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syndesmostic injury- anatomical
repair
AUTHOR-DR GOKULDEV V ,ASSISTANT PROFESSOR
dr_gokuldev@yahoo.com
CO-AUTHOR-DR MOHAMED ASHRAF,PROF AND HOD,
[former HOD TDMC ALLEPPEY KERALA]
drashraf369@gmail.com
DEPT OF ORTHOPAEDICS
TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS
KOLLAM,KERALA,INDIA
EPIDEMIOLOGY
• SYNDESMOSIS INJURIES -20–45% OF MALLEOLAR FRACTURES AND 5–11% OF ANKLE DISTORTIONS1
• 1 MM OF TALAR SHIFT DECREASES CONTACT AREA BY 40%- POST TRAUM DEG CHANGES 2
1.Gardner et al Foot Ankle Int 2006;27:788-792
2. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796.
3. Ramsey PL, Hamilton et al. J Bone Joint Surg Am.
1976;58:356–357.
• POSTOPERATIVE SYNDESMOSIS
MALREDUCTION RATES OF 16% DETECTED ON
PLAIN RADIOGRAPHS AND UP TO 52% ON CT
SCAN
1. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796.
2. Ramsey PL, Hamilton et al. J Bone Joint Surg Am. 1976;58:356–357
WHAT ARE WE DOING FOR ACCURATE
REDN NOW?
CLOSED REDUCTION AND SCREW FIXATION UNDER C- ARM
CRIF WITH INTRA OP CT- NOT FEASIBLE IN OUR SETUP
CRIF WITH 3D CT IMAGING-NOT FEASIBLE IN OUR SETUP
ALSO DIFFERENT IMPLANT CONFIGURATIONS FOR STABILISATION
• ONE SCREW VS TWO SCREWS VS QUAD SCREWS
• SUTURE BUTTON
• SUTURE BUTTON + SCREW
ANATOMY
•Anterior-inferior tibiofibular
ligaments (AITFL)
•Posterior-inferior tibiofibular
ligament (PITFL)
•Interosseous membrane
•Interosseous ligament (IOL)
•Inferior transverse ligament
(ITL)
WHY ANATOMICAL
REPAIR?
• ANATOMICAL APPROACH - DECREASES
SYNDESMOSIS MALREDUCTION FROM
33.3% TO 7.4%
• THE POSTERIOR SYNDESMOSIS COMPLEX
COMPRISES THE PITFL AND ITS BONY
FIXATION, THE DORSAL ASPECT OF THE
DISTAL TIBIA, COMMONLY REFERRED TO AS
THE POSTERIOR MALLEOLUS (PM).
MRI
ULTRASONOGRAPHY
RADIOLOGY
• XRAYS PROVIDE SUBTLE SIGNS
OF SYNDESMOTIC INJURY IN
ABSENCE OF FRACTURE
RADIOLOGY
• INTRA OP THIS LIGAMENT IS
BROAD AND THIN, COMPARED
TO PITFL.
• HENCE MORE SUBSTANCE TEARS
THAN AVULSION #
Posterior tibiofibular ligament
The posterior tibiofibular ligament is stronger than the anterior, and is disposed similarly on
the posterior aspect of the syndesmosis. Its distal, deep part is the inferior transverse
ligament, a thick band of yellow fibres which crosses from the proximal end of the lateral
malleolar fossa to the posterior border of the tibial articular surface
GRAYS ANATOMY 14EDTN
RECENT AVULSION# AITFL
• MECHANISM OF INJURY ARE EXTERNAL ROTATION
,HYPERDORSIFLEXION AND TALAR EVERSION.
• GRADE 3 LIGAMENT INJURY – DELTOID, MCL IN KNEE ARE FIXED,
WHY NOT AITFL?
Joy G, Patzakis MJ, Harvey Jr JP. J Bone Joint Surg Am 1974;56:979–93.
Van Heest TJ, Lafferty PM. J Bone Joint Surg Am 2014;96:603–13.
