EFFECT OF ANTEROINFERIOR TIBIOFIBULAR LIGAMENT REPAIR AND POSTERIOR MALLEOLAR FRACTURE FIXATION ON SYNDESMOTIC STABILITY_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANGZhenyu ¹ ,  WANGWei ¹ , LIYuancheng ² , LICheng ¹ , LIUPeng ¹ , MAJing ³

1. Department of Orthopaedics, Jinzhou Central Hospital, Jinzhou Liaoning, 121000, P. R. China;
2. Department of Orthopaedics, the First Hospital Affiliated to Dalian Medical University;
3. Department of Neurology, Jinzhou Central Hospital, Jinzhou Liaoning, 121000, P. R. China;

Corresponding?author：

WANGWei, Email: weiwang_ly@126.com

Keywords：

Ankle fracture of pronation-external rotation type; Anteroinferior tibiofibular ligament; Posterior malleolar fracture; Biomechanics

DOI：

10.7507/1002-1892.20140102

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Objective To evaluate the biomechanical characteristics and effectiveness of repairing anteroinferior tibiofibular ligament and fixing the posterior malleolar fracture in reconstructing syndesmotic stability after ankle fracture of pronation-external rotation type (PER) stage IV. Methods Twenty-four normal lower extremity cadaver specimens were collected and made into intact ankle specimens. A MTS Bionix 858 test system was used to measure the maximum rotation of the foot under a static axial load of 150 N, internal rotation torque to the tibia at a rate of 1°/second and 4 N·m torque. Then a fracture of PER stage IV model was established in each specimen. Internal fixation of lower tibiofibular ligament union was performed by screws in group A, fixation of posterior malleolar fractures in group B, fixing posterior malleolar fracture combined with repairing anteroinferior tibiofibular ligament in group C (8 specimens each group). Then the maximum rotation of the foot was measured under the same condition, and the syndesmotic stability was calculated. Between July 2009 and September 2012, 32 patients with ankle fracture of PER stage IV were treated. There were 19 males and 13 females with an average age of 35 years (range, 20-63 years). The locations were the left ankle in 14 cases and the right ankle in 18 cases. The time from injury to admission was 3.5 hours on average (range, 1-72 hours). Open reduction and plate compression internal fixation were performed in fibula, and medial malleolus was fixed by conpression screws, then anteroinferior tibiofibular ligament was mended and posterior malleolar fracture was fixed by screws. Results The preservation rates of syndesmotic stability after repair were 46.2%±12.3%, 62.6%±10.7%,and 66.5%±12.6% in groups A, B,and C, respectively; groups B and C were significantly superior to group A (P<0.05),but no significant difference was found between groups B and C (P>0.05). All patients achieved wound healing by first intention, and were followed up 12-24 months (mean,15 months). All fractures healed,with an average healing time of 11.2 weeks (range, 10-14 weeks) on the X-ray films. No seperation of inferior tibiofibular syndesmosis was observed during the follow-up period. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 88.4 on average (range, 61-98) at last follow-up; the results were excellent in 13 cases,good in 15 cases, and fair in 4 cases, with an excellent and good rate of 87.5%. Conclusion In patients with ankle fracture of PER stage IV, a combination of fixing the posterior malleolar fracture and repairing anteroinferior tibiofibular ligament can reconstruct syndesmotic stability effectively.

Citation： ZHANGZhenyu, WANGWei, LIYuancheng, LICheng, LIUPeng, MAJing. EFFECT OF ANTEROINFERIOR TIBIOFIBULAR LIGAMENT REPAIR AND POSTERIOR MALLEOLAR FRACTURE FIXATION ON SYNDESMOTIC STABILITY. Chinese Journal of Reparative and Reconstructive Surgery, 2014, 28(4): 448-451. doi: 10.7507/1002-1892.20140102 Copy

