1. Dr.Rajiv Shah
‘Foot & Ankle Orthopaedics’
Foot & Ankle Surgeon
President, Indian Foot & Ankle Society

2. Ankle fractures are surrounded by
many controversies!!
Ankle fractures are not
that simple as we think!

3.  Early
surgery(within
first 24 hours) is
with better
outcome!
Recent literature
Timing of surgery
 Late
presentations &
poor skin
condition…
 Wait up to 7 days
 Joint spanning
ex-fix
 ‘Wrinkle sign’

4.  No recent data
 Early surgery
prevents blister
formation!
 If present, wait
 Avoid incising
through blisters
Literature?
Blisters

5.  Concerns: PID & DM
 Increased post-op pain +
swelling
 Early ROM is achieved if
tourniquet is not used!
(Konrad G et al – CORR, 2005 )
Recent Literature
Use of tourniquet

6.  Medial swelling
 Medial tenderness
 Medial
ecchymosis
 If –ve then stable
lateral malleolar
fracture
Recent Literature
Stable v/s unstable lat.malleous #
Old Literature
 Medial
examination -
poor predictor
 Manual stress test
 Gravity stress test
 Trial of weight
bearing &
reanalysis

7. Restoration of fibular length
 Medial exploration /Fixation
 Post malleolar fixation
 Assessment of mortise stability
 Syndesmotic fixation
Fixation chronology
Not hard & fast!
Achieving fibular length & syndesmotic
stability are more important!!
If fibula is comminuted, medial side
may be reduced first

8.  Fix if posterior
malleolus #
 >then 25%
 Articular step of >
2mm
 Persistent
subluxation of
joint
Recent Literature
Posterior malleolus #
Old Literature
 Every posterior
malleolar fracture
should be fixed!
 Forms part of
incisura
 Very important
for syndesmotic
stability
Gardner (2006) demonstrated that
posterior malleolar fixation restored
70% of syndesmosis stability
compared with 40% after
syndesmotic screw insertion!

9. Routine X-rays have got poor diagnostic
value!
External rotation lateral view, a must!
CT Scan – gold standard
Posterior malleolus #
Attachment of strong PITFL makes
it mandatory to fix posterior
malleolus fracture
Not the size of fragment but the
stability of ankle is more
significant!
Fix them posterior to anterior
between peronei and FHL!

12.  Occurs in
23% of ankle
fractures
 If deltoid is
also injured
then there is
marked
instability
 Anatomical
reduction is
a must!
Syndesmosis injury

13. Anterior inferior tibio-
fibular ligament

14. Posterior inferior tibio-
fibular ligament

15. Interosseous ligament

16. Medial ligaments

17.  History
 Pain &
swelling
 Ecchymosis
 Tenderness at
syndesmosis
Clinical diagnosis
Special tests
 Squeeze test
 External
rotation
stress test
Dorsiflexion of ankle
+
syndesmosis squeeze or tapping relieves pain
Radiological diagnosis
X-rays
Stress views
CT Scan

18. IncreasedTibio-fibular clear spaceTibio- fibular overlap

19. Increased medial Clear SpaceDisturbedTalocrural angle

20. Lateral talar shift signAnkle instability sign

21. Gravity stress testCT Scan – Gold standardCT definition of anatomic syndesmosis?Surest CT sign =Tibiotalar lineLine from AL fibula to ant.tubercle of tibia, 1 cm above
plafond on axial CT cut
MUST BE WITH INTWO MM FROM ANTERIOR
SURFACE OFTIBIA
MRI
 Syndesmotic ligament
injury
 Associated injuries –
Talar dome OCD -28%
Bone bruise -24%
ATFL -74%

22.  Hook test-pull
fibula laterally &
take image
Five tests
Intra-operative diagnosis
 External rotation test
– hold leg & rotate
foot externally & take
AP image
 Tap test – push tap
forward in
syndesmosis & see
widening
 Modified cotton’s
test – pull fibula
posteriorly & take
LAT image
 Ballottement test
– rock/slide fibula
anteroposteriorly
Arthroscopy has increasing role in
diagnosis!
Open & make sure!
Fragment in syndesmosis = open

