Recent developments in the treatment of acute syndesmotic injuries

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Recent developments in the treatment of acute syndesmotic injuries Neue Entwicklungen in der Behandlung akuter Syndesmosenrupturen am oberen Sprunggelenk Tim Schepers a,∗, Siem A. Dingemans a, Stefan Rammelt b a Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands b Universitäts Centrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus der TU Dresden, Dresden, Germany

Received 20 February 2016; accepted 23 February 2016

KEYWORDS

Summary

Ankle fracture; Syndesmosis; Reduction; Syndesmotic screw

Introduction: The syndesmosis is a dynamic stabilizer of the ankle and consists of 5 individual ligaments. In up to 20% of operatively treated ankle fractures the syndesmosis needs fixation. Below we review the literature and try to form an evidence based approach to the treatment of acute distal tbiofibular syndesmotic injury. Material and method: Comprehensive literature review in Pubmed, Embase, and Google Scholar. Results: Numerous clinical and biomechanical studies have been performed to improve the techniques of fixation. New techniques are increasingly used, however the syndesmotic screw remains the cornerstone in the treatment of syndesmotic disruption. Conclusion: If placed correctly and malreduction is prevented the syndesmotic screw remains the ‘Gold standard’ in the treatment of acute syndesmotic injury. One tricortical 3.5 mm screw placed within 2—4 cm of the tibial plafond is usually enough. An additional tricortical screw may be added if there is doubt considering stability or in case of poor bone stock. There is a growing body of evidence that the syndesmotic screw does not need routine removal. Only in cases with complaints of pain or stiffness, where the screws do not loosen or break, the screws might be removed after a minimum of eight weeks. Syndesmotic malreduction is associated with less favorable outcome and carries the risk of the development of chronic instability and posttraumatic ankle arthritis.

∗ Corresponding author at: Academic Medical Center, Trauma Unit, Department of Surgery, Meibergdreef 9, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel.: +31 20 5666019. E-Mail: [email protected] (T. Schepers).

http://dx.doi.org/10.1016/j.fuspru.2016.02.004

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SCHLÜSSELWÖRTER

Zusammenfassung

Sprungglenkfraktur; Syndesmose; Reposition; Stellschraube

Einleitung: Die tibiofibulare Syndesmose ist ein dynamischer Stabilisator des oberen Sprunggelenks und besteht aus 5 individuellen Bandanteilen. In etwa 20 Prozent aller operativ behandelten Sprunggelenkfrakturen ist eine Stabilisierung der Syndesmose erforderlich. In dieser Arbeit wird versucht, auf dem Boden einer aktuellen Literaturrecherche, evidenzbasierte Behandlungsrichtlinien für die Behandlung der akuten distalel tbiofibularen Syndesmosenverletzungen aufzustellen. Material und Methode: Umfangreiche Literaturecherche in Pubmed, Embase und Google Scholar. Ergebnisse: Zahlreiche klinische und biomechanische Studien wurden durchgeführt um die Techniken zur Stabilisierung der Syndesmose zu verbessern. Neue Techniken werden zunehmend eingesetzt, allerdings bleibt die tibiofibulare Stellschraube die am häufigsten angewandte Methode in der operativen Behandlung akuter Syndesmosenrupturen. Schlussfolgerung: Bei korrekter Platzierung und Vermeidung von Fehlstellungen der distalen Fibula bleibt die Syndesmosen-Stellschraube der ‘Goldstandard’ zur Stabilisierung instabiler akuter Syndesmosenrupturen. Eine trikortikale 3.5 mm Schraube welche 2-4 cm oberhalb des Tibiaplafonds platziert wird ist in der Regel ausreichend. Eine zusätzliche trikortikale Schraube kann hinzugefügt werden falls Zweifel an der Stabilität bestehen bzw. bei schlechter Knochenqualität. Zahlreiche Studien legen nahe, dass Stellschrauben nicht routinemäßig entfernt werden müssen. Lediglich bei Beschwerden aufgrund von Schmerzen oder Bewegungseinschränkungen bei nicht gebrochener Schraube ist eine Entfernung nach ca. 8 Wochen indiziert. Eine Fehlreposition der distalen Syndesmose führt zu schlechteren Behandlungsergebnissen und geht mit der Gefahr der Entwicklung einer chronischen Instabilität und posttraumatischen Arthrose einher.

