title: Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: A prospective and comparative study.
abstract: OBJECTIVE
  Syndesmosis injury is common in external-rotation type ankle fractures (ERAF). Trans-syndesmosis screw fixation, the gold-standard treatment, is currently controversial for its complications and biomechanical disadvantages. The purpose of this study was to introduce a new method of anatomically repairing the anterior-inferior tibiofibular ligament (AITFL) and augmentation with anchor rope system to treat the syndesmotic instability in ERAF with posterior malleolus involvement and to compare its clinical outcomes with that of trans-syndesmosis screw fixation.
  
  
  METHODS
  53 ERAFs with posterior malleolus involvement received surgery, and the syndesmosis was still unstable after fracture fixation. They were randomised into screw fixation group and AITFL anatomical repair with augmentation group. Reduction quality, syndesmosis diastasis recurrence, pain (VAS score), time back to work, Olerud-Molander ankle score and range of motion (ROM) of ankle were investigated.
  
  
  RESULTS
  Olerud-Molander score in AITFL repair group and screw group was 90.4 and 85.8 at 12-month follow-up (P>0.05). Plantar flexion was 31.2° and 34.3° in repair and screw groups (P=0.04). Mal-reduction happened in 5 cases (19.2%) in screw group while 2 cases (7.4%) in repair group. Postoperative syndesmosis re-diastasis occurred in 3 cases in screw group while zero in repair group (P>0.05). Pain score was similar between the two groups (P>0.05). Overall complication rate and back to work time were 26.9% and 3.7% (P=0.04), 7.15 months and 5.26 months (P=0.02) in screw group and repair group, respectively.
  
  
  CONCLUSIONS
  For syndesmotic instability in ERAF with posterior malleolus involvement, the method of AITFL anatomical repair and augmentation with anchor rope system had an equivalent functional outcome and reduction, earlier rehabilitation and less complication compared with screw fixation. It can be selected as an alternative.
authors.affiliation: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
authors.forename: Yu
authors.initials: Y
authors.lastname: Zhan
authors.affiliation: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China. Electronic address: xyyan@sjtu.edu.cn.
authors.forename: Xiaoyu
authors.initials: X
authors.lastname: Yan
authors.affiliation: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
authors.forename: Ronggang
authors.initials: R
authors.lastname: Xia
authors.affiliation: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Cheng
authors.affiliation: Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.
authors.forename: Congfeng
authors.initials: C
authors.lastname: Luo
mesh_terms: D000328:Adult; D000368:Aged; D064386:Ankle Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D001863:Bone Screws; D002681:China; D005260:Female; D005360:Fibula / Q000000981:diagnostic imaging* / Q000601:surgery; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal; D006801:Humans; D007593:Joint Instability; D008022:Ligaments / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016059:Range of Motion, Articular; D013977:Tibia / Q000000981:diagnostic imaging* / Q000601:surgery; D016896:Treatment Outcome; D055815:Young Adult
keywords: Ankle injuries; Ankle joint; Bone fractures; Internal fixation; Syndesmotic injuries; Tibiofibular syndesmosis