Treatment of Ankle Syndesmosis Injuries

handling of mortise-and-tenon joint Syndesmosis InjuriesChapter No. 11. INTRODUCTIONInjuries to the distal tibio calf boner syndesmosis argon complex and remained arguable with respect to diagnosis and management. In United Kingdom, articulatio talocruralis offers ar the most common open frame among patients aged among 20 and 65 with the annual relative incidence describe as 90,000 (1). Twenty percent20% of articulatio talocruralis joint joint fractures requireing internal compulsion (2), and or 10% of only mortise-and-tenon joint fractures are associated with syndesmosis disruption (3). Syndesmotic injuries hand to a fault been account in the absence of fracture and some eon called as senior highschool ankle sprainwith incidence describe somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, on that point is no consensus r egarding the optimum treatment of these injuries, sequeling and sometime results in chthonian or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore important to understand the anatomy, biomechanics and the mechanism of injuries involving the tibiofibular syndesmosis.1.1. processThe inferior tibiofibular engage stick is a syndesmotic joint formed by two b iodines and foursome ligaments. The distal tibia and fibula form the osseous segmentation of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments implicate the introductory inferior tibiofibular ligament (AITFL), the lav inferior tibiofibular ligament (PITFL), the crosswise tibiofibular ligament and the interosseous ligament.At the visor of syndesmosis, the interosseous echo of tibia bifurcates caudally into an preceding and stern margin. The anterior margin ends in the ant ero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The back end margin ends in the posterolateral aspect of the tibial plafond called the croupe tubercle. The anterior and posterior margins of the distal tibia enclose a concave triangular nonch called insisura fibularis, with its bill 6-8 cm supra the level of the talocrural joint (9-11). The anterior tubercle is more(prenominal) prominent than the posterior tubercle and protrudes further laterally and carrefours the medial two thirds of the fibula (9-11). The fibular parcel of the syndesmosis is gibbose and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, similarly bifurcates into an anterior and posterior margin and forms a convex triangle that is turn up above the articulary facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) describe two main morphological patterns in their muse of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent fig while in 33% it was shallow, giving the syndesmosis a rectangular shape (12).The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula Fig. 1.1. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular bowel movement and out-of-door talar rotation (13). The AITFL is the first ligament to pretermit in international rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a sacrosanct ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) Fig. 1.2. PITFL industri al plant along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomic entity called crosswise ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the posterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation Fig. 1.2. The interosseous tibiofibular ligament is a client of lower most part of interosseous membrane and consists of numerous ill-considered, strong, ropey bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these b integritys, providing stability to talocrural joint during loading. The ligament is t hought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsi flexure at the ankle joint and frankincense for some wedging of the beading in the mortise (9).Ogilvie-Harris et al (15) examine the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specimens to pass judgment the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35% the transverse ligament, 33% the interosseous ligament, 22% and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability.1.2. BiomechanicsThe primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows around 15o to 20o of active dorsifl exion which may be increase to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the astragalus is wedge shaped and wider anteriorly than posteriorly with an average oddment of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the astragalus wedges between the medial and lateral malleoli, and much of the mortise becomes occupied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of rig at the mortise as the foot is moved from full plantar flexion to full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20).When fixing ankle fractures, it is vital needed to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can nothingness to world-shattering change in biomechanics and sub optimum long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted in a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by an raw(prenominal) novel understand by Lloyd et al (22) in 2006. Taser et al (23) maneuvered using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint station volume.1.3. Mechanism of InjuryThe 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, inversion of the talus and hyper dorsiflexion (6, 24). outer(prenominal) rotation injuries result in widening o f the mortise as the talus is forcefully driven into external rotation within the mortise. physical eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, the fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30).Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the perspective of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in Pronation-External Rotation (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and last a whirl fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic challenge. These injuries are sometime referred as high syndesmotic sprain (4, 27, 34).1.4. diagnosisDiagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical exams conduct been described in literary productions but lack high predictive time value in acute cases as it might be difficult to perform these tests because of excessive throe in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36).Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic arguments take for been described based on anterior-posterior and mortise dioramas but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The tibiofibular clear space is delimitate as the duration between the lateral border of the posterior tubercle and the medial border of the fibula. The tibiofibular overlap is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial clear space is the distance between the articular surface of medial malleolus and the adjoining surface of talus (32, 37). Harper et al (38) radiograp hically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% agency interval, demonstrated pursual criteria as consistent with a normal tibiofibular relationship (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study reason out that the width of the tibiofibular clear space on some(prenominal) anterior-posterior and mortise views appeared to be the most reliable parameter for detecting primal syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The truth of these measurements has been questioned in several(prenominal) studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positi oning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) invite out that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and magnetic resonance imaging scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42).1.5. Treatment of Syndesmosis diastasis and review of literatureInjuries to distal tibio-fibular syndesmosis are complex and require accurate lessening and fastener for optimal outcome (43, 44) but the choice of reparation pipe down remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilisation on the outcome of ankle fractures in 347 patients at a minimum quest for up of 1 course of instruction and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fix had poorer outc ome as canvasd to patients requiring only malleolar fixation.Although, the use of metal tell apart has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and good turn of spang, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing champion 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but subsequently one year there was no significant difference between the groups in their in operation(p) score, pain or dorsiflexion (46). Further repor t on the alike(p) study group with 8.4 years average follow up did not show all significant difference in clinical outcome (50). Moore et al (51) also reported similar functional outcome with both three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when employ as tricortical screw (48) but when apply as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). issue removal of syndesmosis screw is an other controversial issue. Some authors advocate routine removal before starting full load drift as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw lo osening or fatigue failure (54-57). Miller et al (58) demonstrated improve clinical outcomes following syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients toughened with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group.Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures enured with screw fixation.Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectualness in fixation of diastesis (61-63). However, these ingrafts did not gain popularity because of dreads including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis callable to polymer debris entering the joint (64-67).The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire loop which, tensioned and secured between metal-looking buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological compari son of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American orthopedical Foot and ankle Society (AOFAS) score and returned to work earlier than screw group. As with either novel technique, the follow-up reported in the literature is short and the number of cases are limited Table 1. