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Intraoperative Syndesmotic Reduction: Three-Dimensional Versus Standard Fluoroscopic Imaging
Roy I. Davidovitch, MD1; Yoram Weil, MD2; Raj Karia, MPH1; Jordanna Forman, BS1; Christopher Looze, MD1; Meir Liebergall, MD2; Kenneth Egol, MD1
1 Orthopaedic Trauma Service, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. E-mail address for R.I. Davidovitch: roy.davidovitch@nyumc.org
2 Orthopaedic Trauma Service, Hadassah Hebrew University, P.O.B. 12000, Jerusalem, Israel 91120
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Investigation performed at Jamaica Hospital Medical Center, Jamaica, New York, and Hadassah Hebrew University Hospital, Jerusalem, Israel

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. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, 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 © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 16;95(20):1838-1843. doi: 10.2106/JBJS.L.00382
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The quality of reduction of the syndesmosis is an important factor in the outcome of ankle fractures associated with a syndesmotic injury. The purpose of this study was to directly compare the accuracy of syndesmotic reductions obtained using intraoperative standard fluoroscopic techniques against reductions obtained using three-dimensional imaging of the Iso-C3D fluoroscope.


We prospectively reviewed imaging studies of patients who were diagnosed as having preoperative or intraoperative evidence of syndesmotic diastasis (on the basis of the fluoroscopic Cotton test and/or a manual external rotation stress test) who underwent syndesmotic fixation at one of two level-I trauma centers. Center A used intraoperative computed tomography (CT) imaging to assess reduction (≤2 mm), while Center B assessed reduction under standard fluoroscopic imaging. Postoperative alignment was assessed in a standardized manner, measuring anterior fibular distance, posterior fibular distance, and the anterior translation distance. Measurements were taken on the injured side and the uninjured side and compared between the groups on postoperative axial CT scans.


A total of thirty-six patients in both centers met our inclusion criteria and were included in the data analysis. Despite utilization of the Iso-C3D, a high rate of malreductions was noted in both groups. Anterior translation distance malreductions occurred in 31% of the sixteen patients in Center A and 25% of the twenty patients in Center B (p = 0.72). The number of anterior fibular distance malreductions was similar, with a rate of 38% in Center A and 30% in Center B (p = 0.73). A significant difference among the centers (p = 0.03) was noted, however, when the posterior fibular distance data was analyzed, with 6% being malreduced by >2 mm in Center A and 40% in Center B.


The results of our study support previous investigations that have cited high rates of syndesmotic malreductions and demonstrate that the addition of advanced intraoperative imaging techniques does not help to reduce the rate of malreductions in this cohort.

Level of Evidence: 

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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    Robert-Jan O. de Muinck Keizer, MD, PhD-candidate, J. Carel Goslings, MD, PhD, Professor of Trauma Surgery, on behalf of the EF3X-project group
    Posted on November 25, 2013
    3D-Imaging in Fracture Surgery
    Academic Medical Center, Amsterdam, the Netherlands

    With great interest we read the article by Dr. Davidovitch and coworkers in which they compare the accuracy of syndesmotic reductions obtained by standard versus three-dimensional intra-operative imaging(1). We would like to congratulate the authors with the development of a new measurement method that comprises all aspects of fibular (dis)placement. In the future, it would be interesting to see the correlation between this method and the clinical outcome of syndesmotic injuries.

    The results of the study showed an overall poor quality of reduction of the syndesmosis and no significant difference between the 2D and 3D group. Unfortunately, both groups were operated upon in a different center, thus potentially introducing a bias of the operative technique used. As the authors mentioned, the only significant difference measured between the two groups – posterior fibular distance – could be attributed to a different position of the reduction clamp. In this light, it is relevant to determine how often the use of three-dimensional fluoroscopy actually led to a change in reduction and fixation. Other authors previously described a correction rate of up to 30% after the use of 3D-imaging (2,3). A baseline comparison of the two centers before the implementation of this new technique could potentially have shed light on its attribution.

    To accurately assess the added value of intra-operative three-dimensional imaging, there is a need for a sufficiently powered prospective randomized controlled clinical trial. We currently are conducting such a multicenter trial (EF3X-trial, Dutch Trial Register NTR 1902), randomizing 600 patients with wrist, ankle or calcaneal fractures between availability of intra-operative 3D-imaging or not (i.e. only 2D images available)(4). All included patients are subject to additional intra-operative 3D-imaging; in half of the patients the surgeon is blinded to these results. In both randomization groups a post-operative CT-scan is obtained to determine the quality of fracture reduction and fixation. During the follow-up visits the patient relevant outcomes are determined by joint specific, health economic and quality of life questionnaires, and X-ray’s are taken to assess posttraumatic osteoarthritis.

    This trial is currently in its last phase of including patients, and we look forward to sharing the results with the trauma community.

    1. Davidovitch, R. I. et al. Intraoperative Syndesmotic Reduction : J. Bone Jt. Surg. 95, 1838–1843 (2013).
    2. Von Recum, J., Wendl, K., Vock, B., Grützner, P. A. & Franke, J. [Intraoperative 3D C-arm imaging. State of the art]. Unfallchirurg 115, 196–201 (2012).
    3. Franke, J., von Recum, J., Wendl, K. & Grützner, P. a. [Intraoperative 3-dimensional imaging - beneficial or necessary?]. Unfallchirurg 116, 185–90 (2013).
    4. Beerekamp, M. S. H. et al. Fracture surgery of the extremities with the intra-operative use of 3D-RX: a randomized multicenter trial (EF3X-trial). BMC Musculoskelet. Disord. 12, 151 (2011).

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