Introduction Syndesmotic injuries occur frequently and are mostly associated with an acute ankle fracture. The disruption of the syndesmotic ligaments is more apparent in Pronation External Rotation and Pronation Abduction fractures of the ankle, but can occur in up to 40% of Supination External Rotation fractures [36,28,42,102,107]. Diagnosing the syndesmotic disruption is not always easy, as is the case in gross displacement with frank diastasis. And especially in isolated disruptions without bony injuries (high ankle sprain) it can be a diagnostic dilemma. The distal tibiofibular syndesmotic complex, for which the term syndesmosis is often used synonymously, consists of five separate portions and provides a dynamic stabilization of the mortise [3,84,76,75]: • The anterior inferior tibiofibular ligament (AITFL). • The posterior inferior tibiofibular ligament (PITFL). • The transverse tibiofibular ligament (TTFL), distal to the posterior tibiofibular ligament with a fibrocartilagineous appearance.

• The interosseous tibiofibular ligament (IOL) containing short, strong collagenous and elastic fibers that fan out into a network almost completely filling the space between the tibial incisura and the corresponding aspect of the fibula. • The distal portion of the interosseous membrane (IOM) consisting of aponeurotic fibers that are recruited from the cranial origins of the anterior and posterior tibiofibular ligaments. Numerous biomechanical studies with serial sectioning of the syndesmotic ligaments have been conducted. Most reveal, that a rupture of two or more ligaments results in mechanical laxity [84]. Many articles and reviews have been published on the use and shortcomings of various diagnostic tools. Conventional radiographs are sometimes insufficient and intraoperative testing is mandatory following the surgical stabilization of the bony injuries (Fig. 1). Latent diastasis is proved with stress radiographs, if necessary under regional anesthesia. External rotation stress is applied manually under fluoroscopy or lateral shift with a standardized device on radiographs [84]. Widening of the tibiofibular clear space (TCS) and medial clear space (MCS) of 2 mm and more is considered to be pathological [125].

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Recent developments in the treatment of acute syndesmotic injuries

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Figure 1. Peroperative testing for syndesmotic injury: (a) Pull at the fibula reveals widening of tibiofibular and medial clearspace; (b) fixation with one tricortical screw; and (c) lateral view.

Manual stress testing, gravity stress testing, and weight-bearing radiographs all have been suggested to detect ankle instability in acute malleolar fractures. It appears that there is a structural stability reserve in the ankle with axial loading [113]. Therefore fewer patients that have positive manual or gravity stress radiographs will display a widened mortise on standing radiographs [21,60,121]. The latter may be thus more reliable because they reflect the physiological conditions [85,39,17].

tibial fragment also restores the shape of the tibial incisura and therefore facilitating anatomic reduction of the distal fibula [5]. Currently the ‘Gold standard’ in stabilizing the syndesmosis is still the setting or positioning screw (Fig. 3). Four surveys [91,6,68,124] on the treatment of syndesmotic injuries show that a screw is the most frequently used implant. There is still however a wide variety in the way this implant is used.

Treatment

Aspects of syndesmotic screw placement

The treatment strategy in acute syndesmotic injuries depends largely on the condition of the osseous injuries at the ankle. The height of the fibular fracture and the presence of a medial and/or posterior malleolar fracture add to the instability of the entire tibio-fibular-talar joint complex injury. The same goes for additional less frequently occurring bony injuries as the anterior tibial (Chaput) or fibular (Wagstaffe) avulsion fractures. All of these osseous injuries need to be addressed prior to the testing of the stability of the syndesmosis [85]. Recent biomechanical studies have suggested that the fixation of the posterior tibial (Volkmann) fragment increases stability more than placing a setting screw at the level of the syndesmosis [29,64]. This implicates that during the pre-operative planning a decision needs to be made whether or not the posterior malleolus is stabilized either using screws or an antiglide plate [85]. This might necessitate a different surgical approach (i.e. a posteolateral approach) to address the posterior fragment as well as the fibula [4,83] (Fig. 2). Direct, anatomic fixation of the posterior