Why fix
• ANATOMICALLY FIXED POSTERIOR MALLEOLAR FRACTURE MAY
RESTORE THE POSTERIOR FIBULAR INCISURA, WHICH AIDS IN THE
SUBSEQUENT REDUCTION OF THE FIBULA INTO ITS GROOVE,
CORRECTLY TENSIONS THE PITFL AND IMPROVES SYNDESMOTIC
STABILITY.
• WHY NOT FIX AITFL?
Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures
provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–71.
Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of
syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 2010;468:1129–35.
Inadequately reduced ankle
syndesmosis as evidenced by the TFL
How we do it?
AITFL AWAITING
REPAIR
PASSING SUTURES
ADDITIONAL STABILISATION
• SYNDESMOTIC SCREW FIXATION
• FIBER TAPE ENDOBUTTON
Repaired AITFL
Postop rehab
• NON WEIGHT BEARING TILL 10 DAYS / SUTURE
REMOVAL
• TOE TOUCH WEIGHT BEARING WAS GIVEN AFTER
SUTURE REMOVAL IN A FUNCTIONAL CAST FOR NEXT 3
WEEKS
• ONCE CAST REMOVED ON 4-5TH WEEK, PROGRESSIVE
IMPROVEMENT OF ROM AS TOLERATED AND
ISOMETRIC STRENGTHENING
• 6-7TH WEEK- DORSIFLEXION STRETCHING AND
PROGRESSIVE WEIGHT BEARING,ONCE SYNDESMOTIC
SCREW IS REMOVED
• 8-9TH WEEK-RESISTIVE STRENGTHENING, ACHIEVE FULL
ROM
METHODS
20 patients were included in this study, all age groups
Male
75%
Female
25%
GENDER
0
5
10
15
BIMAL TRIMAL
6
14
TYPE OF FRACTURE
0
5
10
15
age 20-50 age > 50
12
8
AGE
statistics
• 14 patients had posterior malleolus fracture with avulsion of AITFL
• 4 patients had only anterior syndesmotic injury
Posterior malleolus was fixed with T-plate through posterolateral
approach.
Anterior separate incision for additional stabilization and exploration of
AITFL and repair using ethibond 1-0.
20%
70%
10%
LIGAMENT INJURY ANTERIOR ONLY AND
COMBINED
ANT COMB without
FUNCTIONAL
OUTCOME-
OMAS
RESULTS
Average scores at 82.3 in 3 months and 90.7 in 6 months follow up
for 16 patients(Olerud-Molander Ankle Score)
Average score 78.4 in 2 patients in 3 months and 6 months
69.3 in 2 patients in 6 months follow up.
We find that there is early return of patients to there occupation
when anatomical repair was done.
Conclusion
• Conventional treatment -unacceptably high rate of malreduction, -led
to a paradigm shift in the approach to a newer concept of anatomical
repair.
• LIGAMENTS NEED ACCURATE APPOSITION FOR PERFECT HEALING-
GAP LEADS TO SCARRING AND ELONGATION
• The principle -‘directly fix what is broken and repair what is torn’.
• The approach is effective in reducing the rate of syndesmosis
malreduction, increasing the biomechanical strength of syndesmosis
fixation.
Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev. 2018
Jan 25;3(1):24-29. doi: 10.1302/2058-5241.3.170017. PMID: 29657842; PMCID: PMC5890127.
