Forceps Reduction of the Syndesmosis in Rotational Ankle Fractures A Cadaveric Study

Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for P. Phisitkul: . E-mail address for T. Ebinger: . E-mail address for J.L. Marsh: .
The Journal of Bone and Joint Surgery (Impact Factor: 4.31). 12/2012; 94(24):2256-61. DOI: 10.2106/JBJS.K.01726
Source: PubMed

ABSTRACT Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement.
Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan.
In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability.
Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis.
Clamp placement in the neutral anatomical axis appears to be preferred in the syndesmosis reduction.


Available from: Phinit Phisitkul, Mar 13, 2015
  • [Show abstract] [Hide abstract]
    ABSTRACT: Syndesmosis sprains can contribute to chronic pain and instability, which are often indications for surgical intervention. The literature lacks sufficient objective data detailing the complex anatomy and localized osseous landmarks essential for current surgical techniques.
    The American Journal of Sports Medicine 10/2014; DOI:10.1177/0363546514554911 · 4.70 Impact Factor
  • Source
    Acta orthopaedica. Supplementum 02/2015; 83(358):1-35. DOI:10.3109/17453674.2014.1002273
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Anatomic restoration of fibular length, alignment, and rotation is essential for accurate syndesmotic reduction. » Accuracy of syndesmotic reduction can be improved by reduction and fixation of the posterior malleolus and open reduction of the syndesmosis. » Postoperative or intraoperative computed tomography (CT) is the most reliable method of assessing the accuracy of syndesmotic reduction. » There is no consensus regarding many aspects of syndesmotic stabilization, including the method of reduction, the device used for stabilization (metal or titanium screws, suture-button device, or bioabsorbable implant), number of screws, number of cortices engaged, and retention or removal of screws. » Syndesmotic malreduction is common and if left uncorrected is associated with inferior functional outcomes when compared with those of an anatomic syndesmotic reduction. T he distal aspects of the tibia and fibula as well as the associated stabilizing liga-mentous structures are col-lectively known as the ankle syndesmosis. The syndesmosis functions to maintain normal ankle kinematics and provide talar stability through a physiologic range of motion. Disruption of the ligamentous structures can occur in isolation or in the setting of an ankle fracture. The need for recognition and stabilization of syndes-motic instability following ankle trauma is well established. Recently, investigators have reevaluated best practices with regard to the assessment, reduction, and fixation of syndesmotic injuries. The effects of syn-desmotic malreduction and failed stabili-zation have also been examined to a greater degree, resulting in new literature on this topic. The purpose of this article is to present the current evidence on syndes-motic injuries in the setting of an ankle fracture. Anatomy The ankle syndesmosis comprises four lig-amentous structures between the distal as-pects of the tibia and fibula. The anterior inferior tibiofibular ligament originates from the anterolateral (Chaput) tubercle of the distal part of the tibia and inserts into Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
    12/2014; 2(12):e4. DOI:10.2106/JBJS.RVW.N.00028