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Intraoperative Three-Dimensional Imaging in the Treatment of Acute Unstable Syndesmotic Injuries
Jochen Franke, MD1; Jan von Recum, MD1; Arnold J. Suda, MD1; Paul Alfred Grützner, MD1; Klaus Wendl, MD1
1 BG Trauma Center Ludwigshafen at Heidelberg University Hospital (J.F., J.v.R., A.J.S., P.A.G., and K.W.), MINTOS-Medical Imaging and Navigation in Trauma and Orthopaedic Surgery (J.F., J.v.R., and K.W.), Ludwig-Guttmann-Strasse 13, D-67071 Ludwigshafen, Germany. E-mail address for J. Franke: jochen.franke@bgu-ludwigshafen.de. E-mail address for J. von Recum: jan.vonrecum@bgu-ludwigshafen.de. E-mail address for A.J. Suda: suda@bgu-ludwigshafen.de. E-mail address for P.A. Grützner: gruetzner@bgu-ludwigshafen.de. E-mail address for K. Wendl: klaus.wendl@bgu-ludwigshafen.de
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Investigation performed at BG Trauma Center Ludwigshafen at Heidelberg University Hospital, MINTOS-Medical Imaging and Navigation in Trauma and Orthopaedic Surgery, Ludwigshafen, Germany

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. One or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Aug 01;94(15):1386-1390. doi: 10.2106/JBJS.K.01122
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Acute unstable syndesmotic ankle injuries are treated primarily by reduction and stabilization with a syndesmotic screw. Examination with fluoroscopy or standard radiographs may not provide reliable information about the quality of the reduction. There is evidence that intraoperative three-dimensional imaging can demonstrate a large proportion of malreductions. The aim of this study was to determine whether intraoperative three-dimensional imaging improves the detection of inadequate positioning of the distal aspect of the fibula in the tibiofibular incisura after syndesmotic screw insertion compared with the findings on standard intraoperative fluoroscopy.


Of 2286 ankle fractures treated operatively from August 2001 to February 2011, 251 consecutive cases (11%) were identified in a retrospective chart review. All had an unstable syndesmosis and underwent syndesmosis stabilization on the basis of an intraoperative hook test. After fluoroscopy, an intraoperative three-dimensional scan was performed. The result of this scan was documented by the surgeon and analyzed retrospectively with regard to the incidence and nature of the need for intraoperative revisions.


The intraoperative three-dimensional scan altered the surgical outcome in eighty-two ankles (32.7%). In most ankles (seventy-seven; 30.7%), the reduction was improved, with the most common improvement being the alignment of the fibula in the tibiofibular incisura in sixty-four patients (25.5%) followed by correction of the fracture reduction in thirteen patients (5.2%). The other five alterations involved implant corrections. The most common malpositions requiring correction after insertion of a positioning screw, with or without additional fixation, were anterior displacement and internal rotation of the distal aspect of the fibula.


Following open reduction and internal fixation of an ankle fracture, the correct position of the syndesmosis cannot be evaluated reliably with use of conventional radiographs or intraoperative fluoroscopy. In view of the high proportion of positive findings in this study, we believe that any treatment of a syndesmotic injury should include intraoperative three-dimensional imaging or at least a postoperative computed tomography scan.

Level of Evidence: 

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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    Da-wei Chen, Bing Li, Yun-feng Yang, Guang-rong Yu
    Posted on September 09, 2012
    Posterior Malleolar Instability Should Get More Attention in Syndesmotic Injuries
    Department of Orthopaedic Surgery, Tongji Hospital, Tongji University School of Medicine, Shanghai, China

    Syndesmotic injuries, which pose a great challenge to orthopaedic surgeons because of the difficulty in reducing the distal fibula into the fibular notch of the tibia accurately, are common in ankle fractures. On the basis of the traumatic mechanism and Lauge-Hansen classification system, ankle fractures involving injuries of the syndesmosis include supination-external rotation stage 1-4 fractures, pronation-external rotation stage 2-4 fractures, and pronation abduction stage 2-3 fractures. In these patterns, occurrence of a posterior malleolar fracture may cause the ankle to be much more unstable and lead to less satisfactory clinical outcomes and a higher risk of degenerative changes[1]. Regardless of vertical forces, a posterior malleolar fracture resulting from torsional forces can be usually found in supination-external rotation stage 3-4 fractures and pronation-external rotation stage 4 fractures, and sometimes in pronation abduction stage 2-3 fractures. So, a posterior malleolar fracture is almost inevitably combined with injuries of the syndesmosis.

