SLR - June 2010 - Jonathan Wilson
Reference:
Miller, Anna N., Carroll, Eben A., Parker, Robert J., Helfet, David L., Lorich, Dean G. Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation. Clinical Orthopaedics and Related Research (2010) 468:1129-1135
Scientific Literature Reviews
Reviewed by: Jonathan Wilson, DPM
Residency Program: Florida Hospital East Orlando
Podiatric Relevance:
Unstable ankle fractures that include sydesmotic rupture and a posterior malleolar fracture are commonly seen in the podiatric profession. The manner of fixation of these fractures is debated and can include transsyndesmotic screws and suture buttons. This article proposes that open reduction with internal fixation (ORIF) of the posterior malleolar fracture with an intact posterior-inferior tibiofibular ligament(PITFL) can provide a more stable fixation of syndesmotic injury than transsyndesmotic screws.
Methods:
The authors followed 31 patients with ankle fractures prospectively. They were classified into three groups depending on fracture pattern and severity. If a posterior malleolar fracture was seen, it was fixed with open reduction and internal fixation (ORIF) regardless of the size of the fracture. There were 9 in this group and they comprised group 1. Group 2 were patients with syndesmotic injury that lacked a posterior malleolar fracture and were fixed with transsyndesmotic screws, consisting of 14 patients. The third group was a combined group reserved for patients with fracture-dislocations and more severe soft tissue injuries. There were 8 in this group and they were fixed with both transsyndesmotic screws and ORIF of the posterior malleolar fracture. Each patient underwent a preoperative MRI to confirm a syndesmotic injury and an intact PITFL. All patients were followed up with the minimum follow-up being 12 months. Each patient was evaluated at 2, 6, 12, and 24 weeks and 1 year postoperatively with x-rays. The x-rays were evaluated for tibiofibular clear space, tibiofibular overlap, and medial clear space. Each patient was also given a survey to evaluate pain, symptoms, function in activities of daily living, function in sports and recreation, and overall foot-and-ankle-related quality of life.
Results:
The five subsets evaluated by the survey were similar among all three groups. The difference in tibiofiblar clear space from the syndsmotic group was greater than that of the posterior malleolar group, but it was not statistically significant. All other radiographic parameters were found to be essetially similar in all three groups.
Conclusions:
The authors conclude that ORIF of the posterior malleolar fracture, no matter what size, can provide adequate stabilization of the syndesmosis through the PITFL. The also believe that the reduction of the syndesmosis can be more anatomically correct as well. The authors believe that ORIF of the posterior malleolar fracture provides similar results when compared to transsyndesmotic screw fixation without the potential risks for complications (screw fatigue or failure, syndesmosis widening, and possibilty for screw removal).