THANKYOU
“DIRECTLY FIX WHAT IS
BROKEN AND REPAIR
WHAT IS TORN”
Medicity
kollam
kerala
india

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SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx

  • 1. syndesmostic injury- anatomical repair AUTHOR-DR GOKULDEV V ,ASSISTANT PROFESSOR dr_gokuldev@yahoo.com CO-AUTHOR-DR MOHAMED ASHRAF,PROF AND HOD, [former HOD TDMC ALLEPPEY KERALA] drashraf369@gmail.com DEPT OF ORTHOPAEDICS TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS KOLLAM,KERALA,INDIA
  • 2. EPIDEMIOLOGY • SYNDESMOSIS INJURIES -20–45% OF MALLEOLAR FRACTURES AND 5–11% OF ANKLE DISTORTIONS1 • 1 MM OF TALAR SHIFT DECREASES CONTACT AREA BY 40%- POST TRAUM DEG CHANGES 2 1.Gardner et al Foot Ankle Int 2006;27:788-792 2. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796. 3. Ramsey PL, Hamilton et al. J Bone Joint Surg Am. 1976;58:356–357.
  • 3. • POSTOPERATIVE SYNDESMOSIS MALREDUCTION RATES OF 16% DETECTED ON PLAIN RADIOGRAPHS AND UP TO 52% ON CT SCAN 1. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796. 2. Ramsey PL, Hamilton et al. J Bone Joint Surg Am. 1976;58:356–357
  • 4. WHAT ARE WE DOING FOR ACCURATE REDN NOW? CLOSED REDUCTION AND SCREW FIXATION UNDER C- ARM CRIF WITH INTRA OP CT- NOT FEASIBLE IN OUR SETUP CRIF WITH 3D CT IMAGING-NOT FEASIBLE IN OUR SETUP ALSO DIFFERENT IMPLANT CONFIGURATIONS FOR STABILISATION • ONE SCREW VS TWO SCREWS VS QUAD SCREWS • SUTURE BUTTON • SUTURE BUTTON + SCREW
  • 5. ANATOMY •Anterior-inferior tibiofibular ligaments (AITFL) •Posterior-inferior tibiofibular ligament (PITFL) •Interosseous membrane •Interosseous ligament (IOL) •Inferior transverse ligament (ITL)
  • 6. WHY ANATOMICAL REPAIR? • ANATOMICAL APPROACH - DECREASES SYNDESMOSIS MALREDUCTION FROM 33.3% TO 7.4% • THE POSTERIOR SYNDESMOSIS COMPLEX COMPRISES THE PITFL AND ITS BONY FIXATION, THE DORSAL ASPECT OF THE DISTAL TIBIA, COMMONLY REFERRED TO AS THE POSTERIOR MALLEOLUS (PM).
  • 7. MRI
  • 9. RADIOLOGY • XRAYS PROVIDE SUBTLE SIGNS OF SYNDESMOTIC INJURY IN ABSENCE OF FRACTURE
  • 11. • INTRA OP THIS LIGAMENT IS BROAD AND THIN, COMPARED TO PITFL. • HENCE MORE SUBSTANCE TEARS THAN AVULSION # Posterior tibiofibular ligament The posterior tibiofibular ligament is stronger than the anterior, and is disposed similarly on the posterior aspect of the syndesmosis. Its distal, deep part is the inferior transverse ligament, a thick band of yellow fibres which crosses from the proximal end of the lateral malleolar fossa to the posterior border of the tibial articular surface GRAYS ANATOMY 14EDTN
  • 13. • MECHANISM OF INJURY ARE EXTERNAL ROTATION ,HYPERDORSIFLEXION AND TALAR EVERSION. • GRADE 3 LIGAMENT INJURY – DELTOID, MCL IN KNEE ARE FIXED, WHY NOT AITFL? Joy G, Patzakis MJ, Harvey Jr JP. J Bone Joint Surg Am 1974;56:979–93. Van Heest TJ, Lafferty PM. J Bone Joint Surg Am 2014;96:603–13.
  • 14. Why fix • ANATOMICALLY FIXED POSTERIOR MALLEOLAR FRACTURE MAY RESTORE THE POSTERIOR FIBULAR INCISURA, WHICH AIDS IN THE SUBSEQUENT REDUCTION OF THE FIBULA INTO ITS GROOVE, CORRECTLY TENSIONS THE PITFL AND IMPROVES SYNDESMOTIC STABILITY. • WHY NOT FIX AITFL? Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–71. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 2010;468:1129–35.
