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European Journal of Trauma and Emergency Surgery

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Open Access 01-08-2021 | Digital Volume Tomography | Original Article

Validation of radiological reduction criteria with intraoperative cone beam CT in unstable syndesmotic injuries

Authors: Sven Yves Vetter, Jeannie Euler, Nils Beisemann, Benedict Swartman, Holger Keil, Paul Alfred Grützner, Jochen Franke

Published in: European Journal of Trauma and Emergency Surgery | Issue 4/2021

Abstract

Purpose

Acute unstable syndesmotic lesions are regularly treated with closed or open reduction and fixation with either a positioning screw or tight rope. Conventional fluoroscopy is limited to identify a malreduction of the ankle mortise. The aim of the study was to validate the reduction criteria of intraoperative cone beam CT in unstable syndesmotic injuries by analyzing the clinical outcome.

Methods

Acute unstable syndesmotic injuries were treated with a positioning screw fixation, and the reduction in the ankle mortise was evaluated with intraoperative cone beam CT. The patients were grouped postoperatively according to the radiological reduction criteria in the intraoperative 3D images. The reduction criteria were unknown to the surgeons. Malreduction was assumed if one or more reduction criteria were not fulfilled.

Results

Seventy-three of the 127 patients could be included in the study (follow-up rate 57.5%). For 41 patients (56.2%), a radiological optimal reduction was achieved (Group 1), and in 32 patients (43.8%) a radiological adverse reduction was found (Group 2). Group 1 scored significantly higher in the Olerud/Molander score (92.44 ± 10.73 vs. 65.47 ± 28.77) (p = 0.003), revealed a significantly higher range of motion (ROM) (53.44 vs. 24.17°) (p = 0.001) and a significantly reduced Kellgren/Lawrence osteoarthritis score (1.24 vs. 1.79) (p = 0.029). The linear regression analysis revealed a correlation for the two groups with the values scored in the Olerud/Molander score (p < 0.01).

Conclusion

The reduction criteria in intraoperative cone beam CT applied to unstable syndesmotic injuries could be validated. Patients with an anatomic reduced acute unstable syndesmotic injury according to the criteria have a significantly better clinical outcome.

Frank M, Bauwens K, Ekkernkamp A. Fractures of the upper ankle. Orthopade. 2009;38:981–94. https://doi.org/10.1007/s00132-009-1497-4(quiz 995–986).CrossRefPubMed

Rammelt S, Grass R, Zwipp H. Ankle fractures. Unfallchirurg. 2008;111:421–37. https://doi.org/10.1007/s00113-008-1460-6(quiz 438).CrossRefPubMed

Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58:356–7.CrossRef

Tunturi T, Kemppainen K, Patiala H, et al. Importance of anatomical reduction for subjective recovery after ankle fracture. Acta Orthop Scand. 1983;54:641–7.CrossRef

Peterson KS, Chapman WD, Hyer CF, et al. Maintenance of reduction with suture button fixation devices for ankle syndesmosis repair. Foot Ankle Int. 2015;36:679–84. https://doi.org/10.1177/1071100715571631.CrossRefPubMed

Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma. 2013;27:196–200. https://doi.org/10.1097/BOT.0b013e3182694766.CrossRefPubMed

Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227–34.CrossRef

Ebraheim NA, Lu J, Yang H, et al. The fibular incisure of the tibia on CT scan: a cadaver study. Foot Ankle Int. 1998;19:318–21.CrossRef

Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27:788–92.CrossRef

10.

Miller AN, Barei DP, Iaquinto JM, et al. Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma. 2013;27:100–6. https://doi.org/10.1097/BOT.0b013e31825197cb.CrossRef

11.

Pneumaticos SG, Noble PC, Chatziioannou SN, et al. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 2002;23:107–11. https://doi.org/10.1177/107110070202300205.CrossRefPubMed

12.

Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin. 2009;14:277–98. https://doi.org/10.1016/j.fcl.2009.03.003.CrossRef

13.

Franke J, von Recum J, Suda AJ, et al. Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Joint Surg Am. 2012;94:1386–90. https://doi.org/10.2106/JBJS.K.01122.CrossRefPubMed

14.

Vetter SY, Euler F, von Recum J, et al. Impact of intraoperative cone beam computed tomography on reduction quality and implant position in treatment of tibial plafond fractures. Foot Ankle Int. 2016;37:977–82. https://doi.org/10.1177/1071100716650532.CrossRefPubMed

15.

