SLR - August 2016 - Abigail Smith
Reference: Warner SJ, Fabricant PD, Garner MR, Schottel PC, Helfet DL and Lorich DG. The Measurement and Clinical Importance of Syndesmotic Reduction After Operative Fixation of Rotational Ankle Fractures. J Bone Joint Surg-Am. 2015 Dec 2;97(23):1935–44.Scientific Literature Review
Reviewed By: Abigail Smith, DPM
Residency Program: North Colorado Medical Center Podiatric Medicine and Surgery Residency in Greeley, CO
Podiatric Relevance: Syndesmotic reduction following ankle fractures has been a complex topic within the podiatric and orthopedic literature. Debate still exists concerning type of syndesmotic fixation, timing of screw removal and which methods are associated with superior patient outcomes. Recent literature has investigated the quality of syndesmosis reduction and suggested poorer patient outcomes being attributed to malreduction of the syndesmosis. This study aimed to investigate the correlation between syndesmotic reduction and patient outcomes.
Methods: This study included 155 patients with either SER IV (n = 129) or PER IV (n = 26) ankle fractures all requiring ORIF with syndesmotic reduction. The syndesmosis was fixated with transsyndesmotic screw(s), anatomic direct repair or indirect repair with reduction of posterior malleolar fragment or a combination of both transsyndesmotic screw and anatomic repair. Syndesmotic reduction was assessed by each of four different methods, all utilizing computed tomography. Reduction assessment was performed within the first two postoperative days on all patients. Patient outcomes were assessed using the Foot and Ankle Outcome Score, which includes five separate domains, symptoms, pain, activities of daily living, sports and recreation, and quality of life.
Results: No correlation was found between the four methods of assessing syndesmosis reduction and patient outcomes according to FAOS. Patient outcomes were also compared for both the transsyndesmotic screw fixation groups and the anatomic repair group. Although increased malrotation was noted in the syndesmotic screw group compared to the anatomic repair group (6.3° versus 4.8°), there again was no correlation to FAOS scores.
Conclusions: This study raises the question about the importance of syndesmotic reduction influencing patient outcomes. Although ankle fractures with postoperative articular incongruity were excluded in this study, lack of correlation between syndesmotic reduction and patient outcomes found in this study supports the claim that reducing the articular surface is of greater influence on patient outcome than accurately reducing the syndesmosis. The results of this study support the notion that relative anatomic reduction of the syndesmosis is sufficient and minute degrees of malreduction have little, if any, effect on patient outcomes.