Arthrodesis of syndesmotic joint for failed fixation of syndesmosis: A case report

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Case Report
Arthrodesis of syndesmotic joint for failed fixation of syndesmosis: A
case report
John Mukhopadhaya
a
, Arvind Prasad Gupta
b
, Amit Kumar Sinha
c
,
*
a
Department of Orthopaedics, Traumatology and Joint Replacement, Paras HMRI Hospitals, Patna, Bihar, India
b
Department of Sports Injury, Paras HMRI Hospital, Patna, Bihar, India
c
FNB Arthroplasty, Krishna Shalby Hospital, Ahmedabad, India
ARTICLE INFO
Keywords:
Chronic syndesmotic injury
Syndesmosis
Arthrodesis
ABSTRACT
Introduction: Ankle syndesmosis comprises an integral part of the ankle joint complex. As a fibrous structure resists
the axial, rotational, and translational forces and hence maintains the integrity of the ankle mortise.
Clinical features: We hereby present a case report of chronic syndesmotic injury managed initially with screw
fixation with persistent pain and instability after initial fixation who underwent fusion of syndesmosis with
excellent recovery and resolution of his symptoms.
Intervention and outcome: Among the various modes of operative fixation for chronic syndesmotic injuries namely
suture-button fixation, arthroscopy and debridement, and arthrodesis, we resorted to arthrodesis of the syn-
desmotic joint which led to the resolution of the patient's symptoms which were otherwise hampering his ac-
tivities of daily living.
Conclusion: Fusion of ankle syndesmosis is one of the management options for failed fixation of ankle syndesmosis.
1. Introduction
Ankle syndesmosis comprises an integral part of the ankle joint
complex. As a fibrous structure it resists the axial, rotational, and trans-
lational forces and hence maintains the integrity of the ankle mortise.
Ankle syndesmotic injuries comprise a major fraction along with other
associated skeletal and soft tissue injuries around the ankle and are
particularly important due to the rising incidence of ankle fractures in
adults.
1
External rotation force around the ankle is most commonly found
to be associated with syndesmotic injury.
2
There are many documented methods for fixation of syndesmosis
including fixations with screws, bioabsorbable screws, suture buttons
and not to forget conservative management. Howsoever every surgery
has its limitations which might lead to fixation failure and thus chronic
pain and instability around the ankle.
3
We hereby present a case report of
chronic syndesmotic injury managed initially with screw fixation with
persistent pain and instability after initial fixation who underwent fusion
of syndesmosis with excellent recovery and resolution of his symptoms.
2. Case report
A 35-year-old gentleman presented to our emergency department
post twisting injury around his left ankle due to a fall from stairs.
Immediately following the incident pain and swelling developed around
his left ankle and he was not able to bear weight.
On examination, the ankle was grossly deformed. Though it was a
closed injury a thorough distal neurovascular examination was per-
formed which was deemed to be intact. Appropriate radiographs were
taken which suggested Pronation-external rotation as the mechanism of
injury (Fig. 1).
Reduction under anesthesia and external fixator application was done
after informed consent as means of damage control. After the provisional
stabilization with an external fixator appropriate computed tomography
scan of the ankle joint was done for a better assessment of ankle injury
which showed an isolated fibula fracture with tibiofibular joint diastasis
(Fig. 2).
The patient was discharged because of excessive swelling with advice
to return after a week for further management. After 1-week the patient
presented to us in the outpatient department where he was assessed as fit
for surgery as was evidenced by wrinkles on the skin at his left ankle
joint. The patient was operated on with fixation of the fibula with a
locking compression plate and screw fixation of syndesmosis after due
informed consent. At this time the external fixator was left in situ to
provide stability to the ankle joint (Fig. 3).
* Corresponding author. Indrapuri, Road no 1, House no 35, P.0 Keshari Nagar, Patna, 800024, Bihar, India.
E-mail addresses: mukhoj@gmail.com (J. Mukhopadhaya), amitsinhamgims@gmail.com (A.K. Sinha).