Heim U. Oberes sprunggelenk. Unfallheilkunde. 1983;86:248–58.PubMed

16.

Prior CP, Widnall JC, Rehman AK, et al. A simplified, validated protocol for measuring fibular reduction on ankle CT. Foot Ankle Surg. 2017;23:53–6. https://doi.org/10.1016/j.fas.2016.02.005.CrossRefPubMed

17.

Vetter SY, Gassauer M, Uhlmann L, et al. A standardised computed tomography measurement method for distal fibular rotation. Eur J Trauma Emerg Surg. 2019. https://doi.org/10.1007/s00068-019-01120-6.CrossRefPubMed

18.

Bartonicek J, Rammelt S, Kasper S, et al. Pathoanatomy of maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg. 2019;139:497–506. https://doi.org/10.1007/s00402-018-3099-2.CrossRefPubMed

19.

Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin. 2008;13:611–33. https://doi.org/10.1016/j.fcl.2008.08.001.CrossRefPubMed

20.

Tornetta P, Spoo JE, Reynolds FA, et al. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg Am. 2001;83-A:489–92.CrossRef

21.

Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10:156–60.CrossRef

22.

Harper MC. An anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 1993;14:455–8.CrossRef

23.

Chen Y, Qiang M, Zhang K, et al. A reliable radiographic measurement for evaluation of normal distal tibiofibular syndesmosis: a multi-detector computed tomography study in adults. J Foot Ankle Res. 2015;8:32. https://doi.org/10.1186/s13047-015-0093-6.CrossRefPubMedPubMedCentral

24.

Elgafy H, Semaan HB, Blessinger B, et al. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol. 2010;39:559–64. https://doi.org/10.1007/s00256-009-0809-4.CrossRefPubMed

25.

Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26:439–43. https://doi.org/10.1097/BOT.0b013e31822a526a.CrossRefPubMed

26.

Wikeroy AK, Hoiness PR, Andreassen GS, et al. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. 2010;24:17–23. https://doi.org/10.1097/BOT.0b013e3181bedca1.CrossRefPubMed

27.

Vasarhelyi A, Lubitz J, Gierer P, et al. Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int. 2006;27:1115–21. https://doi.org/10.1177/107110070602701219.CrossRefPubMed

28.

Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. J Bone Joint Surg Br. 1995;77:435–8.CrossRef

29.

Ebraheim NA, Lu J, Yang H, et al. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997;18:693–8.CrossRef

30.

Sora MC, Strobl B, Staykov D, et al. Evaluation of the ankle syndesmosis: a plastination slices study. Clin Anat. 2004;17:513–7. https://doi.org/10.1002/ca.20019.CrossRefPubMed

31.

Grunz JP, Kunz AS, Gietzen CH, et al. 3D cone-beam CT of the ankle using a novel twin robotic X-ray system: assessment of image quality and radiation dose. Eur J Radiol. 2019;119:108659. https://doi.org/10.1016/j.ejrad.2019.108659.CrossRefPubMed

32.

Lawlor MC, Kluczynski MA, Marzo JM. Weight-bearing cone-beam CT scan assessment of stability of supination external rotation ankle fractures in a cadaver model. Foot Ankle Int. 2018;39:850–7. https://doi.org/10.1177/1071100718761035.CrossRefPubMed

33.

Privalov M, Euler F, Keil H, et al. Influence of reduction quality on functional outcome and quality of life in treatment of tibial plafond fractures: a retrospective cohort study. BMC Musculoskelet Disord. 2019;20:534. https://doi.org/10.1186/s12891-019-2932-2.CrossRefPubMedPubMedCentral

34.

Vetter SY, Privalov M, Beisemann N, et al. Influence of ankle joint position on angles and distances of the ankle mortise using intraoperative cone beam CT: a cadaveric study. PLoS One. 2019;14:e0217737. https://doi.org/10.1371/journal.pone.0217737.CrossRefPubMedPubMedCentral

Title: Validation of radiological reduction criteria with intraoperative cone beam CT in unstable syndesmotic injuries
Authors: Sven Yves Vetter
Jeannie Euler
Nils Beisemann
Benedict Swartman
Holger Keil
Paul Alfred Grützner
Jochen Franke
Publication date: 01-08-2021
Publisher: Springer Berlin Heidelberg
Keywords: Digital Volume Tomography
Digital Volume Tomography
Published in: European Journal of Trauma and Emergency Surgery / Issue 4/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01299-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Validation of radiological reduction criteria with intraoperative cone beam CT in unstable syndesmotic injuries

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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