Visual inspection, flexible fixation may reduce malreduction risk in syndesmotic injuries
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WAIKOLOA, Hawaii — Surgeons should perform visual inspection, arthroscopic and radiographic evaluation, and use flexible fixation when treating syndesmotic injuries of the ankle to reduce malreduction, according to a presenter here.
When evaluating syndesmotic injuries, Andrew R. Hsu, MD, recommends performing an arthroscopy, which can diagnostically confirm whether the syndesmosis is out. He also noted arthroscopy can be used to evaluate the reduction of the syndesmosis for alignment and gaps that need to be revised.
“When you look at post-reduction, you should not be able to get your 3.5-mm shaver into the syndesmosis,” Hsu said in his presentation at Orthopedics Today Hawaii. “It should be a hard stop, and that’s how you know that it’s completely reduced anterior to posterior.”
Although Hsu noted arthroscopic evaluation of syndesmosis injuries is easier to perform and more reproducible, he added surgeons can also obtain contralateral X-rays to compare the widening of the syndesmosis of the affected and unaffected legs.
For direct visualization, the simplest way of evaluating and reducing the syndesmosis is through the incisura method, which involves directly looking at the anterior tibiofibular ligament to see if it is open, according to Hsu.
“You don’t have to get a special X-ray. You don’t have to get an OR CT scan. You can directly look at it and see if it lines up or not,” Hsu said. “You’ll quickly realize if the syndesmosis is internally or externally rotated after your fixation because it won’t line up properly.”
Surgeons can also use the articular surface method among patients with gross instability or undergoing revision, according to Hsu. He noted the technique involves making an incision directly over the anterior tibiofibular ligament to view the corner of the anterolateral tibia and the anteromedial fibular to see if it lines up correctly.
“This is basically saying, ‘I’m going to look directly at the mortise,’” he said. “I’m going to do a formal arthrotomy and make sure that the mortis is completely lined up.”
When it comes to fixation, Hsu noted that in the past decade the published literature has shown patients experience fewer complications, better overall outcomes and functional outcome benefits with flexible fixation vs. screw fixation. He added flexible fixation also has a considerable amount more forgiveness, with more give than rigid fixation.
“If you fix the syndesmosis in the wrong spot with a screw, it’s not going to find any sweet spot, if you will,” Hsu said. “It will break, the screw will backout and you will have heterotopic ossification within the syndesmosis and be looking at a revision situation.”
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Hsu AR. Treating syndesmosis injuries in 2022. Presented at: Orthopedics Today Hawaii. Jan. 9-13, 2022; Waikoloa, Hawaii.
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