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: 5.28). 12/2012; 94(24):2256-61. DOI: 10.2106/JBJS.K.01726
Source: PubMed


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.

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Available from: Phinit Phisitkul, Mar 13, 2015
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    • "There is substantial anatomic variability in the tibiofibular incisure (Elgafy et al. 2010, Mukhopadhyay et al. 2011, Lepojärvi et al. 2013), and the risk for syndesmotic malreduction is especially high in patients with flatter tibiofibular articulations (Elgafy et al. 2010). In these patients, the vector of the reduction clamp is critical for appropriately positioning the fibula within the tibiofibular incisure during syndesmotic reduction (Phisitkul et al. 2012). "
    Acta orthopaedica. Supplementum 02/2015; 83(358):1-35. DOI:10.3109/17453674.2014.1002273
  • Foot & Ankle International 04/2013; 34(9). DOI:10.1177/1071100713485740 · 1.51 Impact Factor
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    ABSTRACT: Use of Computed Tomography (CT) to evaluate syndesmotic reduction following injury has significantly increased in recent years. The aim of this study was to compare existing clinical measurements of syndesmotic reduction to gold standard measurements of fibular motion obtained from a full 3D model. Three common clinical measures for assessing syndesmotic congruity on axial CT slices were identified in the literature. Each measure was manually performed on 170 cadaveric ankle CT scans obtained with variable degrees of simulated syndesmotic displacement. Clinical measures were assessed for intraobserver and interobserver reliability and compared to objective measures of true medial/lateral and anterior/posterior translation and fibular rotation that were obtained from a 3D model. Pearson correlation coefficients (PCC) were computed to determine which clinical measurements were most accurate for describing syndesmotic motion obtained from the 3D model. All three clinical measurement techniques demonstrated good to excellent interobserver and intraobserver reliability. Medial/lateral displacement of the fibula was best correlated with the difference between the anterior and posterior tibiofibular joint space measurements described by Elgafy et al (PCC = 0.29 small correlation). Anterior/posterior displacement of the fibula was well correlated with the anterior/posterior measurement described by Phisitkul et al (PCC = 0.69 large correlation). Fibular rotation was best correlated with the average of the Elgafy anterior and posterior tibiofibular joint space measurements (PCC = 0.33, moderate correlation). Proximal/ distal displacement of the lateral malleolus was best correlated with the Elgafy posterior tibiofibular joint space measurement (PCC = 0.49, moderate correlation). While the clinical measurements were adequately reproducible, they showed only moderate to small correlations with the 3D measurements of movement of the fibula in the longitudinal, medial/lateral or rotational directions. The only fibular translation measured by the 3D model that was well described by the three clinical measures was fibular movement in the anterior/ posterior direction. This work demonstrates a need for improved clinical measurements of syndesmotic congruity on axial CT scans to serve as surrogates for the true movement of the fibula.
    The Iowa orthopaedic journal 09/2013; 33:40-6.
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