syndesmosis injuries: semi-rigid fixation is the new gold standard

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

Disclosures

•  Arthrex : royalties; consultant •  Arthrosurface : Stock; royalties •  First Ray: SAB; stock •  Smith and Nephew : royalties

Syndesmotic Fixation: Where are we going ?

Syndesmosis “ high ankle” sprain

•  Common injury •  Often misdiagnosed •  Cause of chronic Ankle

dysfunction •  No direct diagnostic test •  Spectrum of severity

•  External rotation •  Acute dorsiflexion •  Severe ankle sprain

Syndesmosis  Injury:  Mechanism    

Ankle Syndesmosis: Function

•  Stability : syndesmosis /deltoid •  Weight transmission •  Accommodate talar motion

Ankle Syndesmosis: Function

•  Stability : syndesmosis /deltoid •  Weight transmission •  Accommodate talar motion

Spectrum of Injury

No instability Mild Complete Normal

Spectrum of Injury

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

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)

Case 4 unstable high ankle sprain

Case 4 unstable high ankle sprain

Case 4 unstable high ankle sprain

Post op regimen

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

Case 5 chronic sprain

Case 5 chronic sprain

Case 5 chronic sprain

Case 5 chronic sprain

Complications : Syndesmosis Fixation

Fractures and Syndesmosis: Reduction and fixation

Reduction and fixation

2 years

Syndesmotic Fixation: Where are we going ?

Syndesmotic Fixation

AOFAS 2013

•  Screws are more rigid •  Suture button is satisfactory

Syndesmotic Fixation

•  Similar rates of malreduction

•  Better earlier ROM with suture button

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

AJSM 2012

Comparison screws vs tightrope

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

Demographics

Naqvi et al : accuracy of CT vs xrays

Naqvi et al : outcomes: malreduction

Naqvi et al : outcomes: WB

Naqvi et al : outcomes: regression analysis

Naqvi et al : discussion weaknesses •  18 mo FU •  2 groups of surgeons/ not randomized •  No immediate post op CT

Outcome of suture button vs screws in fractures : similar outcomes

Advantages of Suture-Button Fixation

Advantages of Suture-Button Fixation

control Screw( malreduced) Screw removed tightrope

Syndesmosis Injuries

Syndesmotic fixation: conclusions

•  Suture button fixation – Earlier return to full WB activity

•  Does not need removal

– Avoid malreduction/ maintain reduction

case2

case2

Case2 : best of both worlds !

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