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of implant removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). iodine of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reported subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series.Despite qualified short term clinical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been powerful investigated. Radiological measurements in most of the studies are perf ormed on radiographs. It has been antecedently noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 calendar months and did not find any malreduction (71). CT scans were performed only subsequently 3 month of mental process and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. profound malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syndesmosis screw (50, 60). As malreduction of syndesmosis is the most important independent predictor of long term functional outcome we organise to fill the wisecrack in literature regarding tightropes ability to maintain syndesmosis integrity in longer term.1.6. Aims and ObjectiveThe primary A aim of this study is to compare the accuracy and living of syndesmotic reduction using tightro pe technique and syndesmosis screw fixation and their consequences on clinical outcome.Population (P) Adult patients with acute fixation of ankle syndesmosis. interpolation (I ) Tightrope fixation of ankle syndesmosis.Comparison (C) Syndesmosis screw fixation.Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan.Chapter No. 22. PATIENTS AND METHODSWe conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. deuce different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and sustainment of syndesmosis reduction and its correlation with the functional outcome stacks after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured in the first place on axial Computed Tomographic (CT) scans and anterio-po sterior (AP) radiographs of ankles using uninjured contralateral ankle as a control.The study was conducted in department of Trauma and orthopedics and the department of radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre informationbase. The info regarding all patients treated for ankle injuries was reviewed.The inclusion criteria were as followsadults ( 18 years) with acute ankle syndesmosis injurywilling to give informed consent to participate in the study, fixation of the injuryed over a 2 years period from July 2007 to June 2009 provided they did not fit into the exclusion criteria.The exclusion criteria set out for this study includeP patients with disperse fracture,I i ndividuals with diabet es ic or neuropathic arthropathy,M multi trauma patients andP patients who had a previous injury or surgery on the contra-lateral ankle as those could n ot be used as a control.Pregnancy was included in exclusion criteria B because of ray of light motion picture in this study. maternal quality was also mentioned as exclusion criteria.i I ndividuals unwilling to consent to the studyPatients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively and intraoperative confirmation under fluoroscopy using e xternal rotation stress test and hoist test in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fractures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either Transosseous Screw or Tightrope depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional grading systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFAS) scoring system (78) and a patient reported Foot and Ankle Disability big businessman (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications. All patients were scanned resupine in the axial plane with no gantry tilt. Survey CT scan image was obtained first instead of scanning the whole ankle, to reduce the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at app roximately 1 cm from the tibial plafond and other at 1.4 cm approx Fig. 2.1. This technique was adopted in order to reduce the radiation exposure to the patient without compromising the quality of the scans and the axial images thus obtained jibe to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond.2.1. Outcome VariablesThe accuracy of syndesmosis reduction on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard aberration of 1.19 mm. As this area corresponds to the tibiofibular clear space on AP radiographs and 6 mm of tibiofibular clear space is considered abnormal, the criterion of 2 mm would be justified.Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including tibiofibular clear space (TFCS 6 mm) and medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alig nment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function.In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses.2.2. Data accruement and MeasurementsDemographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes.Radiographic parameters of syndesmosis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The tibiofibular clear space is defined aTreatment of Ankle Syndesmosis InjuriesTreatment of Ankle Syndesmosis InjuriesChapter No. 11. INTRODUCTIONInjuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In United Kingdom, ankle fractures are the most common fracture among patients aged between 20 and 65 with the annual incidence reported as 90,000 (1). Twenty percent20% of ankle fractures requireing internal fixation (2), and or 10% of all ankle fractures are associated with syndesmosis disruption (3). Syndesmotic injuries have also been reported in