SLR - July 2020 - Samantha A. Miner

Factors Associated with Adverse Events After Distal Tibiofibular Syndesmosis Fixation

Reference: Lemmers DHL, Lubberts B, Stavenuiter R, Guss D, Johnson AH, Kerkhoffs GMMJ, DiGiovanni CW. Factors Associated with Adverse Events After Distal Tibiofibular Syndesmosis Fixation. Injury 2020 Feb; 51(2):542-7.

Scientific Literature Review 

Reviewed By: Samantha A. Miner, DPM
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatric Relevance: Surgical treatment of syndesmotic instability is common after distal tibiofibular joint disruption in order to improve functional outcomes. However, surgical intervention may come at a cost due to complications and adverse outcomes that may delay recovery or result in long-term disability. The purpose of this study was to determine the incidence of adverse events after syndesmotic fixation, as well as identify any associated patient-related and surgical factors.  

Methods: This is a retrospective evaluation of 849 adult patients who underwent surgical treatment of syndesmotic instability with associated fibula fracture between January 2000 and May 2015. Patients were included if they were treated with either screw or suture-button fixation, had no history of prior surgical treatment for syndesmotic instability, and had a minimum of one-year follow-up postoperatively. Patients were excluded if there was an isolated syndesmotic injury or if an open wound was present. Adverse events were identified and divided into infectious complications, unplanned reoperation for removal of hardware, and other remaining complications. Surgical variables included duration of admission, type of operative treatment, and use of an external fixator device before open reduction internal fixation. Patient-related variables included demographic data such as age, sex, body mass index (BMI), tobacco use, and comorbidities. Multivariable logistic regression analysis was utilized to determine factors associated with postoperative adverse events. 

Results: Of the 849 patients included in this study, 56.4 percent (n=479) were male. The median age was 44 years old. The incidence of postoperative complications within one year after surgery was 32.5 percent (n=276). In total, 10.7 percent(n=91 patients) had an infectious complication, and 22.0 percent (n=187 patients) had an unplanned reoperation for removal of hardware. Patients treated with screw fixation had increased risk of complications compared to suture button fixation. However, patients treated with screw fixation were on average older, smokers, had longer hospital stays, and more severe injuries than their counterparts treated with suture button fixation. Multivariable logistic regression analysis demonstrated that patients with increased duration of hospital admission, use of an external fixator, peripheral vascular disease (PVD) and osteoporosis were more likely to have an infectious complication postoperatively. A BMI below 30 was the only significant factor associated with an increased risk of unplanned hardware removal. 

Conclusions: The overall complication rate reported in this large cohort of patients was 32.5%, with an overall infectious complication rate of 10.7 percent and unplanned reoperation rate of 22.0 percent. Their analysis found that increased duration of hospital admission, prior use of an external fixator, PVD, osteoporosis, and BMI < 30 were factors associated with development of postoperative adverse events within one year after fixation of syndesmotic instability. This study has a number of limitations, including the retrospective design, as well as the changes in surgical technique over the 15-year study period, which may have affected the complication rate. This study found that fixation of syndesmotic instability is associated with a relatively high complication rate postoperatively, and the determined associated factors may help guide physicians in their treatment decisions in high-risk patient groups.

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