In general the positioning screw should not be placed in lag mode. It should be placed just above the inferior tibiofibular joint, 30◦ from posterior to anterior, parallel to the tibial joint line, with the ankle in neural position [35]. Correct reduction of the distal fibula into the tibial incisura is alleviated with placing an overriding pointed reduction clamp which is placed on the medial cortex above the center of the medial malleolus and the lateral malleolar ridge [84]. If the syndesmotic screw follows the axis of the clamp it will automatically be placed in the right angulation. Care should be taken to place the clamp exactly along the axis of the ankle joint (i.e. from tip to tip) because malplacement of the clamp may force the distal tibia into malreduction [82]. Open reduction under direct inspection of the syndesmosis is preferable over closed reduction because it allows for clearing the syndesmosis from and refixation of bony avulsions [85], visual and palpatory assessment of the alignment of the anterior tubercles of the distal tibia and fibula (Chaput/Wagstaffe) [83] and is associated with significantly lower rates of malreduction [80].

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Figure 2. Peroperative imaging of posterior malleolar fixation: (a) AP view; and (b) lateral view.

Figure 3. Percutaneous ankle fixation with syndesmotic screw placement in poor soft tissues: (a) AP view and (b) lateral view.

Following manual reduction a temporary Kirschner wire should be places, to prevent secondary malroration when placing the clamp or screw(s).

Position of the ankle and overcompression Due to the complex motion of the fibula in relation to the tibia during plantar- and dorsiflexion

of the ankle it is theoretically possible to induce an increased rate of malreduction when the ankle is placed in full dorsiflexion when inserting the syndesmotic screw. On the other hand due to the trapezoid shape of the talus it is in theory possible to overtighten the syndesmosis with the ankle in plantarflexion [13]. However, several biomechanical studies failed to demonstrate any overtightening of the syndesmosis even with the ankle placed in full plantarflexion [10,114,16].

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Recent developments in the treatment of acute syndesmotic injuries A recent cadaveric study even showed favorable biomechanical results through screw placement in lag mode [10,114,16]. A small randomized clinical trial of 21 patients by Rao et al. [86] compared two groups, one in which the screw was inserted with the ankle in 20◦ dorsiflexion and one with the ankle in plantar flexion. They found no difference in patient related outcome scores, implant failure and dorsiflexion post-operatively at one year. The concept that syndesmotic screws should never be used in lag or compression mode has therefore been disputed [16,52].

Number of screws There is not much evidence on the need for a second syndesmotic screw. In most cases one single syndesmotic screw should be sufficient [123,38]. Placement of an additional syndesmotic screw might be indicated in cases where there is doubt considering the stability of the construct (i.e. in obesity) or bone quality (i.e. diabetes, osteoporosis) [62,79]. Even though most surveys show that high fibular fractures (Maisonneuve) are frequently treated with two syndesmotic screws there is no clear evidence to support this [67,95,101,2]. The use of a single syndesmotic screw in these types of fractures does not appear to lead to increased failure rates.

Screw type and diameter There is no clear biomechanical advantage of a 4.5 mm screw over a 3.5 mm screw to stabilize the syndesmosis [34,108,57,24]. Furthermore, clinical outcome is not influenced by the diameter of the syndesmotic screw [38]. Additionally there appears to be no difference between stainless steel screws and titanium screws [8]. In the treatment of ankle fractures locking plates have gained much attention in the literature. Using two locking screws through a plate provided similar stability at the syndesmosis during axial loading, compared to two 4.5-mm quadricortical screws in a Maisonneuve model. However, the authors found twice as much resistance to external rotation stress testing [30]. Screw breakage occurs between 7% and 29% of cases in which the screw remains in place upon weight-bearing [90,105,43]. A 3.5 mm screw breaks more often than a 4.5 screw if left in place [105]. However, screw breakage does not negatively influence outcome [33,56].

