Search

CASE We report a case of a child with widely divergent congenital inferior tibiofibular diastasis with persistent sciatic artery (PSA). The dysplastic tibia and fibula were widely divergent, and the fibula was displaced proximally and medially with the foot alongside the thigh between the 2 legs, with PSA diagnosed on computed tomography angiogram. The child was treated with fibula-foot complex excision and below-knee prosthesis and was ambulating independently at 1-year follow-up. CONCLUSIONS The combination of a major structural anomaly (tibiofibular diastasis with a separate soft-tissue cover) and an unusual vascular malformation (PSA) has not been reported previously and made surgical reconstruction challenging.

Background. There is no consensus in the literature regarding the necessity of syndesmotic screw removal, but the majority of surgeons prefer screw removal in the operating room. Purpose. The aim of this study is to analyze the safety and cost-effectiveness of syndesmotic screw removal in the clinic. Methods. A retrospective chart review was performed on all acute, traumatic ankle fractures that required syndesmotic stabilization over 5 years at a level 1 trauma center. Radiographs were evaluated for maintenance of syndesmotic reduction. Orthopaedic clinic visits and operating room costs were calculated. Results. Of 269 patients, syndesmotic screws were successfully removed in the clinic in 170 patients and retained in 99 patients. Two superficial infections (1.2%) developed following screw removal. The superficial infection rate was 3.3% (2 of 60) in patients who did not receive antibiotics compared with 0% (0 of 110) in patients who received antibiotics (P = .12). No patient lost syndesmotic reduction after screw removal. Cost savings of $13 829 per patient were achieved by syndesmotic screw removal in the clinic. Conclusion. Our study demonstrates that syndesmotic screw removal in the clinic is safe, does not result in tibiofibular diastasis, is cost-effective, and results in substantial financial savings. Level of Evidence: Level IV

In rare cases of ankle fracture dislocation, the posterior tibial muscle tendon (TP tendon) is incarcerated between the tibia and fibula, thereby impeding reduction. Here we describe a case that presented with such a condition, in which ankle reduction was achieved and surgical repair of the incarcerated TP was delayed. The subject was a 30-year-old male who sustained a fracture dislocation of the left ankle (AO:44-C1.3) in a motorbike accident. After repairing the ankle dislocation, external fixation was performed and osteosynthesis was conducted 10 days after the injury. Plate fixation for the fibula fracture and tight rope fixation for the separation between the tibia and fibula were performed; however, internal fixation for the medial malleolus fracture was delayed because the skin on the medial side of the ankle was in poor condition. One month after the injury, osteosynthesis of the medial malleolus was performed, and the TP tendon was identified in the fracture site. After removing the incarcerated tendon, good reduction of the medial malleolus was achieved, and thus, internal fixation and wound closure could be performed. Re-examination revealed that the TP tendon had an abnormal course. After 3 months, upon re-exposing the entire length of the TP tendon, the TP tendon was incarcerated between the tibia and fibula. To date, although several cases have been reported regarding TP tendon incarceration caused by fracture dislocation of the ankle, no study has reported the anatomical repair of the ankle, regardless of tendon incarceration. In our case, rotational displacement of the medial malleolus fracture remained when the second surgery was completed; however, the presence of some type of incarcerated tissue was suspected. Because leaving the incarcerated TP tendon untreated can cause irreversible long-term complications, early anatomical repair is recommended.

Objectives: To evaluate syndesmosis-only fixation in Weber C ankle fractures with tibiofibular diastasis and to assess the need for additional fibular fixation. Methods: Twenty-one patients with Weber C ankle fractures and tibiofibular diastasis were followed for at least 24 months after treatment. In treatment of the Weber C fractures, only a syndesmosis screw was used through a mini open lateral incision if the syndesmosis could be anatomically reduced and fibular length and rotation could be restored. At follow-up, anteroposterior tibiofibular distance, lateral fibular distance, medial mortise distance and fracture healing were compared and patients were clinically evaluated using the Olerud and Molander ankle scale scoring system. Results: The average duration of follow-up was 49 months and the decreases in anteroposterior tibiofibular distance and lateral fibular distance were statistically significant. At the last follow-up the average clinical score was 86. Ankle mortise was reduced at follow-up in all cases except one, which resulted in a late diastasis. Conclusions: Syndesmosis-only fixation can be an effective method of treating Weber type-C lateral malleolar fractures with syndesmosis disruption in cases where intraoperative fibular length can be restored and anatomical syndesmosis reduction can be achieved. Objetivos: Avaliar a fixação apenas da sindesmose em fraturas do tornozelo de Weber tipo C com diástase tibiofibular e a necessidade de fixação adicional. Métodos: Vinte e um pacientes com fraturas de tornozelo Weber C e diástase tibiofibular foram seguidos por pelo menos 24 meses após o tratamento. No tratamento dessas fraturas, apenas um parafuso para sindesmose foi colocado através de mini-incisão lateral e se a sindesmose pudesse ser anatomicamente reduzida e o comprimento e a rotação da fíbula pudessem ser restaurados. No seguimento, a distância tibiofibular anteroposterior, a distância fibular lateral e a distância medial do encaixe do tornozelo e a consolidação das fraturas foram comparados e os pacientes foram avaliados clinicamente pelo sistema de pontuação da escala de tornozelo de Olerud e Molander. Resultados: A duração média do seguimento foi de 49 meses e as diminuições da distância tibiofibular anteroposterior e fibular lateral foram estatisticamente significantes. No último seguimento, a pontuação clínica média foi de 86. O encaixe do tornozelo foi reduzido em todos os casos, exceto um, que resultou em uma diástase tardia. Conclusões: A fixação apenas da sindesmose pode ser um método eficaz de tratamento de fraturas laterais Weber tipo C com lesão na sindesmose, nos casos em que o comprimento fibular intraoperatório pode ser restaurado e a redução anatômica da sindesmose possa ser obtida. Nível de Evidência IV, Série de Casos.

