Syndesmosis Stabilisation: Screws Versus Flexible Fixation.

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Abstract

[Indexed for MEDLINE] 9. Injury. 2024 Jun;55(6):111537. doi: 10.1016/j.injury.2024.111537. Epub 2024 Apr 6. Historic indications for fixation of posterior malleolus fractures- where did they come from and where are we now? Hunt AA(1), Maschhoff C(2), Van Rysselberghe N(3), Gonzalez CA(4), Goodnough H(3), Gardner M(3), Bishop JA(3). Author information: (1)Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA. Electronic address: aahunt@stanford.edu. (2)University of Illinois at Chicago School of Medicine, Chicago, IL USA. (3)Stanford University, Department of Orthopedic Surgery, 300 Pasteur Drive, Edwards Bldg, R144, Stanford, CA USA. (4)University of Reno, Nevada School of Medicine, Reno, NV USA. INTRODUCTION: The indications for reduction and fixation of the posterior malleolus component of rotational ankle fractures have been controversial for nearly a century. This study aims to identify the historical basis for surgical intervention and trace trends in management strategies over time. METHODS: In March 2023, a systematic review of full-text, English-language articles providing indications for surgical fixation of the posterior malleolus component of rotational ankle fractures was performed. Articles underwent title and abstract screening before undergoing full-text review. RESULTS: Historical indications for surgical fixation were size-dependent, with fractures comprising 25 % to 33 % of the plafond recommended for internal fixation. Modern studies suggest that nonoperative management of posterior malleolus fractures below this threshold results in residual malreduction of the articular surface, syndesmotic instability, and an increased need for independent fixation of the syndesmosis. CONCLUSIONS: Size-based indications for posterior malleolus fracture fixation are based on Level V evidence from small retrospective case series published nearly one century ago and should be retired. While the size of the posterior malleolus component cannot be ignored, additional factors like fracture morphology and location within the plafond should guide modern surgical indications. Contemporary studies indicate that reduction and fixation of small posterior malleolus fractures (comprising less than 25 % of the articular surface) are associated with improved articular reductions, tibiotalar contact pressures, syndesmotic stability with decreased need for independent fixation of the syndesmosis, and superior postoperative outcomes. Copyright © 2024 Elsevier Ltd. All rights reserved. DOI: 10.1016/j.injury.2024.111537