the absence of fracture and sometime called as high ankle sprainwith incidence reported somewhere between 1% and 11% of all ankle fractures or 0.5% of all ankle sprains (4-6). Despite the considerable tremendous amount of work load these injuries provide for orthopaedic surgeons, there is no consensus regarding the optimal treatment of these injuries, resulting and sometime results in under or over treatment of syndesmotic injuries, especially those without fibular fracture. It is therefore important to understand the anatomy, biomec hanics and the mechanism of injuries involving the tibiofibular syndesmosis.1.1. AnatomyThe inferior tibiofibular joint is a syndesmotic joint formed by two bones and four ligaments. The distal tibia and fibula form the osseous part of the syndesmosis held together by four ligaments providing stability that is integral for proper functioning of the ankle joint (6-8). These ligaments include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the transverse tibiofibular ligament and the interosseous ligament.At the apex of syndesmosis, the interosseous border of tibia bifurcates caudally into an anterior and posterior margin. The anterior margin ends in the antero-lateral aspect of the tibial plafond called the anterior tubercle (Chaputs tubercle). The posterior margin ends in the posterolateral aspect of the tibial plafond called the posterior tubercle. The anterior and posterior margins of the distal tibia enclose a concave tri angular notch called insisura fibularis, with its apex 6-8 cm above the level of the talocrural joint (9-11). The anterior tubercle is more prominent than the posterior tubercle and protrudes further laterally and overlaps the medial two thirds of the fibula (9-11). The fibular part of the syndesmosis is convex and matches with its tibial counterpart. The crista interossea fibularis, i.e. the ridge on the medial aspect of the fibula, also bifurcates into an anterior and posterior margin and forms a convex triangle that is located above the articular facet on the lateral malleolus. The base of the fibular triangle is formed by the anterior tubercle (Wagstaffe-Le Fort tubercle) and the, almost negligible, posterior tubercle (9). Shape of insisura fibularis varies among individual. Elgafy et al (12) described two main morphological patterns in their study of 100 normal ankle syndesmoses. In 67% the insisura was deep, giving the syndesmosis a crescent shape while in 33% it was shallow, giving the syndesmosis a rectangular shape (12).The anterior inferior tibiofibular ligament AITFL runs obliquely from anterior tubercle of distal tibia to anterior tubercle of fibula Fig. 1.1. AITFL consists of multifascicular bundle of fibers that run obliquely downwards and laterally and prevents excessive fibular movement and external talar rotation (13). The AITFL is the first ligament to fail in external rotation injuries (9). Posterior inferior tibiofibular ligament PITFL is a strong ligament. It originates from posterior tubercle of distal tibia and runs obliquely downwards and laterally to the posterior lateral malleolus (14) Fig. 1.2. PITFL works along with AITFL to hold the fibula tight in insisura fibularis of the tibia. The lower part of the PITFL runs more horizontally and is considered as a separate anatomical entity called transverse ligament. The transverse ligament is a thick, strong structure with twisting fibers. It passes from the posterior tibial margin to the p osterior margin of malleolar fossa of distal fibula. The location of the transverse ligament below the posterior tibial margin creates a posterior labrum, which deepens the articular surface of the distal tibia and helps to prevent posterior talar translation Fig. 1.2. The interosseous tibiofibular ligament is a thickening of lower most part of interosseous membrane and consists of numerous short, strong, fibrous bands which pass between the contiguous rough triangular surfaces of the distal tibia and fibula and form the strongest connection between these bones, providing stability to talocrural joint during loading. The ligament is thought to act like a spring, allowing for slight separation between the medial and lateral malleolus during dorsiflexion at the ankle joint and thus for some wedging of the talus in the mortise (9).Ogilvie-Harris et al (15) studied the relative importance of each of the ligaments in the distal tibiofibular syndesmosis using 8 fresh-frozen cadaver specim ens to evaluate the percentage of contribution of each ligament during 2 mm of lateral fibular displacement. The anterior inferior tibiofibular ligament provided 35% the transverse ligament, 33% the interosseous ligament, 22% and the posterior inferior ligament, 9%. Thus, more than 90% of total resistance to lateral fibular displacement is provided by 3 major ligaments. Injury to one or more of them result in weakening, abnormal joint motion, and instability.1.2. BiomechanicsThe primary movements at the ankle joint include dorsiflexion and planterflexion. The normal ankle allows approximately 15o to 20o of active dorsiflexion which may be increased to 40o passively and between 45o to 55o of plantar flexion (16). The superior surface of the talus is wedge shaped and