Long-Term Outcome of Pronation-External Rotation Ankle Fractures Treated with Syndesmotic Screws Only

SLR- February 2014- David Liss

Reference: Lambers, K et al. Long- Term Outcome of Pronation-External Rotation Ankle Fractures Treated with Syndesmotic Screws Only. The Journal of Bone and Joint Surgery.95: e122-128. 2013.

 

Scientific Literature Review

Reviewed by: David Liss, DPM
Residency Program: Cedars Sinai Medical Center
 

Podiatric Relevance: This study aimed to investigate the long term clinical and radiographic outcomes of PER type fractures with standardized patient-based and physician-based outcome measures. In addition, they wanted to determine possible predictors of outcome through statistical analysis. 

Methods: The study consisted of 50 patients who were prospectively enrolled in a database between 1974 and 2002 with strictly Maisonneuve type ankle fractures that had only been treated with either one or two syndesmotic screws measuring 3.5 mm or 4.5 mm depending on surgeon preference. The patients had to have a supra syndesmotic fracture which was not open (AO type 44-C). All fractures were treated with standard AO/ASIF fixation techniques. Median age of patients at the time of surgery was 36 years and the median age at time of followup was 58 years. Average followup was 21 years. The functional outcome scores used were the American Orthopaedic Foot and Ankle Society (AOFAS), the Foot and Ankle Ability Measure (FAAM), and the Center for Epidemiologic Studies-Depression (CES-D) Scale. Radiographically, osteoarthritis was graded according to the van Dijk and Takakura scoring systems.
 

Results: The measured clinical outcomes including range of motion of the functional ankle joints with plantarflexion (mean: 45°), dorsiflexion (mean: 20°), inversion (mean: 20°), and eversion (mean: 10°). Average AOFAS score was 93/100. Average FAAM score was 94 points, with 82 percent having an excellent result. At the final followup, 49 percent of patients had osteoarthritis when measured by van Dijk scale. According to the Takakura scale, 35 percent had signs of osteoarthritis.

Conclusions: Overall the paper concluded that the long term outcomes of patients treated with one or two syndesmotic screws for a supra syndesmotic PER type of fracture was good to excellent in a vast majority of the patients and provides evidence that short term investigations into the functional results hold up over the long term. This is in spite of a nearly 50 percent prevalence of osteoarthritis in the patient group evaluated. Despite the osteoarthritis, the most important predictor of functional outcome was actually the subjectively reported pain levels. These also happened to be highly correlated with depression as evaluated by the CES-D.