SLR - January 2020 - Rachelle L. Randall
Reference: Kohake MBJ, Wiebking U, O’Loughlin PF, Krettek C, Gaulke R. Mid- to Long-term Outcomes After Weber B-type Ankle Fractures With and Without Syndesmotic Rupture. In Vivo. 2019 Jan-Feb; 33(1):255-261.Scientific Literature Review
Reviewed By: Rachelle L. Randall, DPM
Residency Program: Beaumont Wayne Hospital, Wayne, MI
Podiatric Relevance: Discussion remains whether to fixate the syndesmosis in Weber B ankle fractures. Many studies suggest that fixation considerations should be addressed on a case by case basis with further debate whether it should be performed in the first place. Disruption of the syndesmosis can lead to instability, arthritic changes, decreased functional outcomes and increased pain if not treated appropriately. This study suggests that previous patient outcome scores in relation to syndesmotic injury have controversial results. The present study assesses radiological and functional results of patients with syndesmotic injury and screw fixation, compared to patients without syndesmotic injury in Weber B ankle fractures.
Methods: This is a retrospective assessment of 21 patients with syndesmotic injury, that required screw fixation, and 40 patients with a stable syndesmosis after weber B fracture. Stability of the syndesmosis was evaluated intra-operatively by using the hook test. Widening of more than 2 millimeters was defined as syndesmotic injury needing repair. Exclusion criteria were open fractures, dementia, fractures of the medial malleolus, patients with multiple injuries and revisions. Multiple different functional/clinical outcome scores were assessed including: Olerud-Molander-Ankle-Score, American Orthopaedic Foot & Ankle Society ankle hindfoot score, and the Short Form Health Survey 36. Weight-bearing radiographs were reviewed to rate post traumatic osteoarthrosis according to the Kellgren-Lawrence score, and finally pain levels were evaluated with a visual analog scale.
Results: The results included 61 patients with a mean follow-up of 6.6 years. The two groups had no significant difference in gender, age, follow-up or body mass index. When evaluating the patient outcome scores, the two groups did not reveal any significant difference in function, pain or clinical outcome scores; nor did the radiographs reveal any significant difference between the two groups. There were no significant differences between the groups when evaluating KLS for osteoarthritis after surgery. Important to note, was that patients with and without hardware removal experienced similar outcomes with regard to functional, radiological and mental outcome scores. The only notable finding was that patients with a syndesmotic injury experienced a significant restriction in dorsiflexion of the ankle joint with a mean difference of 5 degrees.
Conclusions: Though previous studies suggest that syndesmotic injury, regardless of treatment, will lead to worse functional outcomes for a patient, this study showed that there was no significant difference in any outcome score that was evaluated between the groups of Weber B fractures. Both groups experienced restoration of ankle function with “good-to-excellent” results in 92 percent of the patients. The other substantial finding was that patients with syndesmotic rupture showed a significant restriction in dorsiflexion compared to those with an intact syndesmosis, regardless of hardware removal. Patients with hardware removal did not generate improved functional or radiological results. Therefore, hardware removal as a routine procedure would not be recommended with the hope to improve a patient’s clinical outcome. When preparing for surgery or consenting a patient, it is imperative to be able to discuss the post-operative expectations and this study allows for literary analysis to support your discussion.