wider anteriorly than posteriorly with an average difference of 4.2 mm (17). During dorsiflexion, the wider anterior portion of the talus wedges between the medial and lateral malleoli, and much of the mortise becomes occ upied (6). Up to 6o of talar external rotation occurs during ankle dorsiflexion and the talusit rotates internally and supinates slightly during plantar flexion, as a result of its conical and wedged shape (17-19). During normal ankle motion, some movement occurs normally at the distal tibiofibular syndesmosis. Although ankle syndesmosis is a tightly held fibrous joint it allows 1 to 2 mm of widening at the mortise as the foot is moved from full plantar flexion to full dorsiflexion. This widening of mortise occurs partly as a result of 3o to 5o of fibular rotation along its vertical axis during plantar flexion and dorsiflexion (6, 18, 20).When fixing ankle fractures, it is vital necessary to restore normal anatomic relations of distal tibiofibular syndesmosis, as slight discrepancy can lead to significant change in biomechanics and sub optimal long term results. Ramsey and Hamilton (21) demonstrated that as little as 1 mm of lateral shift of the talus in the ankle mortise resulted i n a 40% loss of tibiotalar contact surface area and increase in contact stresses. Similar findings were also confirmed by another recent study by Lloyd et al (22) in 2006. Taser et al (23) showed using three-dimensional computed tomographic (CT) reconstructions that a 1 mm separation of the syndesmosis can lead to a 43% increase in joint space volume.1.3. Mechanism of InjuryThe 3 proposed mechanisms of ankle syndesmotic injury include external rotation of the foot, eversion of the talus and hyper dorsiflexion (6, 24). External rotation injuries result in widening of the mortise as the talus is forcefully driven into external rotation within the mortise. Forceful eversion of the talus also results in widening of the mortise. These mechanisms are most common in sports like football and skiing. Hyperdorsiflexion injuries are seen in jumping sports and also result in widening of mortise when wider anterior part of the talus dome is forcefully driven into the joint space. In all cases, t he fibula is pushed laterally and if the forces are strong enough, leads to diastasis of ankle syndesmosis (24-30).Lauge-Hansen (31) classified the ankle fractures according to the mechanism of injuries. This classification system was based on cadaveric study and takes into account the position of foot at the time of injury and the deforming force. According to this syndesmotic disruption most commonly occurs in Pronation-External Rotation (PER) injuries. Depending on the severity of the force applied, this abnormal movement will result in rupture the deltoid ligament or fracture the medial malleolus in its first stage, with subsequent injury to the syndesmotic ligaments and the interosseous membrane, and finally a spiral fracture of the fibula above the level of syndesmosis (31, 32). Most of the complete syndesmotic disruptions are associated with Weber C fracture with smaller proportion having Weber B fracture with widening of the mortise and, occasionally, a Maissonneuve fracture (33). Syndesmotic diastesis rarely occurs in isolation without bone injury and poses a diagnostic challenge. These injuries are sometime referred as high syndesmotic sprain (4, 27, 34).1.4. DiagnosisDiagnosis of syndesmotic injury can sometime be challenging and depends on high index of suspicion, taking into consideration, the mechanism of injury and the clinical findings and confirming with radiological assessment or examination under anaesthesia. Several clinical tests have been described in literature but lack high predictive value in acute cases as it might be difficult to perform these tests because of excessive pain in acute situations. Some examples of these tests include Squeeze test (34), Point test (35), External rotation test (32, 35) and Fibular translation test (32, 36).Radiographs are important in diagnosis of tibiofibular syndesmotic diastasis. Three radiographic parameters have been described based on anterior-posterior and mortise views but controversy exist among researchers with regard to the optimal parameter for accurate diagnosis. The tibiofibular clear space is defined as the distance between the lateral border of the posterior tubercle and the medial border of the fibula. The tibiofibular overlap is the distance between the medial border of the fibula and the lateral border of the anterior distal tibial tubercle and the medial clear space is the distance between the articular surface of medial malleolus and the adjacent surface of talus (32, 37). Harper et al (38) radiographically evaluated normal tibiofibular relationship in 12 cadaver lower limbs and based on a 95% confidence interval, demonstrated following criteria as consistent with a normal tibiofibular relationship (1) a tibiofibular clear space on the anterior-posterior and mortise views of less than approximately 6 mm (2) tibiofibular overlap on the anterior-posterior view of greater than approximately 6 mm or 42% of fibular width (3) tibiofibular overlap on the mortise view of greater than approximately 1 mm. The study