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CT findings support syndesmotic screw removal for reduction of tibiofibular joint
Researchers found a 40% rate of initial malreduction in the distal tibiofibular joint after screw placement.
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SAN FRANCISCO — The results of a prospective study performed with CT scans show that 83% of malreduced tibiofibular syndesmoses spontaneously reduced following syndesmotic screw removal.
“Although further longer studies are needed, we advocate routine syndesmotic screw removal to achieve final anatomic reduction,” study author Daniel Song, MD, said during his presentation at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting.
Prospective radiographic study
To determine the rate of distal tibiofibular malreduction on CT scans following syndesmotic screw placement and the effect of syndesmotic screw removal on the joint, Song and his colleagues conducted a prospective investigational review board-approved study of 15 adult patients with intraoperative evidence of syndesmotic injury requiring syndesmotic screw placement between 2008 and 2010. Patients had an average age of 24 years.
“As no standard is currently defined in the literature, syndesmotic screw size, number of screws and number of cortices were left up to the discretion of the treating surgeon,” Song said.
The researchers obtained CT scans of patients’ injured and uninjured ankles within 2 weeks postoperatively.
“Patients underwent standard postoperative rehabilitation and screws [were] removed 3 months postoperatively, and a final axial CT scan [was] obtained after 1 month of screw removal.”
A musculoskeletal radiologist evaluated the scans and categorized those with more than 2 mm of difference between the anterior and posterior fibula-incisura distances as malreduced.
The rate of malreduction
Initial postoperative CT scans revealed that six of 15 patients (40%) had malreductions. One month after screw removal and weight bearing, investigators found that five of the six initial malreductions (83%) reduced “spontaneously on axial CT scans,” Song said. Of the five patients whose malreductions reduced, the difference in the anterior and posterior fibula-incisura distance was 2.54 mm, according to the study abstract. The anterior and posterior fibula-incisura distance was 6 mm in the one patient who remained malreduced.
“Although not investigated in our study, the literature shows improved clinical outcomes with the quality of anatomic reduction and with noncomminent screws,” Song said. “Further, longer prospective studies are required for definitive conclusions, but syndesmotic screw removal may be advantageous to achieve final anatomic reduction and continues to be recommended.”
Limitations of the study included a small sample size, lack of functional outcomes and the “possibility of normal anatomic variance,” Song said. – by Renee Blisard
Reference:
- Song D, Lanzi JT, Groth A, et al. The effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint. Paper #617. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.
For more information:
- Daniel Song, MD, can be reached at Tripler Army Med Center, 1 Jarrett White Rd., MCHK-DSO/Ortho TAMC, Honolulu, HI 96859; 808-433-3557; email: song_daniel@hotmail.com.
- Disclosure: The authors have no relevant financial disclosures. The views expressed are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. government.
Perspective
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Paul Tornetta III, MD
This is a timely and interesting study in light of other recent trials. Sagi and colleagues recently reported better patient-based outcomes for patients with anatomically aligned syndesmoses than those without. This is the first such report and gives us, as surgeons, a greater incentive to get perfect alignment. Other studies have not found this relationship.
Additionally, Jordan and colleagues reported that there is some mild widening of the syndesmosis after screw removal, supporting the current study which finds that the syndesmosis tends to self center, similar to the findings of McKinley when evaluating posterior malleolar fractures in an unconstrained model. Finally, the randomized trial of Pakarinen and colleagues for stress positive instability of the syndesmosis after open reduction and internal fixation of WE pattern fractures did not demonstrate any patient-based outcome differences in those fixed and those not, thought the numbers were small.
Taken together, one might conclude, with the help of the current study that fixation of the syndesmosis is advisable, but that removal may be an advantage if the syndesmosis is stabilized in a nonanatomic position. A well-done randomized clinical trial of removal vs. retention is needed.
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