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Three or four cortices With regard to the number of engaged cortices of the syndesmotic screw, biomechanical studies have shown contradicting results [95,8,23,71]. Clinically, at least five studies have been performed, of which one was published again after longer followup [123,38,43,70,44]. All of these studies showed no benefit of four over three cortices [95]. Only a small difference at three months and one year in favor of the tricortical group was found and at an average follow-up of 8.4 years, this difference had disappeared [123,38]. One study reported a significantly higher rate of synostosis with four-cortical screws but this did not influence the clinical outcome [44].

Level of screw placement There are several biomechanical and clinical studies to investigate the effect of the level of syndesmotic screw placement [125,119,63]. Anatomically one should consider the course of the perforating branch of the peroneal artery, which is one of the most important vessels of the syndesmotic ligaments. It penetrates the interosseous membrane at about 3 cm above the tibial plafond [25,61,81]. A recent nationwide survey in the Netherlands showed a preferred screw placement between 2.1 and 4.0 cm from the tibial plafond in three-quarters of the respondents [93]. Biomechanical studies, using different testing protocols, revealed that lower placement gave better stability [71,119,63,59]. From a clinical point of view two studies looked at outcome when comparing the level of screw insertion [95,51]. There was no difference between transsyndesmotic (<2 cm from the tibial plafond) or suprasyndesmotic (>2 cm above the tibial plafond) screw placement [95,51]. One study showed slightly less favorable outcome with screw placement above 4 cm [95]. From an anatomical standpoint, this might be explained by the fact that the tibial incisura ends at this level and there is a lateral tibial ridge where the drill may be difficult to center well and might slide of this ridge [3]. On the other hand, the fibula is subject to more bowing the further proximal the screw is inserted, which might lead to widening at the mortise.

Bioabsorbable versus metallic screw A total of three randomized trials and one comparative retrospective study looked at the use of

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bioabsorbable syndesmotic screws in comparison to metal screws [45,99,106,110]. A recent metaanalysis pooled the data of these four studies and found that bioabsorbable syndesmotic screws and metallic syndesmotic screws were comparable with respect to the incidence of complications and range of motion. However, the absolute number of complications was greater with bioabsorbable screws. Considering patient related outcome scores no differences could be identified [117].

Suture button technique About one decade ago a relatively new device has emerged in the treatment of syndesmotic injuries (Fig. 4). The suture button fixation of the syndesmosis was first described by Thornes et al. [112]. It was meant to be a more physiological fixation method as compared to the rigid syndesmotic screw. A recent systematic review showed marginal differences in the American Orthopaedic Foot Ankle Score when comparing manuscripts using either a tightrope or a metallic syndesmotic screw [91]. Two comparative studies in this review showed an earlier return to work in the suture-button group [91,111]. Although a flexible implant does in theory not need to be removed, implant removal may also be necessary after suture endobutton fixation of syndesmotic injuries. DeGroot et al. [18] reported that 6 of 24 treated with suture button repair required removal due to local irritation or lack of motion. Storey et al reported removal of the suture button in 8 of 102 cases for the following reasons: osteomyelitis, aseptic osteolysis, failure of stabilization, and unexplained pain over the implant [104]. More recent studies comparing flexible syndesmotic fixation with rigid screw fixation have been published. The main findings of these studies

are improved range of motion at the ankle joint [98], improved reduction of the fibula in the tibial notch [72]. Most of these studies, however, failed to show an improved patient reported outcome score (AOFAS) at final follow-up [98,72,50,53]. One study showed a significantly higher Olerud Molander Ankle Score at 12 months of almost six points [53]. It is however difficult to combine the results of these studies, due to the use of a different control group [112,98,72,50,53]. When comparing syndesmotic screw fixation to tightrope fixation in a clinical study, the only variable that had a significant influence on functional outcome was anatomic reduction of the distal fibula into the tibial notch [72].

