Rev. bras. ortop. vol.52 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Supination-external

rotation

ankle

fractures:

analysis

of

clinical

results

after

syndesmotic

screw

removal

夽

João

Mendonc¸a

de

Lima

Heck,

Rosalino

Guareschi

Junior,

Luiz

Carlos

Almeida

da

Silva

∗

_,

Marcelo

Teodoro

Ezequiel

Guerra

HospitalUniversitáriodeCanoas,Servic¸odeOrtopediaeTraumatologia,GrupodePéeTornozelo,Canoas,RS,Brazil

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Articlehistory:

Received19September2016 Accepted6October2016 Availableonline19October2017

Keywords: Anklefractures

Fractureinternalfixation Ankleinjuries

Orthopedicsurgery

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b

s

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Objective:Toevaluatethepostoperativeresultsofpatientswithsupination-externalrotation anklefractureswhounderwentsyndesmoticscrew(SS)removal.

Methods:Retrospectivecohortstudyassessingthelatepostoperativeresultsof35patients operatedfromJanuary2013toJune2015.Patientsundergoingtreatmentofruptureofthe distaltibiofibularsyndesmosiswithSSfixationandwhodidnothaveanyconcomitant surgicalinjuriesinsitesotherthantheanklewereincluded.Patientswhodidnotcomplete appropriatefollow-upaftersurgerywereexcludedfromthestudy.

Results:Therewasnostatisticalsignificantdifferenceintheevaluatedoutcomesamongthe patientswhohadtheirSSremovedandthosewhoremainedwiththeSS.

Conclusion:SSremovaldidnotsignificantlyaltertheclinicalresultsofpatientssurgically treatedwithSSforsupination-externalrotationfractures.

Fraturas

do

tipo

supinac¸ão-rotac¸ão

externa:

análise

dos

resultados

clínicos

da

retirada

do

parafuso

transindesmoidal

Palavras-chave: Fraturasdotornozelo Fixac¸ãointernadefraturas Traumatismosdotornozelo Cirurgiaortopédica

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e

s

u

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o

Objetivo:Avaliaroresultadopós-operatóriodospacientescomfraturadotornozelo pelo mecanismodesupinac¸ão-rotac¸ãoexternaqueforamsubmetidosaretiradadoparafuso transindesmoidal(PT).

Métodos:Estudodecoorteretrospectivoqueavaliouosresultadospós-operatóriostardios de35pacientesoperadosentrejaneirode2013ejunhode2015.Foramincluídospacientes submetidosaotratamentodarupturadasindesmosetibiofibulardistalcomfixac¸ãocom

夽

StudyconductedattheHospitalUniversitáriodeCanoas,Servic¸odeOrtopediaeTraumatologia,GrupodePéeTornozelo,Canoas,RS, Brazil.

∗ _{Corresponding}_author.

E-mail:luizcarlosmedicina@gmail.com(L.C.Silva).

http://dx.doi.org/10.1016/j.rboe.2017.10.008

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PTequenãoapresentavamlesõescirúrgicasconcomitantesemoutrossítiosquenãoo tornozelo.Pacientesquenãoforamdevidamenteacompanhadosnopós-operatórioforam excluídos.

Resultados:Nãohouvediferenc¸aestatisticamentesignificativanosdesfechosavaliadosentre ospacientesquetiveramoPTremovidoeosquepermaneceramcomoPT.

Conclusão: AretiradadoPTnãoalterousignificativamenteoresultadoclínicodospacientes tratadoscirurgicamentecomPTporfraturasdotiposupinac¸ão-rotac¸ãoexterna.

Introduction

Anklefracturescanrangefromnon-displacedandavulsion fracturestocomplexfractures,whichrequirereductionand surgicalfixation;thiscanberealizedbydifferentmethods.1

Rotationallesionsarethemostfrequent,andcanbe clas-sifiedaccordingtotheLauge-Hansenclassification;themost common subgroup is fractures caused by the supination-externalrotationmechanism(SER).2_This_type_of_fracture_is

subdivided into four stages: stage I, lesion of the anterior syndesmosis(anteriortibiofibular ligament)(SER1);stageII, obliquelateralmalleolusfracturewithfracturelinedirection fromanteroinferiortoposterosuperior(SER2);stageIII,lesion ofthe posteriortibiofibularligament orposteriormalleolus fracture(SER3);andstageIV,medialmalleolusfractureor del-toidligamentinjury(SER4).3

Whenananklefractureoccurswithsyndesmoticdiastasis (SD),severalmethodscanbeusedforsurgicalrepair,including syndesmosisfixationwithsyndesmoticscrews(SS).4–6

How-ever,noneofthefixationmethodshaveshowntobesuperior toothers.SS,despitebeingthemostcommonlyusedmethod, alsopresentsfailuresfromboththeclinicaland biomechani-calstandpoints.Oneofthedrawbacksofthisfixationmethod isthatSSremovalisoftennecessary,whichcanleadto addi-tionalcomplications.7,8

Thisstudyisaimedatevaluatingthepostoperativeresults ofpatientswithanklefracturesbytheSERmechanismthat underwentsyndesmoticscrewremoval(SSR).