23.  Fibula to tibia
 25-30 degree PL
to AM
 2 cm above &
parallel to joint
line
Screw
Syndesmotic fixation

24. • No mechanical advantage of 4.5 mm over 3.5 mm in
tricortical fixation
• 4.5 mm superior mechanically in quadricortical fixation
• 3.5mm more likely to break (Panchbari et al)
• Avoid cannulated screws
• Larger diameter screws provide great resistance to shear
forces
3.5mm or 4.5 mm?
Controversies:
syndesmotic screw

25.  No difference in outcomes between tri-
cortical or quadri-cortical but QC can be
removed easily if break and symptomatic
 4 cortices are more likely to break as they
are more stiffer
3 cortices or 4 cortices?
Controversies:
syndesmotic screw

26. ▪ No consensus
▪ Two screws better on mechanical studies
▪ Two screws better stability to torsional stress
▪ Stability is better with a screw through the plate
▪ Stiff construct eliminates even more normal
motion
Single or double screw?
Controversies:
syndesmotic screw

27.  2.5 cm above ankle
 Less than 2 cm = chances of synostosis
 More than 5cm = widening of
syndesmosis on external rotation
Where ?
Controversies:
syndesmotic screw

28.  Over tightening of syndesmosis is
possible?!
 Position of ankle in dorsiflexion during
screw fixation does not matter but
anatomic reduction does matter a great!
Position of ankle?
Controversies:
syndesmotic screw

29.  Every material steel, titanium or bio-
absorbable showed similar results
 Bio-absorbable – early return to work
 Bio-absorbable – FB reaction, wear,
osteolysis, ? Joint damage
SS ,Titanium or bio-absorbable?
Controversies:
syndesmotic screw

30.  Allows natural movement of ankle
 Less likely to give malreduction
 No need for removal
 No difference b/w tightrope and screws
in biomechanics (cadaveric studies)
Screw
or
Tight rope?
Controversies:
syndesmotic screw

31.  Supposed to be biomechanically better
 Some do require re operation (irritation
due to knot)/ suffer from osteolysis and
sinkage
 Have shown improved functional outcomes
and early recovery
Screw
or
Tight rope?
Controversies:
syndesmotic screw

32.  No difference between outcome in
fractures, loosened or removed screws
 Tibiofibular space narrower in intact
screw group
 Screw removal advised for intact screws
Remove or retain?
Controversies:
syndesmotic screw

33.  BetterAOFAS score when screw breaks or
is removed
 Walking prior to removal of screws does not
affect outcome
 Majority screw breaks
Remove or retain?
Controversies:
syndesmotic screw

34.  Tibiofibular space narrower in intact screw
group
 Increased ROM after screw removal
 Screw removal advised for intact screws
 ‘At 3 months follow up if ankle dorsiflexion is
not improving then screw removal’
Remove or retain?
Controversies:
syndesmotic screw

35.  25%-50% malreduction
 80% reduced after screw removal
 Use of tight rope?
 Intra-op direct visualization reduced rate of
malreduction from 44% to 15%!
 Intra-op CT
 Post op CT
How to prevent
malreduction?
 Tibio fibular synostosis
 Reduced external rotation
How to salvage failed
syndesmosis ?

36. • 3.5mm screws 51%
• 4.5mm screws 24%
• Suture device 14%
• 1 screw 44%
• 2 screws 44%
• 3 cortices 29%
• 4 cortices 67%
• Routine removal 65% (95% OR)
(3 months 49%, 4 months 37%, 6months 12%)
• Most common practice: 3.5 mm screw, 4 cortices
routinely removed in OR at 3 months

37.  Wide medial clear space after fibula reduction
 Difficult fibula reduction
 Difficult to maintain fibula reduction
 Medial exploration
 Interposition of deltoid, post tib tendon,
osteochondral fragments
 Routine repair of deltoid is controversial
except rupture with bony fragment or with
association with extensive soft tissue damage
When?
Medial side exploration

38.  Wound healing
 Deep infection
 Implant
loosening
 Loss of fixation
Problems
Fractures in elderly
Solutions
 Posterior antiglide plate
 Bicortical screws
 Fibula pro tibia screws
 + ex fix
 Hook plate
 IM fixation of fibula
 IM k wires + plate
 LCP
 Bone cement
augmentation
 Bone substitutes
 Medical
management

39.  Poor radiological
outcome
 Deep infection
 Revision rates
 Loss of fixation &
conversion in
charcot
Problems
Fractures in diabetics
Solutions
 Medical
management
 Two types of
surgical
guidelines

40. That’s all…
Thank you all..