Post on 31-Dec-2016
transcript
Syndesmosis Injuries: Semi-Rigid Fixation is the NEW Gold Standard
A Amendola MD Professor and Vice Chair Chief, Division of Sports Medicine Department of Orthopaedic Surgery Duke University
Disclosures
• Arthrex : royalties; consultant • Arthrosurface : Stock; royalties • First Ray: SAB; stock • Smith and Nephew : royalties
Syndesmotic Fixation: Where are we going ?
Syndesmosis “ high ankle” sprain
• Common injury • Often misdiagnosed • Cause of chronic Ankle
dysfunction • No direct diagnostic test • Spectrum of severity
• External rotation • Acute dorsiflexion • Severe ankle sprain
Syndesmosis Injury: Mechanism
Ankle Syndesmosis: Function
• Stability : syndesmosis /deltoid • Weight transmission • Accommodate talar motion
Ankle Syndesmosis: Function
• Stability : syndesmosis /deltoid • Weight transmission • Accommodate talar motion
Spectrum of Injury
No instability Mild Complete Normal
Spectrum of Injury
Syndesmosis Sprains
Classification
• Scranton ( AAOS) – A. Acute ( 0-6 wks)
– I: partial AITFL / stable – II: complete AITFL/ partial IM/ stable or unstable – III: complete AITFL/deltoid/ grossly unstable
– B. Subacute ( 6 wk-3 mos) – C. Chronic ( > 3 mos)
AIII
Syndesmosis Sprains
Classification
• Scranton ( AAOS) A. Acute ( 0-6 wks)
I: partial AITFL / stable ( - stress tests/ N xray) II: complete AITFL/ partial IM/ stable or unstable ( + stress tests, N xray) III: complete AITFL/deltoid/ grossly unstable ( + xray)
B. Subacute ( 6 wk-3 mos) C. Chronic ( > 3 mos)
Case 4 unstable high ankle sprain
Case 4 unstable high ankle sprain
Case 4 unstable high ankle sprain
Post op regimen
Case 5 Chronic sprain
• CASE: 18 yo freshman DL recruit • Senior year HS sprained ankle in August
– Played all games – Never reached 100% – January : felt he was 80% – Could not push off , pivot
• Exam – mild swelling – Tender – ++ ER stress/ stabilization test
Case 5 chronic sprain
Case 5 chronic sprain
Case 5 chronic sprain
Case 5 chronic sprain
Complications : Syndesmosis Fixation
Fractures and Syndesmosis: Reduction and fixation
Reduction and fixation
2 years
Syndesmotic Fixation: Where are we going ?
Syndesmotic Fixation
AOFAS 2013
• Screws are more rigid • Suture button is satisfactory
Syndesmotic Fixation
• Similar rates of malreduction
• Better earlier ROM with suture button
Syndesmosis Injury: Treatment What would be the ideal fixation:
1. Avoids malreduction 2. Provides stability 3. Does not require hardware removal 4. low morbidity/ technically reproducible 5. Minimal complications
AJSM 2012
Comparison screws vs tightrope
Naqvi et al : study method • Cohort study • SS calculation : 23 subjects in each group
– 1mm diff on CT scan, power 80%
• 2 ( x23) groups : tightrope vs screw fixation – Primary outcome : CT reduction – Xrays, clinical outcomes AOFAS, FADI,
complications – Min 18 month FU
Demographics
Naqvi et al : accuracy of CT vs xrays
Naqvi et al : outcomes: malreduction
Naqvi et al : outcomes: WB
Naqvi et al : outcomes: regression analysis
Naqvi et al : discussion weaknesses • 18 mo FU • 2 groups of surgeons/ not randomized • No immediate post op CT
Outcome of suture button vs screws in fractures : similar outcomes
Advantages of Suture-Button Fixation
Advantages of Suture-Button Fixation
control Screw( malreduced) Screw removed tightrope
Syndesmosis Injuries
Syndesmotic fixation: conclusions
• Suture button fixation – Earlier return to full WB activity
• Does not need removal
– Avoid malreduction/ maintain reduction
case2
case2
Case2 : best of both worlds !
Summary
• Syndesmosis injury is a spectrum from sprains to fractures
• Unstable injuries can be made more predictable ( RTS) with early stabilization
• No need for removal • Suture button fixation provides some benefits in
every spectrum of injury