Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population
Reference: Paez CJ, Lurie BM, Upasani VV, Pennock AT. Functional outcomes of unstable ankle fractures with and without syndesmotic fixation in the adolescent population. J Child Orthop 2021;15:418-425. DOI: 10.1302/1863- 2548.15.200250
Level of Evidence: III
Reviewed by: Neil Patel, DPM
Residency Program: Beaumont Farmington Hills Hospital, Farmington Hills, MI
Podiatric Relevance: Syndesmotic injuries are common, occurring in 10% to 23% of ankle fractures in the adult population although the incidence and natural history of this injury in pediatric and adolescent patients remains unclear, and few studies have examined functional outcomes. Injury to the syndesmosis in adults has been shown to be associated with worse functional outcomes, pain, stiffness and swelling although very few studies have included a significant number of adolescent patients. This study identifies adolescent patients that underwent operative fixation of either a Weber B or C ankle fracture and compare functional outcomes between those with and without a syndesmotic injury requiring syndesmotic fixation.
Methods: A level III retrospective study was performed for adolescent patients (defined as ages 10 to 19 years) who underwent open reduction internal fixation of a Weber B or C fibula fracture, with minimal one year follow up. A total of 111 surgically treated unable ankle fractures (48 patients in the syndesmotic fixation group and 63 in the no syndesmotic fixation group; 68 Weber B and 43 Weber C fractures) were identified. Functional outcome data was obtained using the Foot and Ankle Ability Measure (FAAM) questionnaire and Single Assessment Numerical Evaluation (SANE) questionnaire. Demographic data, Weber classification, presence of a medial or posterior malleolus fracture, the status of the physis and sport or activity at time of injury, tourniquet time, immobilization time and duration of non-weightbearing were also record.
Results: There were no statistically significant differences between the syndesmotic fixation and no syndesmotic fixation group in terms of age, sex, need for second surgery other than implant removal, complication rates, and return to sport rates. Also, there was no statistically significant difference in functional outcomes between the groups for FAAM scores, SANE scores, and satisfaction scores.
Conclusions: Male sex, lower BMI and longer duration of follow-up were independent positive predictors of functional outcome, whereas syndesmotic fixation was not a predictor of functional outcome. The syndesmotic fixation group had longer tourniquet times, length of weightbearing restrictions and rates of implant removal but had equivalent functional outcomes, rates of return to sport and overall satisfaction compared to the no syndesmotic fixation group. There are a number of limitations in this study including the retrospective nature of the study, functional outcomes being assessed by patient reported outcome scores, and different criteria for intraoperative diagnosis of syndesmotic injuries at other facilities. Future studies including objective data on strength and range of movement could provide valuable information.