Elsevier

Foot and Ankle Surgery

Volume 25, Issue 2, April 2019, Pages 180-185
Foot and Ankle Surgery

Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis

https://doi.org/10.1016/j.fas.2017.10.005Get rights and content

Highlights

  • The authors evaluated 120 ankle fractures with syndesmotic injuries with upto 8 years follow up.

  • 13 patients (11%) developed clinically significant osteoarthritis (cOA) of the ankle.

  • Independent predictors of cOA of the ankle were increasing age and radiographic malreduction of the syndesmosis.

  • Care should be taken to ensure radiographic reduction of the syndesmosis and open reduction should be considered in cases where anatomical reduction is uncertain.

Abstract

Background

The primary aim of this study was to present the incidence of clinically significant end stage osteoarthritis (cOA) after syndesmotic fixation of ankle fractures. The secondary aim was to and identify independent predictors of cOA.

Methods

A retrospective review of consecutive patients presenting to a single University affiliated institution between March 2008 and May 2010 was undertaken. Inclusion criteria were ankle fractures with syndesmotic stabilisation. Patients were excluded if pre or postoperative radiographs were missing or were lost to follow up. Data were gathered regarding demographics, fracture pattern, fixation methods, reduction parameters, screw removal, revision surgery, complications and cOA up to seven years post injury.

Results

Data were available for 120 patients (86%). In total, 13 patients (11%) developed cOA. Univariate analysis showed that increasing age, open fracture, malreduction of the syndesmosis, removal of symptomatic screws, revision surgery and complications were predictors of developing cOA. Cox regression analysis revealed increasing age (hazard ratio (HR) 1.09, p = 0.006), and malreduction (HR 45.5, p = 0.001) were independent predictors of developing cOA.

Conclusions

Ankle fractures with syndesmotic stabilisation represent a severe injury with a high rate of cOA. The only modifiable risk factor for developing cOA in this large series of patients was radiological malalignment. When syndesmotic stabilisation is required, careful intraoperative assessment should be undertaken to ensure the syndesmosis is reduced.

Introduction

Ankle fractures are amongst the most common injuries treated by orthopaedic surgeons [1], accounting for 9% of all fractures [2]. Unstable tibiofibular syndesmotic injuries presenting alongside ankle fracture arise in 10–15% of cases [3], [4]. Ankle fractures with an associated syndesmotic injury represent a more severe injury pattern with poorer functional outcomes when compared to injuries that required malleolar fixation alone [5].

Biomechanical studies previously indicated that syndesmosis fixation would be required if there was a fibular fracture 3.5 cm above the syndesmosis with an irreparable deep deltoid injury [6]. However, the level of fracture does not always predict the level of tear in the interosseous ligament [7] and clinical studies have shown unstable syndesmotic injuries requiring fixation in 20–40% of transyndesmotic fibular fractures [4], [8].

Radiographic post-operative malalignment of the syndesmosis has been demonstrated to result in inferior functional outcomes at 2 years post fracture [4]. There are concerns regarding the reproducibility of AP radiographic measurements due to rotational alignment [8], and recent studies have looked at criteria for radiological alignment in the sagittal plane [9], [10]. Croft et al. showed good reproducibility of the measurement of the anterior tibiofibular ratio on the lateral view in normal radiographs, however this has not yet been validated for use in syndesmotic disruption [10]. Radiographic measurements on coronal radiographs are currently still the foundation for assessment and a recent study has indicated that plain coronal radiographs are sufficient to assess syndesmotic reduction and postoperative CT scanning does not change management [11].

Studies of end stage ankle arthritis have demonstrated that 65–80% of cases are post traumatic [12], [13], [14]. However, there are far fewer studies observing the long term risk of developing osteoarthritis after ankle fracture and these studies include only small numbers of syndesmotic injuries [15], [16].

The primary aim of this study was to quantify the incidence of clinically significant end stage osteoarthritis (cOA) in a large group of patients who sustained ankle fractures with syndesmotic injury and to identify independent risk factors for developing cOA. The secondary aim of this study was to evaluate a large consecutive group of ankle fracture with syndesmotic injuries and provide information on demographics, fracture pattern, fixation methods and outcomes related to revision surgery and complications.

Section snippets

Methods

The study was conducted with the approval of the South East Scotland research ethics service. All patients presenting to a single university-affiliated trauma centre between March 2008 and May 2010 who had an ankle fracture with syndesmotic fixation were eligible for the study. The study centre is the only hospital receiving adult trauma for a defined population of 834,648 [17] and managed 663 ankle fractures per year at the time of initial patient presentations [2].

A prospectively collected

Results

The study cohort consisted of 139 patients. 19 were excluded from the study, due to missing pre or postop radiographs [6] or follow up less than two months [15]. 120 patients were, therefore, included in the study. 54% of patients were male and the mean age was 43. 55% of patients had a dislocation on initial radiographs and 6.7% of fractures were associated with an open injury. The mean time to surgery was two days. 76% of fractures were pronation type injuries, the remaining 24% were

Discussion

In a review of 120 patients with syndesmotic fixation in association with ankle fractures we report the following findings; at 7 years after injury cOA occurs in 11% of patients. Increasing age and malreduction of the syndesmosis are independent predictors of developing cOA. There is considerable variation in the technical aspects of syndesmotic fixation. At least 20% of syndesmotic injuries are associated with supination external rotation fractures This in in keeping with the modern literature

Conflict of interest

The authors declare no conflict of interest.

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