1.	Pankovich AM. Fractures of the fibula proximal to the distal tibiofibular syndesmosis. J Bone Joint Surg (Am), 1978, 60(2):221-229.
2.	Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle, 1989, 9(6):290-293.
3.	Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw on ankle motion. Foot Ankle, 1989, 10(1):17-24.
4.	Colton CL. The treatment of Dupuytren's fracture-dislocation of the ankle. J Bone Joint Surg (Br), 1971, 53(1):63-71.
5.	Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg, 1985, 104(5):299-302.
6.	Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res, 2006, (447):165-171.
7.	De Vries JS, Wijgman AJ, Sierevelt IN, et al. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg, 2005, 44(3):211-217.
8.	Weber M, Ganz R. Malunion following trimalleolar fracture with posterolateral subluxation of the talus-reconstruction including the posterior malleolus. Foot Ankle Int, 2003, 24(4):338-344.
9.	Weber M. Trimalleolar fractures with impaction of the posteromedial tibial plafond:implications for talar stability. Foot Ankle Int, 2004, 25(10):716-727.
10.	van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma, 2009, 66(1):279-284.
11.	趙文, 唐佩福, 彭海州, 等. 后踝固定治療踝關節骨折的臨床療效. 中國修復重建外科雜志, 2010, 24(12):1432-1436.
12.	Hintermann B. Biomechanics of the ankle joint-injury mechanisms. Swiss Surg, 1998, 4(2):63-69.
13.	Hermans JJ, Ginai AZ, Wentink N, et al. The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis. Skeletal Ridiology, 2011, 40(1):75-83.
14.	Michelson JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg (Am), 1996, 78(7):1024-1031.
15.	Michelson JD, Waldman B. An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res, 1996, (328):285-293.
16.	Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instability:an exploratory, prospective study of fifty-two cases. Am J Sports Med, 2004, 32(1):183-190.
17.	Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries:diagnosis and management. Foot Ankle Clin, 2006, 11(3):625-637.
18.	何勇, 顧湘杰, 馬昕, 等. 脛腓下聯合分離的生物力學研究. 中華創傷骨科雜志, 2005, 7(10):943-947.

1. Pankovich AM. Fractures of the fibula proximal to the distal tibiofibular syndesmosis. J Bone Joint Surg (Am), 1978, 60(2):221-229.
2. Kaye RA. Stabilization of ankle syndesmosis injuries with a syndesmosis screw. Foot Ankle, 1989, 9(6):290-293.
3. Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw on ankle motion. Foot Ankle, 1989, 10(1):17-24.
4. Colton CL. The treatment of Dupuytren's fracture-dislocation of the ankle. J Bone Joint Surg (Br), 1971, 53(1):63-71.
5. Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg, 1985, 104(5):299-302.
6. Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res, 2006, (447):165-171.
7. De Vries JS, Wijgman AJ, Sierevelt IN, et al. Long-term results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg, 2005, 44(3):211-217.
8. Weber M, Ganz R. Malunion following trimalleolar fracture with posterolateral subluxation of the talus-reconstruction including the posterior malleolus. Foot Ankle Int, 2003, 24(4):338-344.
9. Weber M. Trimalleolar fractures with impaction of the posteromedial tibial plafond:implications for talar stability. Foot Ankle Int, 2004, 25(10):716-727.
10. van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures. A systematic review of the literature. J Trauma, 2009, 66(1):279-284.
11. 趙文, 唐佩福, 彭海州, 等. 后踝固定治療踝關節骨折的臨床療效. 中國修復重建外科雜志, 2010, 24(12):1432-1436.
12. Hintermann B. Biomechanics of the ankle joint-injury mechanisms. Swiss Surg, 1998, 4(2):63-69.
13. Hermans JJ, Ginai AZ, Wentink N, et al. The additional value of an oblique image plane for MRI of the anterior and posterior distal tibiofibular syndesmosis. Skeletal Ridiology, 2011, 40(1):75-83.
14. Michelson JD, Ahn UM, Helgemo SL. Motion of the ankle in a simulated supination-external rotation fracture model. J Bone Joint Surg (Am), 1996, 78(7):1024-1031.
15. Michelson JD, Waldman B. An axially loaded model of the ankle after pronation external rotation injury. Clin Orthop Relat Res, 1996, (328):285-293.
16. Hintermann B, Valderrabano V, Boss A, et al. Medial ankle instability:an exploratory, prospective study of fifty-two cases. Am J Sports Med, 2004, 32(1):183-190.
17. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries:diagnosis and management. Foot Ankle Clin, 2006, 11(3):625-637.
18. 何勇, 顧湘杰, 馬昕, 等. 脛腓下聯合分離的生物力學研究. 中華創傷骨科雜志, 2005, 7(10):943-947.

Chinese Journal of Reparative and Reconstructive Surgery

EFFECT OF ANTEROINFERIOR TIBIOFIBULAR LIGAMENT REPAIR AND POSTERIOR MALLEOLAR FRACTURE FIXATION ON SYNDESMOTIC STABILITY

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