Control of reduction First of all it is of paramount importance to check the accuracy of reduction [28,42,84,89,97,118]. Perioperative imaging with fluoroscopy or plain radiographs has its limitations and fails to detect up to 30◦ of external rotation [58]. In a previous survey less than 5% of the respondents checked the accuracy of the reduction using a CT scan. Most of them used plain radiographs to confirm reduction [93]. A normal relationship of the distal fibula in relation to the tibia can be assessed using plain radiographs [83,87]. However, the literature shows a rate of non-anatomical reduction after syndesmotic fixation varying between 16% and 52% [28,89,97,118,27,120,100]. These failures in reduction can either be detected intra-operatively by using 3D scanning [27,88] or post-operatively by using CT-scanning [28,84,89,97,118]. There are many different ways to measure the position of the fibula in relation to the incisura [120,19,47,73]. A wealth of clinical studies shows a clear association between malreduction of the syndesmosis and a less

Figure 4. Use of suture-button device in fixation of recurrent diastasis: (a) Peroperative imaging; (b) axial CT view; and (c) coronal CT view. Please cite this article in press as: T. Schepers, et al., Recent developments in the treatment of acute syndesmotic injuries, Fuß & Sprunggelenk – FussSprungg (2016), http://dx.doi.org/10.1016/j.fuspru.2016.02.004

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Recent developments in the treatment of acute syndesmotic injuries favorable outcome [72,89,118,122,55,14,69,46]. A recent study showed no inferior results if the distal fibula was reduced within 1.32—1.88 mm of displacement and 5.75◦ of rotation [120] which is consistent with the results from biomechanical studies [109]. In order to prevent malreduction several tips and tricks, besides per-operative scanning, have been proposed. Several authors have pointed out that the faulty use of reduction clamps can introduce malreduction [12,26,66]. To prevent anterior migration or rotation of the fibula either a reduction by hand should be used or a Kirchner wire from fibula to tibia as glidepath [74] or temporary fixation [84]. Peri-operatively, in the absence of 3D-imaging, a lateral image of the contralateral side can be of help to prevent malreducing the fibula [96,48,32]. In particular, the anteroposterior tibiofibular ration and anterior tibiofibular interval should be evaluated [83,32] (Fig. 5).

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After-care Regarding the after-treatment of syndesmotic fixation, the choice between early weight-bearing using a cast or boot or early non weight-bearing full range of motion exercises is a topic for debate. One systematic review comparing the literature on operatively treated syndesmotic injuries using screw fixation was unable to detect a significant difference between these two strategies [94]. Weight-bearing in a cast has the advantage of increased mobility, which can be especially of benefit in the elderly population. This treatment regimen does not appear to increase the risk of screw breakage [116], as the normal translations and rotations of the fibula during a full dorsi- and plantar flexion of the ankle do not occur in a cast [94,41]. The possibility of partial weight-bearing has been confirmed in a biomechanical study, without the use of a cast [103]. As has been noted above,

Figure 5. Different aids in preventing malreduction: (a) Open reduction at level of syndesmosis; (b) ‘Gildepath’ technique with temporary K-wire fixation; (c) lateral view of uninjured leg; and (d) per-operative 3D scanning. Please cite this article in press as: T. Schepers, et al., Recent developments in the treatment of acute syndesmotic injuries, Fuß & Sprunggelenk – FussSprungg (2016), http://dx.doi.org/10.1016/j.fuspru.2016.02.004

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the mere presence of screw breakage does not negatively influence outcome [33,56].

Routine removal It has been common practice to routinely remove the syndesmotic screw after healing of the syndesmosis [35]. However, since about ten years now a gradual increase in clinical data emerges that this might be overtreatment [38,7]. A recent systematic review looked at the need for routine removal of the syndesmotic screw [90]. Assessing the data of seven studies, no clear benefit of routine removal could be detected [38,33,56,70,122,7,22]. Those advocating routine removal suggest that is restores normal anatomy and biomechanics of the ankle. One study saw a significant increase in range of motion two weeks after routine removal of the implants at four months [65]. This study however used locked syndesmotic screws through an angle stable plate, which is a much more rigid fixation than a regular syndesmotic screw, even if used through four cortices [30]. There was no control group with tri- or four-cortical screws left in place. A recent small prospective study by Song et al. suggested that syndesmotic malreduction as detected by postoperative CT scans might reduce spontaneously one month after removing the syndesmotic screw and full weight-bearing [100]. Several recent publications also failed to show any benefit of routine removal of the syndesmotic screw [43,49,115]. Recently one randomized clinical trial was published comparing routine removal at three months versus retention of the screw. At one year no functional, clinical or radiological difference was detected between these two groups using the Olerud Molander Ankle Score and range of motion testing [9]. Further, secondary arguments to retain the syndesmotic screws are an increase in costs [54,11] and the relatively high complication rate associated with syndesmotic screw removal [92,1,15]. In conclusion there is very little evidence that routine syndesmotic screw removal leads to improved outcome. Intact screws, without loosening, causing limitations in dorsiflexion might be an indication to remove screws after a minimum of three months. In those cases patient should be carefully educated on the risks of removal. If removal is indicated on an individual basis, for example in case of limitation in range of motion, than removal should not be performed prior to eight weeks, due to the increased risk of recurrent syndesmotic diastasis [92,40].

