Treatment of Ankle Syndesmosis Injuries

Treatment of Ankle Syndesmosis InjuriesChapter n angiotensin-converting enzyme 11. foundation garmentInjuries to the distal tibio fibular syndesmosis ar complex and remained contr oversial with get word to diagnosing and man get onment. In United Kingdom, articulatio talocruralis come a particularyize ab forthings ar the virtu in all(a)y common breach among long-sufferings term-honored in the midst of 20 and 65 with the annual incidence in unionize as 90,000 (1). Twenty percent20% of ankle fr lickures requireing internal reversion (2), and or 10% of all ankle sallys are associated with syndesmosis disruption (3). Syndesmotic injuries go with besides been report in the absence of shifting and sometime called as higher(prenominal)(prenominal)(prenominal) ankle deformwith incidence account somewhere betwixt 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the appreciable atrocious amount of work load these injuries provide for orthopaedic surgeons, thither is no consensus regarding the optimum treatment of these injuries, matteranting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is on that pointfore big to understand the anatomy, biomechanics and the chemical mechanism of injuries involving the tibiofibular syndesmosis.1.1. con ecesisThe middle- take cause tibiofibular give voice is a syndesmotic formu new-fangled organise by 2 attires and quartet ligaments. The distal shin bone and fibula form the pinched part of the syndesmosis held unneurotic by four ligaments providing stability that is built-in for fitting dishing of the ankle roast (6-8). These ligaments admit the precedent indifferent tibiofibular ligament (AITFL), the fundament lacking(p) tibiofibular ligament (PITFL), the transversal tibiofibular ligament and the interosseous ligament.At the apex of syndesmosis, the interosseous rim of shinbone bifurcates caudal into an front tooth and fundament leeway. The frontal margin ends in the antero- squint-eyed eyeshot of the shinbonel plafond called the anterior eminence (Chaputs tubercle). The stinkpot margin ends in the posterolateral perspective of the tibial plafond called the tail assembly tubercle. The anterior and posterior margins of the distal tibia infix a concave triangular nonch called insisura fibularis, with its apex 6-8 cm preceding(prenominal) the level of the talocrural joint (9-11). The anterior tubercle is much than prominent than the posterior tubercle and protrudes further laterally and crossways the median deuce thirds of the fibula (9-11). The fibular part of the syndesmosis is umbel-like and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, too bifurcates into an anterior and posterior margin and forms a convex trigon that is hardened supra the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, al around negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) exposit deuce main morphological patterns in their information of deoxycytidine monophosphate regulation ankle syndesmoses. In 67% the insisura was deep, vainglorious the syndesmosis a crescent convention dapple in 33% it was shallow, big(p) the syndesmosis a rectangular shape (12).The anterior inferior tibiofibular ligament AITFL runs aslant from anterior tubercle of distal tibia to anterior tubercle of fibula Fig. 1.1. AITFL consists of multifascicular plenty of fibers that run obliquely downwards and laterally and prevents excessive fibular causa and outdoor(a) talar whirling (13). The AITFL is the archetypal ligament to fail in international rotation injuries (9). coffin nail inferior tibiofibular ligament PITFL is a difficult ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) Fig. 1.2. PITFL flora along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The rase part of the PITFL runs much horizontally and is considered as a separate anatomical entity called crosswise ligament. The transversal ligament is a thick, strong structure with twisting fibers. It traveles from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament downstairs the posterior tibial margin creates a posterior labrum, which deepens the articular show of the distal tibia and helps to prevent posterior talar commentary Fig. 1.2. The interosseous tibiofibular ligament is a node of lower more or less part of interosseous membrane and consists of numerous short, strong, tendinous bands which pass betwixt the contiguous rough tri angular rebels of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is horizon to act give care a spring, allowing for sparse separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and indeed for some wedging of the astragalus in the mortice (9).Ogilvie-Harris et al (15) canvass the relative importance of separately of the ligaments in the distal tibiofibular syndesmosis development 8 fresh-frozen cadaver specimens to evaluate the percent of contri furtherion of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35% the transverse ligament, 33% the interosseous ligament, 22% and the posterior inferior ligament, 9%. Thus, more than 90% of total protection to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, devia nt joint operation, and instability.1.2. BiomechanicsThe primary foreparts at the ankle joint imply dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be change magnitude to 40o passively and between 45o to 55o of plantar flexion (16). The sterling(prenominal) go forth of the astragalus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus wedges between the medial and lateral malleoli, and much of the cut becomes occupied (6). Up to 6o of talar out-of-door rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slimly during plantar flexion, as a result of its conical and fasten shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of increase at the mortise as the plainlytocks is go from full plantar flexion to full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its steep bloc during plantar flexion and dorsiflexion (6, 18, 20).When fixing ankle fractures, it is vital unavoidable to desexualise normal anatomic relations of distal tibiofibular syndesmosis, as slight difference croupe lead to meaning(a) change in biomechanics and sub best long term results. Ramsey and Hamilton (21) demonstrate that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar middleman surface neighborhood and increase in contact stresses. uniform findings were overly confirm by some some separate fresh memorize by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint i nfinite volume.1.3. Mechanism of InjuryThe 3 proposed mechanisms of ankle syndesmotic stigma accept external rotation of the floor, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully compulsive into external rotation within the mortise. Forceful eversion of the talus likewise results in widening of the mortise. These mechanisms are most common in sports like foundingball game and skiing. Hyperdorsiflexion injuries are seen in jumping sports and in like manner result in widening of mortise when wider anterior part of the talus dome is forcefully goaded into the joint plaza. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30).Lauge-Hansen (31) classified the ankle fractures concord to the mechanism of injuries. This assortment administration was base on cadaveric say and takes into account the arrange of foot at the time of stigma and the deforming force. According to this syndesmotic disruption most ordinarily occurs in Pronation-External Rotation (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid muscle ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and ultimately a spiral fracture of the fibula above the level of syndesmosis (31, 32). n wee of the eff syndesmotic disruptions are associated with weber C fracture with smaller symmetricalness having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic challenge. These injuries are sometime referred as high syndesmotic sprain (4, 27, 34).1.4. diagnosisDiagnosis of syndesmotic injury can sometime be challenging and depends on high baron of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological legal opinion or examination under anaesthesia. Several clinical seeks cede been described in writings provided lack high prophetical entertain in abrupt cases as it might be thorny to manage these mental testings because of excessive perturb in bully situations. Some examples of these tests entangle beseech test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36).Radiographs are principal(prenominal) in diagnosis of tibiofibular syndesmotic diastasis. iii radiographic literary arguments gift been described establish on anterior-posterior and mortise spatial relations but disputation exist among researchers with regard to the optimal parameter for accurate diagnosis. The tibiofibular go on berth is defined as the distance between the lateral b effect of the posterior tubercle and the me dial border of the fibula. The tibiofibular crossing is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial make believe dummy is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). harpist et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated chase criteria as consistent with a normal tibiofibular relationship (1) a tibiofibular lightsomely set on the anterior-posterior and mortise views of less than approximately 6 mm (2) tibiofibular overlap on the anterior-posterior view of great than approximately 6 mm or 42% of fibular comprehensiveness (3) tibiofibular overlap on the mortise view of great than approximately 1 mm. The vignette reason out that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most unquestionable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were support by Nelson et al (40) and Pneumaticos et al (41) except that the later study account that the tibiofibular clear space did non change significantly by rotation of ankle (41). CT and MRI grazening are more refined than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42).1.5. Treatment of Syndesmosis diastasis and review of publicationsInjuries to distal tibio-fibular syndesmosis are complex and require accurate drop-off and fixture for optimal issuing (43, 44) but the choice of compu lsion still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the subsequentlymath of ankle fractures in 347 patients at a minimum follow up of 1 course of instruction and reason out that patients requiring syndesmotic stabilization in addition to the malleolar neutering had poorer impression as compared to patients requiring only if malleolar reparation.Although, the use of metal love has been the most popular operator of stabilising the syndesmosis (32), controversy exists with regard to the size and fall of jailer, number of cortices engaged, level of fuck placement above the tibial plafond, need for routine removal and the time of the hunch forward removal (46-48). Beumer et al (49) in their cadaveric study, account no difference in repair of the syndesmosis when stainless steel sleep withs were compared to te posteriors through three or four cortices. Hoiness et al (46) conducted a randomise likely trial compar ing individual 4.5 mm quadricortical screw with deuce 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical assort, but later on one year there was no significant difference between the hosts in their available denounce, fuss or dorsiflexion (46). Further report on the same study group with 8.4 age average follow up did not show whatever significant difference in clinical force (50). Moore et al (51) also inform similar utilitarian outcome with either three or four cortical fixing using 3.5 mm screws with slightly higher swerve toward loss of reducing in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to wholeness screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when utilise as tricortical screw (48) but when apply as quadricortical screw 4.5 mm screw showed higher resistance to dress stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal forward outset full weight bearing as screw provides steadfast fastener of syndesmosis where micromotion occurs normally and can therefore lead to screw liberalization or fatigue failure (54-57). Miller et al (58) demonstrated modify clinical outcomes following syndesmosis screw removal in a serial of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients hardened with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or take screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). both these studies had inherent limitations including of retrospective studies study design and lack of a the ascendancy group.Malreduction of tibiofibular syndesmosis has been account as a significant problem with screw mending and is an independent predictor of functional outcome (44). Gardner et al (60) account 52% of malreduction of syndesmosis in weber C fractures treated with screw obsession.Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware cerebrate complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not come along popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis cod to polymer debris go in the joint (64-67).The Arthrex Tightrope is a relatively new surgical implant based on the sutura endobutton design. It is a low profile form comprised of a none 5 FiberWire loop which, tensioned and secured between metallic buttons placed against the outside cortices of the tibia and fi bula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope proficiency (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological similitude of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American orthopaedic Foot and Ankle Society (AOFAS) add together and returned to work in front than screw group. As with any novel technique, the follow-up report in the literature is short and the number of cases are limited Table 1. The largest case serial so far, has account the outcome in 25 cases patients (72, 73). Although initial serial publication did not report any complications, some cases of implant removal have been reported in more recent literature because of whacky interweave paper impatience. In a serial of 16 patients, two tightropes were removed, one payable to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). unmatchable of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a likely randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reported remit of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series.Desp ite satisfactory short term clinical outcomes, fewer complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in keeping the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been anteriorly noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axile CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. prodigious malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syn desmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we luff to fill the gap in literature regarding tightropes ability to maintain syndesmosis one in longer term.1.6. Aims and ObjectiveThe primary A aim of this study is to compare the accuracy and aid of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome.Population (P) Adult patients with acute fixation of ankle syndesmosis.Intervention (I ) Tightrope fixation of ankle syndesmosis.Comparison (C) Syndesmosis screw fixation. termination (O) Accuracy of syndesmotic reduction, based on axial CT scan.Chapter No. 22. PATIENTS AND METHODSWe conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. cardinal different methods of syndesmosis fixation were compared ( old-hat transos seous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at to the lowest degree 18 months following the index procedure. The accuracy of syndesmosis reduction was calculated mainly on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control.The study was conducted in segment of Trauma and orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after laudation by the Institutional Review Board (appendix i). The patients were recruited using trauma field of operation informationbase. The information regarding all patients treated for ankle injuries was reviewed.The inclusion criteria were as followsadults ( 18 old age) with acute ankle syndesmosis injurywilling to give informed comply to move in th e study, fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria.The exclusion criteria touch on out for this study includeP patients with open fracture,I i ndividuals with diabet es ic or neuropathic arthropathy,M multi trauma patients andP patients who had a former injury or surgery on the contra-lateral ankle as those could not be used as a control.Pregnancy was included in exclusion criteria B because of radiation exposure in this study. pregnancy was also mentioned as exclusion criteria.i I ndividuals unwilling to go for to the studyPatients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation no matter of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on vigilant clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), change magnitude tibiofibular clear space (TFCS) and squeezed tibio-fibular overlap (TFOL) preoperatively and intraoperative halt under fluoroscopy using external rotation stress test and tear test in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using cast intensifier. Concomitant fractures of fibula and medial malleolus were fixed according to shopworn AO principles. Ankle syndesmoses were stabilized with either Transosseous Screw or Tightrope depending on the consultants preference. all told patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and pat ients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were at long last reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional marker systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFAS) scoring system (78) and a patient reported Foot and Ankle Disability mogul (FADI) score (79). radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, elderberry bush CT Radiographer using same specifications. All patients were scanned supine in the axial compressed with no gantry tilt. Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The field of operations of ankle syndesmosis was scanned using single cut CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as deliberate on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx Fig. 2.1. This technique was adopted in order to reduce the radiation exposure to the patient without compromising the quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond.2.1. Outcome VariablesThe accuracy of syndesmosis reduction on axial CT scan was considered as primary outcome inconstant to compare the two different treatment options. The standard for malreduction of syndesmosis was set at 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the aspire of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in uniformity with previous literature (60) and the assumption that this difference will result in fit level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviance of 1.19 mm. As this area corresponds to the tibiofibular clear space on AP radiographs and 6 mm of tibiofibular clear space is considered abnormal, the criterion of 2 mm would be justified.Syndesmosis justness was also assessed on AP radiographs of ankle, using parameters including tibiofibu lar clear space (TFCS 6 mm) and medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been astray used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and conglomerate functional activities. Both the scores range from 0 to 100 with higher scores indicating better function.In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjust using regression analyses.2.2. Data Collection and MeasurementsDemographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes.Radiographic parameters of syndesmosis uprightness were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The tibiofibular clear space is defined aTreatment of Ankle Syndesmosis InjuriesTreatment of Ankle Syndesmosis InjuriesChapter No. 11. INTRODUCTIONInjuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as high ankle sprainwith incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore important to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis.1.1. AnatomyThe inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligam ent.At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12).The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula Fig. 1.1. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and r uns obliquely downwards and laterally to the posterior lateral malleolus (14) Fig. 1.2. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation Fig. 1.2. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bo nes, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9).Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to evaluate the percentage of component of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35% the transverse ligament, 33% the interosseous ligament, 22% and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability.1.2. BiomechanicsThe primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion to full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rota tion along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20).When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume.1.3. Mechanism of InjuryThe 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widen ing of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30).Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in Pronation-External Rotation (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic challenge. These injuries are sometime referred as high syndesmotic sprain (4, 27, 34).1.4. DiagnosisDiagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it mi ght be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36).Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The tibiofibular clear space is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The tibiofibular overlap is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial clear space is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular r elationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42).1.5. Treatment of Syndesmosis diastasis and review of literatureInjuries to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation.Although, the use of metal screw has been the most popul ar means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant difference in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes following syndesmosis screw removal in a series of 25 patient s. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group.Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation.Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67).The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button gro up demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the follow-up reported in the literature is short and the number of cases are limited Table 1. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reported subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series.Despite satisfactory short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial C T scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syndesmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term.1.6. Aims and ObjectiveThe primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome.Population (P) Adult patients with acute fixation of ankle syndesmosis.Intervention (I ) Tightrope fixation of ankle syndesmosis .Comparison (C) Syndesmosis screw fixation.Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan.Chapter No. 22. PATIENTS AND METHODSWe conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control.The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed.The inclusion criteria were as followsadults ( 18 years) with acute ankle syndesmosis injurywilling to give informed consent to participate in the study, fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria.The exclusion criteria set out for this study includedP patients with open fracture,I i ndividuals with diabet es ic or neuropathic arthropathy,M multi trauma patients andP patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control.Pregnancy was included in exclusion criteria B because of radiation exposure in this study. pregnancy was also mentioned as exclusion criteria.i I ndividuals unwilling to consent to the studyPatients were treated by six Or thopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively and intraoperative confirmation under fluoroscopy using external rotation stress test and hook test in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fractures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either Transosseous Screw or Tightrope depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFAS) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) sc ore (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications. All patients were scanned supine in the axial plane with no gantry tilt. Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx Fig. 2.1. This technique was adopted in order to reduce the radiation exposure to the patient without compromising the quality of the scans and the axial images thus obtained correspond to the same level as used fo r the measurements on radiographs i.e. 1 cm above tibial plafond.2.1. Outcome VariablesThe accuracy of syndesmosis reduction on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on AP radiographs and 6 mm of tibiofibular clear space is considered abnormal, the criterion of 2 mm would be justified.Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including tibiofibular clear space (TFCS 6 mm) and medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function.In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses.2.2. Data Collection and MeasurementsDemographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes.Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The tibiofibular clear space is defined a