"Flexible nature of fixation" in syndesmotic stabilization of the inferior tibiofibular joint affects the radiological reduction outcome

Robert Hennings, Carolin Fuchs, Ulrich J Spiegl, Jan Theopold, Firas Souleiman, Christian Kleber, Annette B Ahrberg, Robert Hennings, Carolin Fuchs, Ulrich J Spiegl, Jan Theopold, Firas Souleiman, Christian Kleber, Annette B Ahrberg

Abstract

Purpose: Fibular mobility after suture button stabilization (SBS) of inferior tibiofibular joint (syndesmosis) injuries has been described. This effect is called the "flexible nature of fixation (FNF)." In this study, we aimed to quantify FNF in syndesmotic stabilization.

Methods: Postoperative bilateral computed tomography (CT) of ankle fractures with syndesmosis stabilization by SBS or syndesmotic screw (SYS) was retrospectively analyzed. The transverse offset (TO) and vertical offset (VO) were defined by evaluating the drill channels. The reduction outcome was evaluated by the side-to-side difference between the clear space and the anterior tibiofibular distance (antTFD). The calculated anterior tibiofibular distance (cal-antTFD) was calculated by subtracting the TO from the validated antTFD. Subsequently, a reevaluation of the reduction outcomes after SYS or SBS stabilization was performed using cal-antTFD.

Results: Sixty patients (44 with SBS and 16 with SYS stabilization) were analyzed. The intra-rater and inter-rater reliabilities for TO and VO were excellent (α > 0.92). SYS stabilization showed lower mean TO (- 0.02 mm; SD 0.14) and VO (0.11 mm; SD, 0.29 mm) than SBS stabilization (TO 1.16 mm, SD 1.4 mm; VO 0.2 mm, SD 0.8 mm; p = 0.001). The rate of malreduction according to cal-antTFD was higher than that of antFTD (p = 0.033).

Conclusion: The presented method, which evaluates the position of the tibial to the fibular drill channel, allowed the quantification of the "FNF." The often described difference in the dynamic stabilization of SBS compared to the rigid stabilization by SYS could be objectified. Considering cal-antTFD illustrates that FNF potentially reduces the rate of malreduction in SBS stabilization.

Keywords: Ankle; Flexible fixation; Inferior tibiofibular joint; Suture button; Syndesmosis.

Conflict of interest statement

The authors declare no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Computed tomography in axial (a) and coronal (b) reconstruction of a left ankle fracture classified as AO 44B3.1 after open reduction and internal fixation of the lateral malleolus (lag screw and neutralization plate) and dynamic stabilization of the distal tibiofibular joint
Fig. 2
Fig. 2
Axial (a) and coronal (b) computed tomography reconstruction of a left ankle after open reduction and internal fixation of the lateral malleolus (plate) with anatomical dynamic stabilization of the distal tibiofibular joint, lateral endobutton, and medial flip anchor. a Assessment of the axial plane: A–B fibular line, C–D tibial line, E–F transversal offset (TO). b Assessment of the coronal plane: A–B fibular line, C–D tibial line, distance E–F = vertical offset (VO)
Fig. 3
Fig. 3
a Schematic representation of the measurement of the anterior tibiofibular distance (antTFD). b Illustration of the calculated tibiofibular distance (cal-antTFD) and the assumed tibiofibular relations after computational neutralization of TO (distance E–F) by subtracting TO from antTFD with the image processing program Gimp (GNU Image Manipulation Program, V 2.10.20). The distance C–E was rotated on C until the points E and F overlapped. The distance C–E is the same as that of C–F

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