Contents lists available at ScienceDirect
Journal of Orthopaedic Reports
journal homepage: www.journals.elsevier.com/journal-of-orthopaedic-reports
https://doi.org/10.1016/j.jorep.2023.100156
Received 29 December 2022; Received in revised form 11 March 2023; Accepted 30 March 2023
Available online 6 April 2023
2773-157X/©2023 The Author(s). Published by Elsevier B.V. on behalf of Prof. PK Surendran Memorial Education Foundation. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Journal of Orthopaedic Reports 2 (2023) 100156

The patient was discharged home in stable condition and was advised
of non-weight bearing for 8 weeks. Sutures were removed after 2 weeks;
the external fixator after 4 weeks following which the ankle was
immobilized in a cast and toe touch weight bearing was allowed (Fig. 4).
After 8 weeks of complete immobilization, the patient started graded
weight bearing and gradually returned to his activities of daily living but
Fig. 1. Radiograph showing ankle fracture dislocation with Pronation-External rotation as a possible mechanism of injury.
Fig. 2. CT Scan showing tibiofibular joint diastasis.
J. Mukhopadhaya et al. Journal of Orthopaedic Reports 2 (2023) 100156
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kept on complaining about mild pain in his ankle joint during weight
bearing with occasional episodes of swelling which resolved on taking
rest and limb elevation.
After 10 months of the primary fixation, the patient started com-
plaining of persistent moderate pain around his ankle with limited daily
and recreational activities. His AOFAS Ankle-Hindfoot Score was 40/
100. On Visual Analog Scale his score was 7/10. He was evaluated
clinically and with appropriate radiographs. There was breakage of the
syndesmotic screw with tibiofibular clear space >5mm and overlap
<10mm in the Antero-posterior view (AP) of the ankle suggestive of
syndesmotic disruption.
4
(Fig. 5).
This was confirmed with Computed tomography (CT) scan which
again confirmed tibiofibular space widening>5mm thereby confirming
failed fixation of syndesmotic injury.
4
(Fig. 6).
The patient was counseled, infection was ruled out, appropriate
consent was taken and the patient was planned for the fusion of syn-
desmosis with bone graft and screws. After induction, the original skin
incision was taken and the implant from the fibula was removed. The
Fig. 3. Radiograph showing Fracture &Syndesmosis fixation with ankle external fixator in situ.
Fig. 4. Radiograph after removal of external fixator.
J. Mukhopadhaya et al. Journal of Orthopaedic Reports 2 (2023) 100156
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broken syndesmotic screw was left as it was (Fig. 7, A). After appropriate
exposure and decortication, the space was filled in with bone graft taken
from the ipsilateral iliac crest (Fig. 7, B). Compression and hence
reduction of the syndesmotic joint were achieved with a collinear
Fig. 5. Radiograph showing disruption of the tibiofibular syndesmosis with broken screw in situ.
Fig. 6. CT Scan showing increased tibiofibular joint space.
J. Mukhopadhaya et al. Journal of Orthopaedic Reports 2 (2023) 100156
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reduction clamp (Fig. 7, C) followed by fixation with 3 cortical screws
(Fig. 7, D). Closure in layers was done followed by cast application
(Fig. 8).
The patient was again advised strict non-weight bearing for 4 weeks
and toe touch for another 8 weeks following which the cast was removed
and graded weight bearing was begun. Stitches were removed after 12
days of surgery, and the entire postoperative period was uneventful.
Following are the patient's clinical (Fig. 9) and radiographic pictures
Fig. 7. Intraoperative steps for revision fixation of syndesmosis.
Fig. 8. Immediate Postoperative radiograph after revision fixation of syndesmosis.
J. Mukhopadhaya et al. Journal of Orthopaedic Reports 2 (2023) 100156
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(Fig. 10) after 13 months of revision with excellent recovery (Fig. 11) and
no pain. Postoperatively after 18 months, his AOFAS Ankle-Hindfoot
Score improved to 94/100. On Visual Analog Scale his score was 0/10.
3. Discussion
The modes of operative fixation for chronic syndesmotic injuries are
suture-button fixation, arthroscopy and debridement, and arthrodesis
5
Stabilization of the syndesmosis using arthrodesis is relatively un-
common and is taken as a last resort to treat chronic ankle instability and
pain due to tibiotalar arthritis to relieve the patient of pain and improve
function. There are still controversies among orthopedists regarding the
patient's indication and efficacy of the procedure.