    Franke et al. presented a retrospective study of 251 consecutive cases with unstable syndesmosis and emphasized the importance of application of the intraoperative three-dimensional scan. Interestingly, the authors found the most common malpositions requiring correction were anterior displacement and internal rotation of the distal aspect of the fibula after the positioning screw fixation of the syndesmosis. What could be the reasons for this? Unfortunately, the authors just introduced this phenomenon and didn’t give a thorough explanation.

    As mentioned by the authors in this article, we noticed that 105 patients (42%) of all 251 patients had  posterior malleolar fractures, of which 75 (71.4%) remained untreated because of minimal size or displacement of the fragment. This means that posterior malleolar instability still existed in 30% of all fracture patients before the fixation of the syndesmosis using the syndesmotic screw. In our opinion, the posterior malleolar instability might be the reason for the two most common malpositions of the distal fibula. If the two most common malpositions occurred in all those patients who did not have  fixation of the posterior malleolus, then our inference could be true. However, the authors didn’t provide detailed data.

    As is known, because the fibula is posterior to the tibia, the syndesmotic screw must be angled 25 to 30 degrees from posterolateral to anteromedial in order to engage the tibia. In the precondition of the posterior malleolar instability, inserting the screw from back to front might easily cause anterior displacement and internal rotation of the distal fibula. We think inappropriate insertion site and direction of the screw and improper position of the ankle joint can also affect the syndesmotic reduction results. The authors reported that 10 patients (20%) of the 50 patients whose scan data were sufficient for analyzing the nature of the malposition of the distal end of the fibula had a persistently wide mortise. We thought this might be due to a relative higher insertion of the screw, which cause the tip of the fibula to shift outward.

    At present, fixation of the posterior malleolar fragment still remains controversial. Based on different sizes of the fragments and involving extent of the articular surface, the treatment choices could be different[2]. In conjunction with the syndesmotic injury, a posterior malleolar fracture increases the instability of the ankle joint. After reduction and fixation of the syndesmosis, maybe it is not necessary to fix the posterior malleolar fragments that are small have or minor displacement, because of relative satisfactory stability. However, a biomechanical study performed by Gardner et al.[3] indicated that reducing and stabilizing the posterior malleolus restored 70% of the stiffness of the distal tibiofibular articulation, while only 40% of the intact stiffness was restored after syndesmosis stabilization by a syndesmotic screw.

    As far as we are concerned, in selected patients, with use of a posterolateral approach through which the fibular fracture and the posterior malleolar fracture can be reduced and fixed at the same time, fixation of the posterior malleolus can bring about some benefits, such as eliminating the worry of syndesmotic screw breakage, reducing the chance of a secondary operation to remove the syndesmotic screw, and reducing the malreduction of the distal tibiofibular articulation caused by syndesmotic screw fixation. The latter can be confirmed by Miller et al.[4]. Their clinical comparative study showed that reduction of posterior malleolar fractures resulted in a more anatomic reduction of the distal tibiofibular articulation than syndesmotic screw fixation. The authors presented a good study and significantly improved the syndesmotic reduction with the use of the intraoperative three-dimensional scan. However, before the universal application of this useful instrument, a sound reduction of the syndesmosis relied on an excellent technique of syndesmotic fixation and a thorough knowledge of the anatomic structures maintaining the stability of the ankle joint.

    With regard to the most common malpositions of the distal fibula in this article, we think the posterior malleolar instability should get more attention in syndesmotic injuries. Although fixation of the posterior malleolus yields more clinical data to show the effectiveness and benefit of this procedure for syndesmotic injuries, we think a stable posterior malleolus is essential for syndesmotic stability. Sometimes, when the posterior inferior tibiofibular ligament is intact, maybe after fixation of the posterior malleolus, it doesn’t need to use the syndesmotic screws, or at least, fixation of both the posterior malleolus and the syndesmosis could lead to a better reduction. In accordance with the opinion of Miller et al.[4], we hold that all posterior malleolar fractures, regardless of sizes of the fragments, should be fixed if the posterior inferior tibiofibular ligament is intact.

    1. Mingo-Robinet J, López-Durán L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. J Foot Ankle Surg. 2011 Mar-Apr;50(2):141-5.

    2.Gardner MJ, Streubel PN, McCormick JJ, Klein SE, Johnson JE, Ricci WM. Surgeon practices regarding operative treatment of posterior malleolus fractures. Foot Ankle Int. 2011 Apr;32(4):385-93.

    3.Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006 Jun;447:165-71.

    4.Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009 May;30(5):419-26.

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