Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway.
Steadman Philippon Research Institute, Vail, Colorado, USA.
Am J Sports Med. 2023 Mar;51(4):997-1006. doi: 10.1177/03635465231151448. Epub 2023 Feb 13.
Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs.
To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF.
Controlled laboratory study.
Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system.
With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs.
Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially.
Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%.
在伴有后踝骨折（PMF）的情况下，使用缝线纽扣（SB）进行经联合固定、使用螺钉进行后踝固定以及使用缝线带（ST）进行前下胫腓韧带（AITFL）增强，这些方法都被认为是潜在的治疗方法。然而，对于 PMF 的最佳治疗方法尚未达成共识。
确定（1）经联合 SBs、（2）后踝螺钉和（3）使用 ST 进行 AITFL 增强这三种方法的最佳组合，以恢复 25%和 50% PMF 后胫腓骨和踝关节的正常运动学。
对照实验室研究。
将 20 个尸体小腿标本分为 2 组（25%或 50% PMF），并使用 6 自由度机器人臂在 7 种状态下进行生物力学测试：完整、PMF 伴联合损伤、经联合 SBs、经联合 SBs+AITFL 增强、经联合 SBs+AITFL 增强+后踝螺钉、后踝螺钉+AITFL 增强和后踝螺钉。在中立位和 30°跖屈位下进行 4 项生物力学测试：外旋、内旋、后抽屉和外侧抽屉。使用 5 相机运动捕捉系统记录胫骨、腓骨和距骨的位置。
在外旋时，带 AITFL 增强的后踝螺钉可使腓骨和踝关节获得最佳稳定性。在内旋时，所有包含后踝螺钉的修复均使腓骨和踝关节稳定。后抽屉和外侧抽屉在完整和损伤状态之间仅产生较小的差异。在 25%和 50% PMF 之间，治疗效果没有差异。
与经联合 SBs 相比，后踝螺钉可获得更高的联合稳定性。当与后踝螺钉结合使用时，AITFL 增强可提供额外的外旋稳定性。经联合 SBs 并不能提供任何额外的稳定性，反而容易使腓骨向内侧移位。
在治疗伴有不稳定联合和≥25% PMF 的急性踝关节损伤的患者时，使用 ST 进行后踝固定和 AITFL 增强可能是首选的手术方法。
