Sagittal Instability with Inversion is Important to Evaluate After Syndesmosis Injury and Repair: a Cadaveric Robotic Study

Overview

Journal J Exp Orthop

Publisher Wiley

Specialty Orthopedics

Date 2020 Apr 2

PMID 32232587

Citations 6

Authors

Neel K Patel

Conor I Murphy

Thomas R Pfeiffer

Jan-Hendrik Naendrup

Jason P Zlotnicki

Richard E Debski

MaCalus V Hogan

Volker Musahl

Affiliations

Soon will be listed here.

Abstract

Purpose: Disruption of the syndesmosis, the anterior-inferior tibiofibular ligament (AITFL), the posterior-inferior tibiofibular ligament (PITFL), and the interosseous membrane (IOM), leads to residual symptoms after an ankle injury. The objective of this study was to quantify tibiofibular joint motion with isolated AITFL- and complete syndesmotic injury and with syndesmotic screw vs. suture button repair compared to the intact ankle.

Methods: Nine fresh-frozen human cadaveric specimens (mean age 60 yrs.; range 38-73 yrs.) were tested using a six degree-of-freedom robotic testing system and three-dimensional tibiofibular motion was quantified using an optical tracking system. A 5 Nm inversion moment was applied to the ankle at 0°, 15°, and 30° plantarflexion, and 10° dorsiflexion. Outcome measures included fibular medial-lateral translation, anterior-posterior translation, and external rotation in each ankle state: 1) intact ankle, 2) AITFL transected (isolated AITFL injury), 3) AITFL, PITFL, and IOM transected (complete injury), 4) tricortical screw fixation, and 5) suture button repair.

Results: Both isolated AITFL and complete injury caused significant increases in fibular posterior translation at 15° and 30° plantarflexion compared to the intact ankle (p < 0.05). Tricortical screw fixation restored the intact ankle tibiofibular kinematics in all planes. Suture button repair resulted in 3.7 mm, 3.8 mm, and 2.9 mm more posterior translation of the fibula compared to the intact ankle at 30° and 15° plantarflexion and 0° flexion, respectively (p < 0.05).

Conclusion: Ankle instability is similar after both isolated AITFL and complete syndesmosis injury and persists after suture button fixation in the sagittal plane in response an inversion stress. Sagittal instability with ankle inversion should be considered when treating patients with isolated AITFL syndesmosis injuries and after suture button fixation.

Level Of Evidence: Controlled laboratory study, Level V.

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References

Klitzman R, Zhao H, Zhang L, Strohmeyer G, Vora A . Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis. Foot Ankle Int. 2010; 31(1):69-75. DOI: 10.3113/FAI.2010.0069. View

Clanton T, Whitlow S, Williams B, Liechti D, Backus J, Dornan G . Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques. Foot Ankle Int. 2016; 38(2):200-207. DOI: 10.1177/1071100716666278. View

Beumer A, Valstar E, Garling E, Niesing R, Ranstam J, Lofvenberg R . Kinematics of the distal tibiofibular syndesmosis: radiostereometry in 11 normal ankles. Acta Orthop Scand. 2003; 74(3):337-43. DOI: 10.1080/00016470310014283. View

Gerber J, Williams G, Scoville C, Arciero R, Taylor D . Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998; 19(10):653-60. DOI: 10.1177/107110079801901002. View

Goetz J, Davidson N, Rudert M, Szabo N, Karam M, Phisitkul P . Biomechanical Comparison of Syndesmotic Repair Techniques During External Rotation Stress. Foot Ankle Int. 2018; 39(11):1345-1354. DOI: 10.1177/1071100718786500. View

Pakarinen H, Flinkkila T, Ohtonen P, Hyvonen P, Lakovaara M, Leppilahti J . Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2012; 93(22):2057-61. DOI: 10.2106/JBJS.J.01287. View

Latham A, Goodwin P, Stirling B, Budgen A . Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ Open Sport Exerc Med. 2017; 3(1):e000175. PMC: 5530120. DOI: 10.1136/bmjsem-2016-000175. View

Teramoto A, Kura H, Uchiyama E, Suzuki D, Yamashita T . Three-dimensional analysis of ankle instability after tibiofibular syndesmosis injuries: a biomechanical experimental study. Am J Sports Med. 2007; 36(2):348-52. DOI: 10.1177/0363546507308235. View

Hunt K, Goeb Y, Behn A, Criswell B, Chou L . Ankle Joint Contact Loads and Displacement With Progressive Syndesmotic Injury. Foot Ankle Int. 2015; 36(9):1095-103. DOI: 10.1177/1071100715583456. View

10.

Shoji H, Teramoto A, Suzuki D, Okada Y, Sakakibara Y, Matsumura T . Suture-button fixation and anterior inferior tibiofibular ligament augmentation with suture-tape for syndesmosis injury: A biomechanical cadaveric study. Clin Biomech (Bristol). 2018; 60:121-126. DOI: 10.1016/j.clinbiomech.2018.10.014. View

11.

Mait A, Forman J, Nie B, Donlon J, Mane A, Forghani A . Propagation of Syndesmotic Injuries During Forced External Rotation in Flexed Cadaveric Ankles. Orthop J Sports Med. 2018; 6(6):2325967118781333. PMC: 6077923. DOI: 10.1177/2325967118781333. View

12.

Van Heest T, Lafferty P . Injuries to the ankle syndesmosis. J Bone Joint Surg Am. 2014; 96(7):603-13. DOI: 10.2106/JBJS.M.00094. View

13.

Markolf K, Jackson S, McAllister D . Force and displacement measurements of the distal fibula during simulated ankle loading tests for high ankle sprains. Foot Ankle Int. 2012; 33(9):779-86. DOI: 10.3113/FAI.2012.0779. View

14.

Grood E, Suntay W . A joint coordinate system for the clinical description of three-dimensional motions: application to the knee. J Biomech Eng. 1983; 105(2):136-44. DOI: 10.1115/1.3138397. View

15.

Peterson K, Chapman W, Hyer C, Berlet G . Maintenance of reduction with suture button fixation devices for ankle syndesmosis repair. Foot Ankle Int. 2015; 36(6):679-84. DOI: 10.1177/1071100715571631. View

16.

Czajka C, Tran E, Cai A, Dipreta J . Ankle sprains and instability. Med Clin North Am. 2014; 98(2):313-29. DOI: 10.1016/j.mcna.2013.11.003. View

17.

Westermann R, Rungprai C, Goetz J, Femino J, Amendola A, Phisitkul P . The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. J Bone Joint Surg Am. 2014; 96(20):1732-8. DOI: 10.2106/JBJS.N.00198. View

18.

Sagi H, Shah A, Sanders R . The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012; 26(7):439-43. DOI: 10.1097/BOT.0b013e31822a526a. View

19.

Grassi A, Samuelsson K, DHooghe P, Romagnoli M, Mosca M, Zaffagnini S . Dynamic Stabilization of Syndesmosis Injuries Reduces Complications and Reoperations as Compared With Screw Fixation: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2019; 48(4):1000-1013. DOI: 10.1177/0363546519849909. View

20.

Gan K, Xu D, Hu K, Wu W, Shen Y . Dynamic fixation is superior in terms of clinical outcomes to static fixation in managing distal tibiofibular syndesmosis injury. Knee Surg Sports Traumatol Arthrosc. 2019; 28(1):270-280. DOI: 10.1007/s00167-019-05659-0. View