concluded that the width of the tibiofibular clear space on both anterior-posterior and mortise views appeared to be the most reliable parameter for detecting early syndesmotic widening and medial clear space greater than a superior clear space is indicative of deltoid ligament injury (38). The accuracy of these measurements has been questioned in several studies. Beumer et al (39) demonstrated that these measurements are greatly influenced by the positioning of ankle while taking radiographs. Similar findings were confirmed by Nelson et al (40) and Pneumaticos et al (41) except that the later study reported that the tibiofibular clear space did not change significantly by rotation of ankle (41). CT and MRI scanning are more sensitive than radiography for detecting minor degrees of syndesmotic injury and provide an important diagnostic tool in suspicious cases (7, 42).1.5. Treatment of Syndesmosis diastasis and review of literatureInjuri es to distal tibio-fibular syndesmosis are complex and require accurate reduction and fixation for optimal outcome (43, 44) but the choice of fixation still remained controversial. Kenneth et al (45) studied the effect of syndesmotic stabilization on the outcome of ankle fractures in 347 patients at a minimum follow up of 1 year and concluded that patients requiring syndesmotic stabilization in addition to the malleolar fixation had poorer outcome as compared to patients requiring only malleolar fixation.Although, the use of metal screw has been the most popular means of stabilizing the syndesmosis (32), controversy exists with regard to the size and number of screw, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal (46-48). Beumer et al (49) in their cadaveric study, reported no difference in fixation of the syndesmosis when stainless steel screws were compared to titanium screws through three or four cortices. Hoiness et al (46) conducted a randomised prospective trial comparing single 4.5 mm quadricortical screw with two 3.5mm tricortical screws for ankle syndesmosis injuries in 64 patients. The study showed improvement in early function in the tricortical group, but after one year there was no significant difference between the groups in their functional score, pain or dorsiflexion (46). Further report on the same study group with 8.4 years average follow up did not show any significant difference in clinical outcome (50). Moore et al (51) also reported similar functional outcome with either three or four cortical fixation using 3.5 mm screws with slightly higher trend toward loss of reduction in tricortical group. Although there is no clinical consensus regarding number and size of the screws, biomechanical studies have shown that two screws are mechanically superior to single screw (52). There is no significant difference between 3.5 mm and 4.5 mm syndesmosis screw when used as tricortical screw (48) but when used as quadricortical screw 4.5 mm screw showed higher resistance to shear stress than 3.5 mm screw (53). Routine removal of syndesmosis screw is another controversial issue. Some authors advocate routine removal before starting full weight bearing as screw provides rigid fixation of syndesmosis where micromotion occurs normally and can therefore lead to screw loosening or fatigue failure (54-57). Miller et al (58) demonstrated improved clinical outcomes following syndesmosis screw removal in a series of 25 patients. Manjoo et al (59) retrospectively reviewed 106 patients treated with syndesmosis screw. Seventy-six returned for follow up. The study concluded that intact screw was associated with a worse functional outcome as compared with loose, broken or removed screws. However there were no differences in functional outcomes comparing lose or broken screws with removed screws (59). Both these studies had inherent limitations including of retrospective studies study design and lack of a the control group.Malreduction of tibiofibular syndesmosis has been reported as a significant problem with screw fixation and is an independent predictor of functional outcome (44). Gardner et al (60) reported 52% of malreduction of syndesmosis in weber C fractures treated with screw fixation.Bioabsorbable screws haves also been used as an alternative to metal screws to avoid hardware related complications and haves demonstrated equal effectiveness in fixation of diastesis (61-63). However, these implants did not gain popularity because of concerns including osteolysis, foreign-body reaction, late inflammatory reaction and osteoarthritis due to polymer debris entering the joint (64-67).The Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire loop which, tensioned and secured between metallic buttons placed against the outer cortices o f the tibia and fibula, provides physiologic stabilization of the ankle mortise and obviates the need for a second procedure for removal, therefore late diastasis is unlikely (68). Biomechanical testing and clinical trials have shown equivalent strength and improved patient outcome with the tightrope technique (69, 70). In 2005 Thornes et al (71) performed a clinical and radiological comparison of 16 patients treated with suture-button techniques with similarand a similar cohort of patients