Category: Trauma Introduction/Purpose: Reduction of the tibiofibular syndesmosis is one of the most important factors that affect the clinical outcome after ankle malleolar fractures with syndesmotic diastasis. Recent studies have shown that suture-button fixation can yield better syndesmotic reduction than screw fixation immediately after surgery. However, the time-dependent change in the reduction for each fixation method has not been well studied. The purpose of this study was to compare the postoperative changes in the syndesmotic reduction after surgical treatment of ankle malleolar fractures between suture-button fixation and screw fixation using bilateral computed tomography. Methods: Patients who sustained ankle malleolar fractures with tibiofibular diastasis and underwent tibiofibular fixation were included. Suture-button fixation (Group B; n=14; age, 39 years) was used between 2015 and 2016, and syndesmotic screw fixation (Group S; n=20; age, 35 years) was used between 2012 and 2014. The syndesmotic screws were routinely removed. Patients underwent CT scanning of the bilateral ankles at 2 time points: at 2 weeks and 1 year after fracture fixation. Side-to-side differences in the anterior and posterior tibiofibular distances, and anteroposterior fibular translation were measured. Syndesmotic melreduction was defined as a side-to-side difference?2 mm in either of the measurements. The changes in each measurement and incidence of malreduction for each group were assessed using the Wilcoxon signed-ranks test and McNemar’s test. Differences between the two groups at each time point were also compared. Results: At 2 weeks after fracture fixation, the side-to-side difference in anterior tibiofibular distance was significantly wider in Group B (1.9 mm) than in Group S (0.7 mm) (p=0.03). Additionally, the fibulas were more translated posteriorly in Group B (1.5 mm) than in Group S (0.2 mm). At 1 year, the anterior tibiofibular distance decreased to 0.8 mm in Group B (p=0.09). On the contrary, it significantly increased to 1.9 mm in Group S (p=0.002). In Group B, the incidences of malreduction were 4/14 and 2/14 at 2 weeks and 1 year, respectively (p=0.74). Two ankles, which were malreduced at 2 weeks, changed to a reduced syndesmosis at 1 year. In Group S, the incidences were 8/20 and 9/20 at 2 weeks and 1 year, respectively (p=0.35). Conclusion: Syndesmotic alignment changed over time in both fixation methods, however, the patterns of change were different. Using suture-button fixation, the anterior tibiofibular distance decreased over time. As a result, the widened syndesmoses at 2 weeks changed to reduced syndesmoses at 1 year. On the contrary, using tibiofibular screw fixation, the anterior tibiofibular distance widened after screw removal. Our result suggests that the flexible suture-button fixation allows the fibula to move to the optimal location over time.

Pure tibiotalar dislocations without associated fracture are rare. The authors report a case of an unusual closed tibiotalar dislocation without fracture, involving proximal ascension of the talus. Despite immediate closed reduction, a tibiofibular diastasis remained, therefore two syndesmosis screws were inserted, followed by six weeks of plaster casting. After 5 years of follow-up, functional results were excellent, MRI showed slight arthritic degenerative changes.

Syndesmotic stabilization is recommended for tibiofibular diastasis, a Maisonneuve fracture, or syn-desmotic instability after fixation of distal tibia-fibula fractures. In the case presented, a syndesmotic stabilization was performed with a screw inserted 2 cm above the tibiotalar joint Subsequent failure occurred due to the weight of the patient and a lack of compliance with the necessary nonweightbearing protocol. The Ilizarov frame was used to reduce and maintain a stable syndesmosis with a simple two-ring construct which allowed the patient to bear weight on the injured limb while his syndesmosis healed. This is not recommend as a routine method of treatment, but is presented as an extended indication of the Ilizarov frame for difficult cases.

A case of simple lateral rotatory dislocation of the ankle without fracture is reported. No similar case has been found in the English literature. The mechanism of injury is a minor inversion type of injury. There is no roentgenographic evidence of tibiofibular diastasis. Treatment consisted in closed reduction followed by a below-the-knee non-weight-bearing plaster cast for six weeks. A good anatomical, roentgenographic, and functional result was obtained.