6
Katznelson et al.
7
published a series wherein 5 patients underwent
ankle arthrodesis with bone plugs derived ipsilaterally from the tibia and
fibula. They reported that fusion occurred within 10 weeks in all patients
of their series and all patients were pain-free by one year of the surgery.
Another study reported by Olson et al.
6
reported10 patients who
underwent ankle syndesmosis fusion at a mean of 9 months after their
initial injury, with a mean follow-up for 3.4 years. They found that the
mean AOFAS score improved from 37 to 87 points (P <.05) and the
mean pain score improved from 17 to 31 points (P <.05). Complications
reported in the series included malunion, removal of hardware, and a
re-operation rate of 50%.
Fig. 9. Clinical pictures of his movements at the ankle joint post 13 months of revision fixation of syndesmosis.
Fig. 10. Radiographs after 13 months of revision fixation of syndesmosis.
J. Mukhopadhaya et al. Journal of Orthopaedic Reports 2 (2023) 100156
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Han et al.
8
resorted to arthroscopic debridement with or without
trans fixation in patients with chronic syndesmosis injury and reported
that 90% of patients in the series reported good to excellent clinical
outcomes of the surgery.
Parlamas et al.,
9
reported a meta-analysis comparing the success rates
of treatment modality for chronic syndesmosis injury fixation and found
that success rates were 87.9% for screw fixation and 79.4% for
arthrodesis, and 78.7% for arthroscopic debridement.
Chronic syndesmosis injury is a debilitating condition and may lead
to a reduction in quality of life posed by chronic ankle pain. This insta-
bility may lead to the development of early tibiotalar arthritis. However,
in our case patient is pain-free and apart from the mild restriction of
dorsiflexion, he has a full range of movements at his ankle as well as
subtalar joints with no evidence of tibiotalar as well as subtalar joint
arthritis.
Regarding the cause of failure of initial surgery, tibiofibular diastasis
with interosseous membrane rupture was there to start with but the post-
operative picture did not suggest any malreduction of the syndesmosis.
Regarding the number of screws and the number of engaging cortices,
there is still a prevailing controversy. Although there is biomechanical
evidence that a single screw fails under a lesser load,
10
there is no dif-
ference found in radiographic parameters between one screw and two,
11
and in addition, there is no functional difference between two small
fragment screws and one large fragment screw.
12
A retrospective study of 46 patients compared a single quadricortical
or tricortical screw (size not specified) followed by routine removal at
3–7 months in particular in relation to the formation of tibiofibular
synostosis.
13
There was a statistically significant increase in the rate of
MRI-detected obliteration of the syndesmosis in the quadricortical group
however, there was no difference in functional outcome.
In a prospective randomized study comparing tri- or quadricortical
screws in 127 patients, two 3.5 mm screws no significant difference was
found in screw breakage, screw loosening, loss of reduction, or need for
the removal of hardware.
14
Thus overall, it can be said that there is no clear evidence to favor
either tricortical or quadricortical fixation either from biomechanical
studies, and there is no evidence of the functional difference between the
two groups.
Though various modalities are mentioned in the literature, we
advocated and hence report a case wherein syndesmosis fusion was done
using screws with bone graft augmentation taken from the ipsilateral
iliac crest which led to the resolution of the patient's symptoms which
were otherwise hampering his activities of daily living.
Author's contribution
All authors contributed equally to this work.
Funding information
No funding sources.
Declaration of competing interest
There are no conflicts of interest.
Acknowledgments
The authors certify that they have obtained all appropriate patient
consent forms. In the form, the patient has given consent for his images
and other clinical information to be reported in the journal.
We are thankful to our head of the Department, Dr. John Mukho-
padhaya sir for extending his support toward the completion of this work.
We are also thankful for the full extended support from the patient that
has helped us report this article.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.jorep.2023.100156.
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Fig. 11. Clinical pictures of his movements at the subtalar joint post 13 months of revision fixation of syndesmosis.
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