  • 15.
  • 16. Inadequately reduced ankle syndesmosis as evidenced by the TFL
  • 17. How we do it? AITFL AWAITING REPAIR
  • 19. ADDITIONAL STABILISATION • SYNDESMOTIC SCREW FIXATION • FIBER TAPE ENDOBUTTON
  • 21. Postop rehab • NON WEIGHT BEARING TILL 10 DAYS / SUTURE REMOVAL • TOE TOUCH WEIGHT BEARING WAS GIVEN AFTER SUTURE REMOVAL IN A FUNCTIONAL CAST FOR NEXT 3 WEEKS • ONCE CAST REMOVED ON 4-5TH WEEK, PROGRESSIVE IMPROVEMENT OF ROM AS TOLERATED AND ISOMETRIC STRENGTHENING • 6-7TH WEEK- DORSIFLEXION STRETCHING AND PROGRESSIVE WEIGHT BEARING,ONCE SYNDESMOTIC SCREW IS REMOVED • 8-9TH WEEK-RESISTIVE STRENGTHENING, ACHIEVE FULL ROM
  • 22. METHODS 20 patients were included in this study, all age groups Male 75% Female 25% GENDER 0 5 10 15 BIMAL TRIMAL 6 14 TYPE OF FRACTURE 0 5 10 15 age 20-50 age > 50 12 8 AGE
  • 23. statistics • 14 patients had posterior malleolus fracture with avulsion of AITFL • 4 patients had only anterior syndesmotic injury Posterior malleolus was fixed with T-plate through posterolateral approach. Anterior separate incision for additional stabilization and exploration of AITFL and repair using ethibond 1-0. 20% 70% 10% LIGAMENT INJURY ANTERIOR ONLY AND COMBINED ANT COMB without
  • 25. RESULTS Average scores at 82.3 in 3 months and 90.7 in 6 months follow up for 16 patients(Olerud-Molander Ankle Score) Average score 78.4 in 2 patients in 3 months and 6 months 69.3 in 2 patients in 6 months follow up. We find that there is early return of patients to there occupation when anatomical repair was done.
  • 26. Conclusion • Conventional treatment -unacceptably high rate of malreduction, -led to a paradigm shift in the approach to a newer concept of anatomical repair. • LIGAMENTS NEED ACCURATE APPOSITION FOR PERFECT HEALING- GAP LEADS TO SCARRING AND ELONGATION • The principle -‘directly fix what is broken and repair what is torn’. • The approach is effective in reducing the rate of syndesmosis malreduction, increasing the biomechanical strength of syndesmosis fixation. Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev. 2018 Jan 25;3(1):24-29. doi: 10.1302/2058-5241.3.170017. PMID: 29657842; PMCID: PMC5890127.
  • 27. THANKYOU “DIRECTLY FIX WHAT IS BROKEN AND REPAIR WHAT IS TORN”

Editor's Notes

  1. LIKE ANY INTRA ARTICULAR INJURY, ESPECIALLY IN A WEIGHT BEARING JOINT, ABSOLUTE REDUCTION PREVENTS DEGENERATIVE CHANGES
  2. AITFL IS AN OBLIQUE LIGAMENT, VERY MUCH OBLIQUE, SOMETIMES REACHES THE TIP OF LAT MAL. BASSETS LIGMNT- HINDERING TALAR MOVTS
  3. SHOWS LOSS OF NORMAL FIBRILLARY PATTERN
  4. CT CUTS 1CM ABOVE THE TIBIAL ARTICULAR SURFACE TFL- TIBIO FIBULAR LINE IN AXIAL CUT
  5. Olerud-Molander Ankle ScoreThe scale is a functional rating scale from 0 (totally impaired) to 100 (completely unimpaired) and is based on nine different items: pain, stiffness, swelling, stair climbing, running, jumping, squatting, supports and activities of daily living.