cm 7 2.1–4.0 cm 90 >4.1 cm 21 Accuracy of reduction Open inspection 9 Plain X-ray 90 CT-scan 5 Combination 19
(10.5) (68.6) (1.2) (19.7)
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100% in case of missing values.
in 28.5% and general in 2.9%; no preference was reported by 11.1% of surgeons. The timing of removal was between 6 and 8 weeks in 73.9%, between 8 and 10 weeks in 17.9% and between 10 and 12 weeks in 3.9% (other or unknown in 4.3%). During the removal procedure,
Item
Weight bearing post placement No After some weeks In walking cast Screw removal Standard practice Rarely In case of complaints Main reason for removal Expected limited ROM Risk of breakage Both Type of anaesthesia Local Regional General No preference Timing of screw removal 6–8 weeks 8–10 weeks 10–12 weeks Stability test post-removal No Yes Weight-bearing post-removal Immediate (if possible) NWB exercise Walking cast
Trauma surgeons (N = 121)
Orthopaedic surgeons (N = 86)
p-Value
45 (52.3) 24 (27.9) 15 (17.4)
>0.05 >0.05 >0.05
104 (86.0) 3 (2.5) 12 (9.9)
76 (88.4) 2 (2.3) 7 (8.1)
>0.05 >0.05 >0.05
35 (28.9) 42 (34.7) 40 (33.1)
18 (20.9) 41 (47.7) 23 (26.7)
>0.05 >0.05 >0.05
71 27 2 20
45 32 4 3
(52.3) (37.2) (4.7) (3.5)
>0.05 >0.05 >0.05 >0.05
97 (80.2) 18 (14.9) 1 (0.8)
56 (65.1) 19 (22.1) 7 (8.1)
>0.05 >0.05 >0.05
98 (81.0) 20 (16.5)
69 (80.2) 17 (19.8)
>0.05 >0.05
102 (84.3) 2 (1.7) 5 (4.1)
70 (81.4) 7 (8.1) 2 (2.3)
>0.05 >0.05 >0.05
77 (63.6) 21 (17.4) 19 (15.7%)
(58.7) (22.3) (1.7) (16.5)
Data are shown as number with percentages between brackets. Data were analysed using a Chi-squared analysis. Percentages not always add up to 100%, in case of missing values. NWB, non-weight bearing.
17.9% tested the tibiofibular syndesmosis for stability and 83.1% of patients were allowed to start weight bearing as soon as possible. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. When comparing the answers of the trauma surgeons and orthopaedic surgeons, only the more frequent use of 4.5-mm screws by the orthopaedic surgeons was statistically significantly different. Discussion With over 200 respondents and an average response rate of 74% of the addressed surgeons and 87% of all Dutch hospitals, the current survey is the largest and most complete available in the literature. This gives a valuable insight into the current opinion on managing acute distal tibiofibular syndesmotic injuries. The pre-selection of (orthopaedic) surgeons with an interest in trauma might have biased the results of the current survey, in a way that there might be an underestimation in the variation of treatments. On the other hand, our data have almost national coverage, whereas previous studies by Wood and Feldman and by Monga et al. concern parts of the UK.16,17 The first survey to evaluate the use of the syndesmotic screw was by Wood and Feldman from 2004.16 The survey was held in Scotland and the Northwest region of England. Monga et al. used a postal survey administered to orthopaedic surgeons in a different region (West Midlands) in England to establish an overview of syndesmotic screw management.17 Although almost all consultants used syndesmotic screw(s) for stabilisation, there was great variety in the technical aspects of the placement and the postoperative management.17 In a more recent study by Bava et al., a survey was taken among orthopaedic trauma surgeons from the Orthopaedic
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Table 5 Comparison of the current survey with three previous postal questionnaires. Item
Schepers 2012 Trauma surgeons
Orthopaedic surgeons
N (response rate %) Included Weber type(s) Single:two screws (B-type) (%) Single:two screws (C-type) (%) 3.5 mm:4.5 mm screw (C-type) (%) Cortices engaged 3:4 (C-type) (%) Placed as lag screw (%) Routine removal (%) Timing removal <8 weeks (%) Timing removal >12 weeks (%)
121 (85) B and C (Maisonneuve) 79:10 26:71 89:9 58:39 6 86 80 0
86 (62) B and C (Maisonneuve) 84:8 31:59 77:22 61:35 7 88 65 0
Bava 201018
Monga 200817
Wood 200416
77 (50) C NA 44:44 43:19 29:67 NA 65 0 100
189 (61) NA NA NA 50:32 59:34 11 84 NA NA
116 (54) C NA NA 51:42 60:37 11 92 99 1
A total percentage of 100% per item is not reached in this table, as there were frequently more than two answering possibilities, or more than one answer was given. NA, not available.