Management of complications Malreduction of the distal fibula into the tibial incisura after syndesmotic disruption is associated with inferior outcome and the risk of early development of posttraumatic arthritis [72,89,118,122,55,14,69,46]. Treatment consists of anatomic reduction as early as possible [83,78]. The risk of failure of syndesmotic fixation is considerably increased in obese patients [62], patients with complicated diabetes, and severe osteoporosis [85]. Revision surgery should be considered with more stable fixation. Multiple tibiofibular screws, augmented fixation with bone cement and fibular plate fixation with multiple screws have been suggested for obtaining a stable fixation these patients [85,79,30]. After suture button syndesmotic repair, DeGroot et al. [18] observed osteolysis and subsidence of the device into the bone in 4 of 24 cases requiring revision and implant removal. Wound problems and soft tissue irritation at the knot over the fibula have also been described with tightrope fixation [72]. Burying the knot in a recess beneath the fibular periosteum has been suggested to avoid these complications. Heterotopic ossifications at the distal tibiofibular syndesmosis and/or the interosseous membrane are frequently observed in follow-up radiographs after syndesmotic injury but they are not necessarily symptomatic [83,44,20]. The development of a tibiofibular synostosis has been reported to be associated with male sex, syndesmotic screw fixation, the use of bioabsorbable screws, quardricortical screw fixation (compared with tricortical screw fixation) and tibiofibular dislocation [44,37]. Not all synostoses seen on plain radiographs are truly complete on CT examination [83]. Although ankle range of motion is significantly reduced in patients with radiographic tibiofibular synostosis, there appears to be no difference with regard to the functional outcomes [20,37]. Only a symptomatic synostosis requires surgical removal of the bony bridge and sealing with bone wax has been suggested [84]. Reduced range ankle of motion following syndesmotic injury may also be due to intra-articular adhesions, synovial hypertrophy and impingement. Arthroscopic debridement relieves symptoms in the short term [84,76]. Chronic syndesmotic instability results from inadequate treatment or fixation of syndesmotic disruption. It is characterized by continued pain, limited range of motion and the inability to perform on a preinjury level after syndesmosis injuries with or without malleolar fractures. Treatment consists in a secondary, near-anatomic syndesmoplasty, preferably with one half of the peroneus longus

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Recent developments in the treatment of acute syndesmotic injuries tendon [31]. Other treatment options include advancement of a bone block at the tibial tubercle, corrective fibular osteotomy, and tibiofibular arthrodesis [84,77].

Conclusion If placed correctly and malreduction is prevented the syndesmotic screw remains the ‘Gold standard’ in the treatment of acute syndesmotic injury. One tricortical 3.5 mm screw placed within 2—4 cm of the tibial plafond is usually enough. An additional tricortical screw may be added if there is doubt considering stability (obesity or high ‘Weber-C type’ fibular fracture) of the construct or in case of poor bone stock (osteoporosis and/or diabetes). There is a growing body of evidence that the syndesmotic screw does not need routine removal. Only in cases with complaints of pain or stiffness, where the screws do not loosen or break, the screws might be removed after a minimum of eight weeks. Syndesmotic malreduction is associated with less favorable outcome and carries the risk of the development of chronic instability and posttraumatic ankle arthritis.

Conflict of interest The authors declared that they have no conflict of interest.

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Please cite this article in press as: T. Schepers, et al., Recent developments in the treatment of acute syndesmotic injuries, Fuß & Sprunggelenk – FussSprungg (2016), http://dx.doi.org/10.1016/j.fuspru.2016.02.004