treated with syndesmosis screw fixation. Patients in suture button group demonstrated significantly better American Orthopaedic Foot and Ankle Society (AOFAS) score and returned to work earlier than screw group. As with any novel technique, the follow-up reported in the literature is short and the number of cases are limited Table 1. The largest case series so far, has reported the outcome in 25 cases patients (72, 73). Although initial series did not report any complications, some cases of impla nt removal have been reported in more recent literature because of soft tissue irritation. In a series of 16 patients, two tightropes were removed, one due to infection, and the other due to soft-tissue irritation (74). Willmott et al (75) reported 2 cases of tightrope removal because of soft tissue inflammation, out of 6 patients treated with ankle tightrope (33%). One of them was removed because of inflammation over medial button. Coetzee et al (76) in their results of a prospective randomized clinical trial also reported removal of one tightrope because of infection, out of 12 cases. In a most recent series of 24 cases DeGroot et al (77) reported removal of hardware in 6 patients due to soft tissue complication. They also reported subsidence of endo-button due to osteolysis in adjacent bone in 4 cases but did not have any effect on clinical outcome as it was a late occurrence. There were also 3 cases of heterotopic bone formation in this series.Despite satisfactory short term cli nical outcomes, few complications have also been reported related to soft tissue irritation and also there is a concern that tightrope might be inferior to screw in maintaining the syndesmosis. So far, the literature is limited with regard to tightrope fixation and the issue of malreduction has not been properly investigated. Radiological measurements in most of the studies are performed on radiographs. It has been previously noted that radiographic measurements are influenced by the rotation of ankle and therefore not accurate. Thornes et al performed axial CT scan on 11 of 16 patients treated with tightrope at 3 months and did not find any malreduction (71). CT scans were performed only after 3 month of surgery and none of the patient in control group had a CT scan and therefore undermines the significance of this part of their study. Significant malreduction of tibiofibular syndesmosis has been reported in literature for patients treated with syndesmosis screw (50, 60). As malred uction of syndesmosis is the most important independent predictor of long term functional outcome we aim to fill the gap in literature regarding tightropes ability to maintain syndesmosis integrity in longer term.1.6. Aims and ObjectiveThe primary A aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using tightrope technique and syndesmosis screw fixation and their consequences on clinical outcome.Population (P) Adult patients with acute fixation of ankle syndesmosis.Intervention (I ) Tightrope fixation of ankle syndesmosis.Comparison (C) Syndesmosis screw fixation.Outcome (O) Accuracy of syndesmotic reduction, based on axial CT scan.Chapter No. 22. PATIENTS AND METHODSWe conducted a cohort study to assess the radiological and clinical outcomes of patients after treatment of ankle injuries involving distal tibiofibular syndesmosis. Two different methods of syndesmosis fixation were compared (standard transosseous syndesmosis screw fixation and a relatively new, Tightrope fixation technique) for the accuracy and maintenance of syndesmosis reduction and its correlation with the functional outcome scores after at least 18 months following the index procedure. The accuracy of syndesmosis reduction was measured primarily on axial Computed Tomographic (CT) scans and anterio-posterior (AP) radiographs of ankles using uninjured contralateral ankle as a control.The study was conducted in department of Trauma and Orthopaedics and the department of Radiology in Our Lady of Lourdes Hospital, Drogheda, Republic of Ireland after approval by the Institutional Review Board (appendix i). The patients were recruited using trauma theatre database. The data regarding all patients treated for ankle injuries was reviewed.The inclusion criteria were as followsadults ( 18 years) with acute ankle syndesmosis injurywilling to give informed consent to participate in the study, fixation of the injuryed over a 2 years period from July 2007 to June 20 09 provided they did not fit into the exclusion criteria.The exclusion criteria set out for this study includedP patients with open fracture,I i ndividuals with diabet es ic or neuropathic arthropathy,M multi trauma patients andP patients who had a previous injury or surgery on the contra-lateral ankle as those could not be used as a control.Pregnancy was included in exclusion criteria B because of radiation exposure in this study. pregnancy was also mentioned as exclusion criteria.i I ndividuals unwilling to consent to the studyPatients were treated by six Orthopaedic consultants in a single trauma unit using two different techniques for syndesmosis fixation including traditional screw and tightrope fixation technique. Three consultants used screw fixation while the other three