Trauma Association and the American Orthopaedic Foot and Ankle Society concerning specifically the Weber-C fractures (i.e., Pronation Exorotation IV injuries according to Lauge-Hansen).18 The number of participants and response rates in the current study were higher than in the previous ones (Table 5). Considering a few controversial items in the treatment of acute syndesmotic injuries, the findings of the current survey were compared with the available literature. Peroperative stability testing In a recent cadaver study by Stoffel et al., the lateral stress (i.e., hook or Cotton) test appeared to be superior to the external rotation stress test for the detection of syndesmotic instability in ankle fractures on radiographs.19 Leeds et al. used 2-mm diastasis of the tibiofibular clear space as a cut-off point. A total of 86% of surgeons using the hook test in the Netherlands is therefore not remarkable, although higher than in the UK (68.8% of surgeons).17,20 Candal-Couto et al. applied the hook test in a sagittal plane (with lateral imaging), resulting in a larger and thus more easily visible displacement.21 The direction of the force applied was not considered in the current study. Reduction and confirmation of accuracy Postoperative malreduction of the fibula in the tibial incisura occurs in 16–52% of cases.22–24 The occurrence of malreduction has been explained by the use of a large (Weber) reduction clamp25 and is likely to remain undetected in intra-operative fluoroscopy or postoperative conventional radiographs.23,26 Stabilisation of the syndesmosis with a screw with the fibula in up to 308 of external rotation might not be detected by intra-operative fluoroscopy alone.26 Our data indicate that over 50% of respondents use a large reduction clamp as common practice; however, this should be discouraged in light of the above-named literature. Open inspection of the syndesmosis is reported by only 8.7% of the respondents (compared with peroperative fluoroscopy in 72.0%), which could lead to lower rates of malreduction if performed more often.27 A simple aid in reducing the syndesmosis is the use of a temporary Kirschner-wire fixation, which has shown a significant reduction in the rate of malreduction of the syndesmosis.24 This is used only in about 2% in the Netherlands. Even though the use of a postoperative CT-scan or peroperative use of 3D-fluoroscopy is not standard practice in the Netherlands (0.5% of respondents), literature data imply that malreduction occurs far more frequently than previously thought. Syndesmotic malreduction has a clear association with less favourable outcome22 and can be avoided or corrected when detected. There should be a low threshold for the use of a postoperative CT scan from a literature point of view.
