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Oblique Trans-syndesmotic Screw to Augment Fixation of Distal Fibular Fractures: A Retrospective Cohort Study and Technique Guide
Lauren A. Foropoulos, MD
David R. Richardson, MD
University of Tennessee Health Science Center – Campbell Clinic Department of Orthopaedic Surgery and Biomedical Engineering, Memphis, Tennessee
ABSTRACT
This study was approved by the Institutional Review Board of the University of Tennessee Health Science Center (#22-09109-XP).
This research was presented at the MidAmerica Orthopaedic Association annual meeting on April 12, 2024 in Bonita Springs, Florida.
The incidence of ankle fractures has increased among elderly patients due to osteoporosis and increased activity levels. Open reduction and internal fixation (ORIF) is the standard treatment for displaced lateral malleolus fractures, though it poses challenges due to poor bone quality in this population, leading to complications such as implant failure and nonunion. We retrospectively reviewed 50 patients treated with an oblique trans-syndesmotic screw for transverse and short oblique fibular fractures between January 2011 and December 2022. This technique involved placing a screw from the distal fibula to the tibia in an oblique direction, either through a one-third tubular plate, outside the plate, or without a plate altogether. The procedure aimed to enhance fixation and prevent loss of reduction in osteoporotic bone while also offering a method to limit incision size in at-risk patients. The technique demonstrated effectiveness with satisfactory outcomes and minimal complications. Patients initiated weight-bearing at an average of 6.9 weeks postoperatively, with hardware removal occurring at approximately 4 months. The oblique trans-syndesmotic screw technique proved to be a valuable approach for distal fibular fracture fixation, especially in elderly patients, those with osteoporosis and neuropathy, and patients at risk of wound complications. This method facilitates outpatient procedures and enables quicker rehabilitation, addressing the unique challenges in these patient populations.
Level of Evidence: Level IV
Keywords: oblique trans-syndesmotic screw, ankle fractures, elderly patients, osteoporosis, internal fixation
HISTORICAL PERSPECTIVE:
Corresponding Author:
David R. Richardson, MD
1211 Union Avenue, Suite 510 Memphis, Tennessee 38104 drrichardson@campbellclinic.com
Ankle fractures are one of the most common orthopaedic injuries, with an incidence of 187 per 100,000 people per year.1 Malleolar fractures account for 9% of all adult fractures.2 In elderly individuals, these ankle injuries are the third most common fracture, following hip and wrist fractures. Studies have shown an increase in the incidence of ankle fractures in elderly patients likely due to the rising prevalence of osteoporosis,3 and the active lifestyle of today’s older adults.4 The treatment of choice for displaced lateral malleolus fractures is open reduction and internal fixa-
RESULTS:
This study evaluated the outcomes of distal oblique trans-syndesmotic screw placement for supplemental fixation in transverse, short oblique Danis-Weber B distal fibular fractures. We analyzed data on 50 patients who underwent operative ankle procedures between 2011 and 2022 to demonstrate appropriate indications and outcomes for this technique (Table 1).
The screw was placed under fluoroscopic guidance and typically removed after fracture union, similar to standard syndesmosis screws. Patients began weight-bearing at an average of 6.9 weeks postoperatively. This relatively short immobilization period for elderly patients helped minimize severe adverse complications associated with prolonged immobilization. The majority of patients underwent removal of the oblique-trans-syndesmotic screw along with any other syndesmotic screws, with an average time to removal of 125.2 days (approximately 4 months). This procedure was performed under light conscious sedation with local anesthetic. Postoperatively, patients were allowed to fully weight-bear in a walking boot until suture removal, which occurred 10-14 days after screw removal. Patients were then transitioned to a lace-up ankle brace and continued PT as needed.
POSSIBLE CONCERNS, FUTURE OF THE TECHNIQUE:
The senior author has employed this technique for many years. There has been only one case of implant failure and major complication: a patient with alcohol-induced neuropathy who fell while intoxicated, requiring conversion to a tibiotalocalcaneal (TTC) nail/ plate construct.
Several population-based studies have projected an increase in ankle fractures among elderly patients over the next several decades. Consequently, orthopaedic surgeons will continue to be challenged with the fixation of unstable osteoporotic ankle fractures.10 Restoration of the ankle mortise and return to preoperative level of function are the treatment goals of ankle fractures.10 Traditionally, unstable ankle fractures of the distal fibula have been managed using either lateral fibular plating with an interfragmentary lag screw or posterior lateral plating with an antiglide plate.10 While both techniques have provided adequate fixation for most distal fibular fractures, they have limitations in
Table 1: Study results.
Mechanism of injury - twisting injuries
Average time to full weight-bearing
Procedure to remove screws
Average time to hardware removal
Average duration of follow-up 182 days
specific cases. Particularly challenging are transverse or short oblique fibular fractures at or below the tibiotalar joint level, especially in patients with poor bone quality or those at increased risk of wound complications. To the best of our knowledge, no technique has been developed to adequately stabilize these specific fracture patterns in these high-risk patient groups.
Several biomechanical studies evaluating osteoporotic ankle-fracture fixation have demonstrated that locking plates provide a superior construct to non-locking plates in supination external rotation ankle fractures, when comparing peak torque to failure, angle at failure, and maximal torque.11-13 Combination locked plates have been found to be biomechanically superior to a standard one-third tubular plate in fixation of fibular fractures of osteoporotic patients.10 However, Dingemans et al. (2016) discovered that locked lateral plates do not offer biomechanical advantages over conventional lateral plates. Effectiveness of locked plating seems independent of bone mineral density, suggesting its suitability for stabilizing severe osteoporotic fractures.7
This study had a few limitations. It was retrospective and had the intrinsic flaws of that design method. Additionally, this study reflected a small cohort of patients having undergone internal fixation of ankle fractures with a particular component of transverse fibular
fractures close to the level of the tibiotalar joint. Due to the small sample size, this study may not be generalizable to the elderly population. Therefore, the results should be interpreted carefully. Finally, the mean follow-up time was less than 1 year.
In conclusion, placement of a distal oblique trans-syndesmotic screw is a simple and effective technique that can be used to supplement or replace current fibular fracture fixation constructs. Our study proved that
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this screw allows surgeons to treat ankle fractures even in patients with osteoporosis or increased risk of wound complications. The procedure can be done on an outpatient basis and utilized in lateral malleolus fractures, bimalleolar fractures, bimalleolar equivalent fractures, and trimalleolar fractures. Overall, this technique has produced good outcomes in our patients at a large urban tertiary referral center.
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