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There is still no general agreement about the most effective form of syndesmosis fixation with syndesmotic screws for patients affected by ankle fractures that are accompanied by syndesmotic injuries. In the same manner, no consensus has been reached yet on whether or not the tibiofibular syndesmotic screw is more beneficial if removed or not, as well as the exact timing of removal if this proves superiority. The purpose of this research was to verify whether or not removing syndesmotic screws reduces the risk of developing a diastasis and compare outcomes in patients whose syndesmotic screw was or was not removed at all. A retrospective observational study was carried out to cover a period of five years and a computed sample size of almost 300 cases. Patients were included in the current study if their history was positive for ankle fracture with distal tibiofibular diastasis repair with syndesmotic screws. Loss of reduction was more frequent after screw removal (8.5% vs. 2.1%), although the quality of reduction was generally excellent in both groups. The mean AOFAS score was significantly better in patients who had their tibiofibular screw removed (92.6 vs. 88.4), but the tibiofibular clear space and incisura fibularis depth widened more following the second intervention (3.8 mm vs. 3.6 mm, and, respectively, 4.3 vs. 4.1). Lastly, the same patients with tibiofibular screw removal had a significantly higher cost of total interventions and more days of medical leave (21 vs. 15 days on average). It seems that a strong conclusion in favor of removing or not removing syndesmotic screws after distal tibiofibular diastasis repair cannot be given. However, several radiographic findings lean toward the benefit of those patients whose tibiofibular screws were not removed, although mobility was notably better after the screw was removed. Furthermore, treatment expenses are greatly lowered if a subsequent operation for screw removal is avoided, as well as if individuals who have a single surgery take a shorter medical leave.

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

Introduction: Congenital distal tibiofibular diastasis is an extremely rare entity of unknown etiology that compromises the feet and ankles with different degrees of deformity, although in general, the feet show equinovarus deformity, and the talus is proximally dislocated due to the separation of the distal tibial and fibular epiphyses. There are few reports of this disorder in the literature, and most describe cases that ultimately lead to limb amputation. We present the cases of 2 patients treated from birth to skeletal maturity. Methods: Two female patients with clubfoot at birth were diagnosed with congenital distal tibiofibular diastasis. One of them had the deformity of the right foot, and the other had deformity of both limbs. Both patients underwent early distal tibiofibular arthrodesis and serial stretching of the compromised feet and legs. Results: After 20 years of clinical follow-up and after reaching skeletal maturity, both patients had plantigrade feet without significant shortening of the lower limbs or pain, and both performed activities of daily living without restrictions, wearing conventional shoes. Conclusion: Early distal tibiofibular arthrodesis followed by limb stretching was effective for treating congenital distal tibiofibular diastasis and is a good alternative to amputation, which is indicated in the literature.

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.

Case Congenital tibiofibular diastasis is a relatively rare form of limb deficiency, characterized by distal tibial tapering, absent ankle mortise, equinovarus foot deformity, and variable lower leg shortening. Treatment described has ranged from various forms of foot centralization with or without leg lengthening to amputation. We describe 2 cases treated in childhood by staged foot centralization by soft-tissue distraction, distal tibiotalar fusion, tibial lengthening, and subsequent limb length discrepancy equalization. At skeletal maturity, both patients ambulated independently without aid. Conclusions Staged reconstruction with foot centralization and distal tibiotalar fusion is an option for carefully selected patients with tibiofibular diastasis who refuse foot ablation.

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.

The authors present a brief overview of tibiofibular diastasis and the mechanisms of injury associated with it. This type of injury is frequently misdiagnosed or improperly treated. Two case studies are presented with specific emphasis placed on the use of a transyndesmotic bolt in the reduction of the tibiofibular diastasis. The authors have found this to be more beneficial in the treatment of this condition, as opposed to the traditional use of a transmalleolar screw.

The tibiofibular diastasis requires an appropriate surgical treatment in order not to run into negative results such as decreased range of motion and chronic instability. We have conducted a comparative study between the transfixation screw and a new technique based upon the reabsorbable cerclage, a less invasive technique.We enrolled 30 patients affected by tibiotarsal distortion with an acute lesion of the syndesmosis, and we divided them in 2 groups randomly. The first group of patients (15 cases) has been treated with a tricortical, or quadricortical syndesmotic screw, and the second group of patients (15 cases) has been treated with a tibiofibular cerclage with reabsorbing wires. The evaluation of the lesions was documented through comparative radiographies of the ankle in the AP, LL and mortise projections.In group 1, we observed an excellent outcome in 4 patients, while in the remaining 11 cases there was evidence of alterations in the evaluated parameters. In group 2, we observed an excellent outcome in 6 patients, and only in half of the remaining cases it was found a slight alteration only when the articulation is stressed.The main indications for the tibiofi bular cerclage are the syndesmotic lesions not associated to fi bular fractures. The achieved results support the validity of the cerclage technique, showing evidence of advantages concerning the functional recovery. The cerclage also allows to avoid the subsequent surgery required for the screw removal. Therefore the tibiofi bular cerclage represents a valid alternative to the treatment with the syndesmotic screw.

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.

Four children with distal tibiofibular diastasis associated to talipes equinovarus deformity are described. Tibial hypoplasia resulting in tibiofibular diastasis is believed to be the underlying cause of the deformity. This complex deformity is usually associated with other congenital malformations including congenital cardiac defects and other limb anomalies. Surgical therapy has centered on establishment of an ankle mortise; however, several authors believe that the best treatment is early ankle disarticulation rather than reconstructive surgery. Radiographs should be made of all apparent clubfoot deformities in order to rule out the more serious distal tibiofibular diastasis deformity.

The late results of treatment of 24 legs in 21 children with congenital deficiency of the tibia are presented. A new classification is proposed which correlates well with recommendations for treatment and with the final functional result. Three types of deficiency were recognised: Type I, total absence of the tibia; Type II, distal absence; Type III, distal deficiency with tibiofibular diastasis. The early radiographic appearances, the functional status of the quadriceps and the severity of flexion contracture of the knee were important factors in the selection of the operations likely to give the best function.