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. 2021 Jul;42(7):877-885.
doi: 10.1177/1071100721990008. Epub 2021 Feb 9.

Anatomic Repair vs Closed Reduction of the Syndesmosis

Christopher Del Balso  1 , Al-Walid Hamam  1   2 , Moaz Bin Yunus Chohan  1 , Christina Tieszer  1 , Abdel-Rahman Lawendy  1 , David William Sanders  1
Affiliations

Anatomic Repair vs Closed Reduction of the Syndesmosis

Christopher Del Balso et al. Foot Ankle Int. 2021 Jul.

Abstract

Background: The goal of the study was to compare radiographic and functional outcomes between conventional closed syndesmotic reduction and screw fixation with open reduction, direct repair of the anterior inferior tibiofibular ligament (AiTFL) and screw fixation. We hypothesized that open reduction with restoration of the AiTFL would provide an improved reduction with better radiographic and functional outcomes.

Methods: Fifty consecutive patients with OTA 44-C ankle fractures were enrolled. Treatment was nonrandomized and based on surgeon preference. Patients were treated with either open reduction, suture-anchor AiTFL repair, and screw fixation (ART group), or conventional closed reduction of the syndesmosis followed by screw fixation (CR group). The primary outcome measure was anteroposterior (AP) displacement of the fibula on CT scan at 3 months postoperatively. Secondary outcome measures included the Maryland Foot Score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score, and the Foot and Ankle Outcome Score (FAOS).

Results: Mean AP difference between injured and noninjured ankles was decreased in the ART group compared with the CR group (0.7 ± 0.3 mm vs 1.5 ± 0.3 mm, P = .008). No differences were observed between groups in overall scores for secondary outcome measures. The ART group displayed a significant difference in Maryland Foot Shoe subscore at 12 months (ART = 9.5 vs CR = 8.3, P = .03) and FAOS Quality of Life subscore at 12 months (64.1 compared to 38.3, P = .04).

Conclusion: Open anatomic syndesmotic repair resulted in improved radiographic outcomes compared with closed reduction. Cosmesis was worse at 6 weeks compared to the CR group; however, quality of life and shoewear were improved in the ART group at 1 year postoperatively.

Level of evidence: Level II, prospective comparative study.

Keywords: arthritis; outcome studies; syndesmosis; trauma.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Christopher Del Balso MBBS, MSc, FRCSC, Moaz Bin Yunus Chohan MBBS, MSc, and Christina Tieszer, MSc, report grants from Smith & Nephew, during the conduct of the study. ICMJE forms for all authors are available online.

Figures

Figure 1.
Figure 1.
Anatomic repair technique (ART). (A) Intraoperative stress fluoroscopy demonstrating decreased tibiofibular overlap, and increased medial clear space. (B) Clinical photograph depicting the incision for open reduction of the syndesmosis, location of the anterior inferior tibiofibular ligament (AiTFL), and planned sites of syndesmotic screw fixation. (C) Intraoperative photograph showing suture anchor AiTFL repair. (D) Final intraoperative stress fluoroscopy following the ART demonstrates a congruent ankle mortise with a reestablished tibiofibular overlap, and appropriate medial clear space.
Figure 2.
Figure 2.
Anteroposterior difference was calculated as the distance between the anterior and posterior facets of the tibial incisura and the fibula. This patient (from Figure 1) underwent the anatomic repair technique (ART). The operative side (black) is compared to the uninjured side (white) on computed tomography (CT) at 3 months postoperatively.
Figure 3.
Figure 3.
Anteroposterior (AP) difference comparison. The mean difference in translation (AP difference) between injured and uninjured ankles was significantly decreased in the ART group (0.7 ± 0.3 mm) when compared to the CR group (1.5 ± 0.3 mm) (*P = .008). ART, anatomic repair technique; CR, closed reduction.
Figure 4.
Figure 4.
Maryland Foot Score. The Cosmesis subscore was significantly greater at 6 weeks postoperatively in the CR group (10.0 ± 0.0) compared with the ART group (8.6 ± 1.7) (*P = .05). A difference between the ART (9.5 ± 0.5) and CR (8.3 ± 0.9) group was observed for the Shoe subscore at 12 months (#P = .03). ART, anatomic repair technique; CR, closed reduction.
Figure 5.
Figure 5.
AOFAS Hindfoot Score. No differences between groups (ART vs CR) were observed for AOFAS total score, or any subscore. AOFAS, American Orthopaedic Foot & Ankle Society; ART, anatomic repair technique; CR, closed reduction.
Figure 6.
Figure 6.
Foot and Ankle Outcome Score (FAOS). A significantly greater QoL subscore was observed at 12 months (*P = .04) in the ART group (64.1 ± 9.3) compared with the CR group (38.3 ± 8.1). ADL, activities of daily living; ART, anatomic repair technique; CR, closed reduction; QoL, Quality of Life.
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