SLR - February 2024 - Adams
Title: Comparison the treatment of anterior inferior tibiofibular ligament anatomical repair and syndesmosis screw fixation for syndesmotic injuries in ankle fractureReference: Lin X, Tu C, Lin W, Xie W, Guo X, Liu Q. Comparison the treatment of anterior inferior tibiofibular ligament anatomical repair and syndesmosis screw fixation for syndesmotic injuries in ankle fracture. BMC Surg. 2023 Apr 10;23(1):80. doi: 10.1186/s12893-023-01982-z. PMID: 37038119; PMCID: PMC10084683.
Level of Evidence: IV
Scientific Literature
Review Reviewed By: Luke Adams, DPM PGY2
Residency Program: Mercy Health St. Vincent’s Medical Center, Toledo, Ohio
Podiatric Relevance: A common injury associated with ankle fracture and ankle fracture dislocations is injury to the distal tibia-fibula syndesmosis complex. Traditionally, gold standard for fixation of the syndesmosis typically involves either static screw fixation or dynamic suture button fixation. However, recent advancements and literature support fixation of the syndesmosis complex involving the AITFL anatomic repair technique (AAR). This technique can provide long lasting effects on reduction on the syndesmosis. Furthermore, AAR has an overall low morbidity as compared screw fixation of the syndesmosis. This study analyzes 62 cases to compare the clinical and radiographic outcomes between AITFL anatomic repair and syndesmotic screw fixation in syndesmotic injuries.
Methods: A level IV retrospective cohort study was performed for all patients who underwent open reduction and internal fixation with syndesmotic injury either treated with AITFL anatomic repair technique (AAR) or syndesmotic screw (SS) fixation. A total of 62 patients between 2017 and 2020 whom all underwent open reduction internal fixation with standard plate and screw fixation by one surgeon received syndesmotic injury treatment with AITFL anatomical repair technique (30 patients) or syndesmotic screw fixation (32 patients). Radiographic evaluation was done on all included patients with bilateral ankle CT scans at 6 months postoperatively. Syndesmotic screws were routinely removed at 3 mo postoperatively, while plate and other screws were routinely removed at 1 year in all patients. Prospective outcomes were evaluated at 1,3,5 months, and at 1 and 2 years by using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcomes measures were including the Olerud- Molander Ankle score (OMA), and the visual analog scale (VAS) for pain.
Results: Of the 62 patients within the investigation- the mean age in all patients was 43.7 years old. Amongst patients in AITFL and SS groups, axial CT revealed no statistically significant radiographic difference when assessing syndesmotic reduction at 6 months postoperatively. Clinical outcomes scores for AAR show improvements in AOFAS, OMA VAS at 1- and 3-months postoperatively. However, there was no significant differences in AOFAS, OMA, and VAS scores between the 2 groups at 1 and 2 years, suggesting noninferior results.
Conclusion: The authors concluded that equivalent radiographic outcomes between both study groups suggest AITFL anatomical repair technique can maintain syndesmotic reduction as well as syndesmotic screw fixation. They demonstrated that patients in the AAR technique group showed improved ankle function and lower pain immediately post operatively up to 3 months. However, but both methods of fixation had equivocal results long term. The AAR technique provides significant stability while still allowing micromotion, whereas screw fixation is a rigid fixation that have high necessity for hardware removal. Overall, this article helps emphasize the importance of anatomic reduction with regards to ankle fractures with syndesmotic injury for best clinical and radiographic outcome. Further studies are needed to test different patient populations, larger scale to determine clinical significance, and to test outcomes with comparison to dynamic suture button fixation.