Number of screws Using a biomechanical model, Xenos et al. found a higher mechanical strength in two-screw fixation compared with onescrew fixation. In a randomised study in which one- and two-screw fixation was compared, no differences were found in functional outcome, dorsiflexion and pain.28 Suggestions for using two-screw fixation in obese patients, non-compliant patients or in case of complete diastasis have been made.29–31 In our data, this may explain the higher percentage of fixation with two screws in Maisonneuve fractures (66.2%) compared with Weber-B fractures requiring syndesmotic stabilisation (9.2%). Diameter of screws Biomechanical studies in which the strength of the stabilisation was tested suggest little advantage of 4.5-mm over 3.5-mm screws in withstanding axial shear and external rotation stress.32,33 Even though some studies have shown higher breakage rates with 3.5-mm screws,34 in clinical studies both the 3.5-mm and the 4.5-mm screws show adequate stabilising qualities.35–37 This might explain why the majority of surgeons in our survey used the 3.5-mm screw (86.0%) in distal fibular fractures and in Maisonneuve fractures (84.1%), which are higher percentages compared with data in previous literature where 4.5mm screws are predominantly used (Table 5). The larger screw head of a 4.5-mm screw might facilitate the percutaneous removal in an outpatient department setting.18 Three or four cortices From a biomechanical point of view, a four-cortical screw fixation might seem a more rigid method of stabilisation of the syndesmosis than a three-cortical fixation. This however reduces the physiological movement in the ankle mortise and may consequently lead to a higher hardware failure rate.36 In biomechanical research, no difference was found in fixation of the syndesmosis through three or four cortices.38,39 In a prospective randomised study by Moore et al., 127 people with syndesmotic disruptions were treated with 3.5-mm cortical screws placed through three or four cortices, with a mean follow-up of 150 days. No differences in loss of reduction, screw breakage or need for hardware removal were found.40–43 One advantage of a four-cortical screw might be the easier removal in case of a broken screw.18,44 The number of cortices engaged in distal ankle fractures in this survey was three in 63.8% and four in 30.9% of patients. In Maisonneuve injuries, these percentages were 58.9 and 37.2, respectively. These percentages are in line with other surveys (Table 5).
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Position of the screw Available literature regarding the position of the screw is not conclusive. McBryde et al. advised placement 2 cm above the tibiotalar joint. They found less syndesmotic widening in external rotation with screw placed at 2 cm compared with 3.5 cm proximal to the tibial plafond.45 Sproule et al. recommended placement of the screw at 4 cm above the tibiotalar joint in Maisonneuve fractures.46 Kukreti et al. however found no significant difference in clinical and radiological outcome between placement of the screw through or above the syndesmosis.47 The vast majority (76.3%) of surgeons in the current survey placed the screw according to the advised position in literature, that is, between 2.1 and 4.0 cm above the tibial plafond just above the tibiofibular joint.48,49 Routine removal In a recent overview of the literature, in which data of seven clinical studies were reviewed, no differences in outcome between retained or removed screws were found.50 Patients with broken or loosened screws had at least similar outcome compared with patients in whom the screws had been removed. Besides the additional costs of secondary surgery and associated work absence, the routine removal of syndesmotic screws exposes patients to an avoidable complication rate of more than 20%, including mainly recurrent diastasis and wound infections.51 In addition, in previous surveys a trend was noted towards decreased routine syndesmotic screw removal over time16–18 (Table 5). Despite the above, most screws (87%) are still removed routinely in the Netherlands because of expected complaints of pain and diminished motion and because of the change of breakage. Alternatives (suture-button device, primary suture or bioabsorbable screws) were on average reported in less than 1% in the current study. A total of 73.9% of surgeons remove the syndesmotic screws between 6 and 8 weeks after placement, even though early removal harbours a high rate of recurrent syndesmotic diastasis of 8.9%51 to 11.5%.52 In conclusion, the current survey study gives a valuable insight into the current practice on the treatment of acute distal tibiofibular syndesmotic injuries. Compared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication. The majority of respondents pledged interest in participation in such a trial. Conflicts of interest and source of funding No conflict of interest or funding is declared by any of the authors. References 1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures – an increasing problem? Acta Orthopaedica Scandinavica 1998;69:43–7. 2. Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. Journal of Bone and Joint Surgery 1984;66-A:490–503. 3. Lloyd J, Elsayed S, Hariharan K, Tanaka H. Revisiting the concept of talar shift in ankle fractures. Foot and Ankle International 2006;27:793–6. 4. Pettrone FA, Gail M, Pee D, et al. Quantitative criteria for prediction of the results after displaced fracture of the ankle. Journal of Bone and Joint Surgery 1983;65A:667–77. 5. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. Journal of Bone and Joint Surgery 1976;58-A:356–7.
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