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Syndesmosis Injuries: Semi-Rigid Fixation is the NEW Gold Standard
A Amendola MD Professor and Vice Chair Chief, Division of Sports Medicine Department of Orthopaedic Surgery Duke University
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Disclosures
• Arthrex : royalties; consultant • Arthrosurface : Stock; royalties • First Ray: SAB; stock • Smith and Nephew : royalties
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Syndesmotic Fixation: Where are we going ?
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Syndesmosis “ high ankle” sprain
• Common injury • Often misdiagnosed • Cause of chronic Ankle
dysfunction • No direct diagnostic test • Spectrum of severity
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• External rotation • Acute dorsiflexion • Severe ankle sprain
Syndesmosis Injury: Mechanism
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Ankle Syndesmosis: Function
• Stability : syndesmosis /deltoid • Weight transmission • Accommodate talar motion
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Ankle Syndesmosis: Function
• Stability : syndesmosis /deltoid • Weight transmission • Accommodate talar motion
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Spectrum of Injury
No instability Mild Complete Normal
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Spectrum of Injury
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Syndesmosis Sprains
Classification
• Scranton ( AAOS) – A. Acute ( 0-6 wks)
– I: partial AITFL / stable – II: complete AITFL/ partial IM/ stable or unstable – III: complete AITFL/deltoid/ grossly unstable
– B. Subacute ( 6 wk-3 mos) – C. Chronic ( > 3 mos)
AIII
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Syndesmosis Sprains
Classification
• Scranton ( AAOS) A. Acute ( 0-6 wks)
I: partial AITFL / stable ( - stress tests/ N xray) II: complete AITFL/ partial IM/ stable or unstable ( + stress tests, N xray) III: complete AITFL/deltoid/ grossly unstable ( + xray)
B. Subacute ( 6 wk-3 mos) C. Chronic ( > 3 mos)
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Case 4 unstable high ankle sprain
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Case 4 unstable high ankle sprain
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Case 4 unstable high ankle sprain
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Post op regimen
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Case 5 Chronic sprain
• CASE: 18 yo freshman DL recruit • Senior year HS sprained ankle in August
– Played all games – Never reached 100% – January : felt he was 80% – Could not push off , pivot
• Exam – mild swelling – Tender – ++ ER stress/ stabilization test
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Case 5 chronic sprain
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Case 5 chronic sprain
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Case 5 chronic sprain
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Case 5 chronic sprain
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Complications : Syndesmosis Fixation
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Fractures and Syndesmosis: Reduction and fixation
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Reduction and fixation
2 years
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Syndesmotic Fixation: Where are we going ?
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Syndesmotic Fixation
AOFAS 2013
• Screws are more rigid • Suture button is satisfactory
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Syndesmotic Fixation
• Similar rates of malreduction
• Better earlier ROM with suture button
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Syndesmosis Injury: Treatment What would be the ideal fixation:
1. Avoids malreduction 2. Provides stability 3. Does not require hardware removal 4. low morbidity/ technically reproducible 5. Minimal complications
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AJSM 2012
Comparison screws vs tightrope
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Naqvi et al : study method • Cohort study • SS calculation : 23 subjects in each group
– 1mm diff on CT scan, power 80%
• 2 ( x23) groups : tightrope vs screw fixation – Primary outcome : CT reduction – Xrays, clinical outcomes AOFAS, FADI,
complications – Min 18 month FU
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Demographics
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Naqvi et al : accuracy of CT vs xrays
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Naqvi et al : outcomes: malreduction
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Naqvi et al : outcomes: WB
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Naqvi et al : outcomes: regression analysis
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Naqvi et al : discussion weaknesses • 18 mo FU • 2 groups of surgeons/ not randomized • No immediate post op CT
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Outcome of suture button vs screws in fractures : similar outcomes
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Advantages of Suture-Button Fixation
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Advantages of Suture-Button Fixation
control Screw( malreduced) Screw removed tightrope
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Syndesmosis Injuries
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Syndesmotic fixation: conclusions
• Suture button fixation – Earlier return to full WB activity
• Does not need removal
– Avoid malreduction/ maintain reduction
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case2
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case2
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Case2 : best of both worlds !
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Summary
• Syndesmosis injury is a spectrum from sprains to fractures
• Unstable injuries can be made more predictable ( RTS) with early stabilization
• No need for removal • Suture button fixation provides some benefits in
every spectrum of injury
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