consultants used tightrope technique for all of their patients requiring syndesmosis fixation irrespective of age, sex and the type of associated fractures. The diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including widening of medial clear space (MCS), increased tibiofibular clear space (TFCS) and reduced tibio-fibular overlap (TFOL) preoperatively and intraoperative confirmation under fluoroscopy using external rotation stress test and hook test in which fibula was pulled laterally after fixation of fracture using a bone hook and widening of syndesmosis was observed using image intensifier. Concomitant fractures of fibula and medial malleolus were fixed according to standard AO principles. Ankle syndesmoses were stabilized with either Transosseous Screw or Tightrope depending on the consultants preference. All patients were immobilized in below knee plaster back slab for two weeks followed by non-weight bearing cast for another four weeks. Casts were removed in after six weeks time and patients were referred for physiotherapy and allowed full-weight bearing as tolerated. Patients were followed up in clinic at 2 weeks, 6 weeks and then after 3 months. Patients were finally reviewed in January 2011 for the collection of study data. Patients who consented for the research participationto this study underwent a clinical examination by an independent clinician who was blinded for the type of syndesmosis fixation. Two functional scoring systems were used to assess clinical outcome, including a clinician reported American Orthopaedic Foot and Ankle Society (AOFAS) scoring system (78) and a patient reported Foot and Ankle Disability Index (FADI) score (79). Radiographic assessment included anterior-posterior radiograph of both the ankles together and an axial CT scan of both the ankles together at 1 cm above the tibial plafond. All the CT scans were performed by single, senior CT Radiographer using same specifications. All patients were scanned supine in the axial plane with no gantry tilt. Survey CT scan image was obtained first instead of scanning the whole ankle, to r educe the radiation dose. The area of ankle syndesmosis was scanned using single slice CT scan. The thickness of the CT slice was 3.8 mm and was centred at 12 mm from the tibial plafond as measured on the survey scan image. This sSingle slice scan provided two axial images, one at approximately 1 cm from the tibial plafond and other at 1.4 cm approx Fig. 2.1. This technique was adopted in order to reduce the radiation exposure to the patient without compromising the quality of the scans and the axial images thus obtained correspond to the same level as used for the measurements on radiographs i.e. 1 cm above tibial plafond.2.1. Outcome VariablesThe accuracy of syndesmosis reduction on axial CT scan was considered as primary outcome variable to compare the two different treatment options. The criterion for malreduction of syndesmosis was set at 2 mm of difference in the width of syndesmosis as compared with the normal contralateral ankle when measured on the axial CT scan. The width of posterior part of syndesmosis joint space was measured for the purpose of this comparison as this measurement correspond to the tibiofibular clear space on AP radiographs. The criterion was set at 2 mm in accordance with previous literature (60) and the assumption that this difference will result in sufficient level of joint incongruity which may lead to increased contact pressures in ankle joint and the risk of early degenerative changes (21, 22). Elgafy et al (12) reported that the average width of syndesmosis posteriorly is 4 mm with standard deviation of 1.19 mm. As this area corresponds to the tibiofibular clear space on AP radiographs and 6 mm of tibiofibular clear space is considered abnormal, the criterion of 2 mm would be justified.Syndesmosis integrity was also assessed on AP radiographs of ankle, using parameters including tibiofibular clear space (TFCS 6 mm) and medial clear space (MCS Clinical outcomes were assessed using two functional scores, time to full weight bearing and rate of complications. Functional scoring systems include American Orthopaedics Foot and Ankle Society (AOFAS) score (appendix ii) which has been widely used in previous ankle studies. It is a clinician reported scoring system which looks at the pain, functional status, alignment and range of motion of foot and ankle. Foot and Ankle Disability Index (FADI) score (appendix iii) is a patient reported functional scoring system and looks at pain and various functional activities. Both the scores range from 0 to 100 with higher scores indicating better function.In the statistical analysis, factors considered potential confounders were patients age and the durationtime since surgery. These confounders were adjusted using regression analyses.2.2. Data Collection and MeasurementsDemographic data of the patients and the data regarding the mechanism of injury, type of fractures and the type of fixation were extracted from patients clinical notes.Radiographic parameters of syndesm osis integrity were measured on preoperative and the latest AP ankle radiographs 1 cm proximal to the tibial plafond. The tibiofibular clear space is defined a