Material

and

methods

Thisisaretrospectivecohortstudy,whichassessedthelate postoperativeresultsof35patientsoperatedbetweenJanuary 2013andJune2015.ThisstudywasapprovedbytheResearch Ethics CommitteeunderregistrationNo. 117817/2014/CAAE 40153914.4.0000.5328.

Theinclusioncriteriaconsistedofpatientswhounderwent surgicaltreatment byopen reduction and internalfixation of unilateral closed ankle fractures with SER-type trauma mechanism, without other associated fractures, who had undergone preoperative examinations without a cast with bilateralankleradiographywithanteroposterior,mortiseand lateralviews,andwhosignedtheInformedConsentForm.

Exclusioncriteriawere asfollows:patients submittedto conservative treatment of the fracture for reasons unique tothe patientor becausetherewas nosurgicalindication;

associatedfractures;lackofadequateskincondition,edema, and phlyctena in the lateral region of the foot, without resolution until the moment of surgery; ankle fractures by mechanisms other than the SER type; lack of clinical conditionsduetovasculardisorders,cardiopathies,or decom-pensateddiabetes;severetraumaticbraininjury;psychosocial issues; heavy smoking; refusal to undergo surgical treat-ment;bilateralfractures;fixationofthesyndesmosiswithtwo screws,removaloftheone-thirdtubularplateorotherfixation materialorbothinassociationwithSSR;spontaneous break-ingoftheSS;andrefusaltosigntheInformedConsentForm. Duringthisperiod,92feetof75patientsweresubmitted tothesamesurgicaltreatmentforanklefracture with syn-desmoticlesion.Allpatientswerecalledinforreassessment; 35 patientsunderwent surgicaltreatmentwithSS,met the inclusioncriteria,andwereincludedinthestudy.

Allpatientswereassessedbythesamesurgeonwho per-formedthesurgery.TheAmericanOrthopedicFootandAnkle Society(AOFAS),GlobalSocialFunctioningScale(GSFS),visual analog(VAS),andMedicalOutcomesStudy36(SF-36)scales wereused.9

Clinically,the followingaspectswere analyzed:rangeof motion(ROM)oftheankleinflexionandextension,returnto normalactivities,calfdiameter,anklewidth,physicaltherapy duringpostoperativerecovery,andcomorbidities.The Lauge-Hansenclassificationwasusedtocategorizethefractures.2

Likewise,allpatientsunderwentlatepostoperative analy-siswithbilateralankleradiographswithmonopodalsupport inlateralandanteroposteriorviews,andanteroposteriorview with15◦_of_internal_rotation.

Thesamplewasdividedintotwogroups,accordingtothe needforSSR.GroupIwascomposedofpatientswhoremained withSS.GroupIIincludedpatientswhounderwentSSR. Indi-cationforSSRwasbasedonthepatient’scomplaintsregarding irritationattheSSfixationsite.

InthesurgicalprocedurefortheinsertionofaSS,patients underwentspinalanesthesia,andwerethenpositionedina dorsalrecumbentposition,withacushionunderthe sacroil-iac region,ipsilateral tothe fracture, and withthe kneeat approximately30◦_–45◦_of_flexion,_held_by_a_medical_assistant. Preoperatively2gofintravenouscephalothinwere adminis-tered.Thereafter,trichotomyandantisepsiswereperformed withalcoholicchlorhexidine,andsterilesheetswereplaced. ThelimbwassubjectedtovenousdrainagewithanEsmarch bandage,followedbytheapplicationofatourniquetonthe proximalportionofthethigh.Surgerybeganwiththefibula, throughaposterolateralapproach,10_from_the_distal_end_of_the

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theplacementofthechosenplate,preservingtheintegrityof thefibulartendonsheathandavoidingextensivedetachment oftheperiosteumandligaments.Subsequently,byamedial approachtothe ankle,10 _the_medial_malleolus_was_reached

fordefinitivetreatmentofboneand/orligamentinvolvement, whenpresent.Theselectedplate wasalwaysthatofsmall fragments(AO one-thirdtubularplate) appliedonthe pos-terolateralaspectofthefibula,oftheshortestpossiblesize; therelationshipwiththefibulartendonsinthedistalportion ofthefibulawasobservedandinterfragmentarycompression wasperformedbyusingacompressionscrew.11

In order to assess the integrity ofthe syndesmosis, an intraoperativecottontestwasperformedbyholdingthefibula withaBackhaustowelclamp,followedbylateraltraction.The stresstestwasconsideredpositivewhenalateral displace-mentgreaterthan3or4mmwasobserved;inthesecases,the syndesmosiswasfixed12 _through_the_insertion_of_a_cortical

screw.Orthogonallytotheplate,thescrewisinsertedfrom thefibulatothetibia,withfixationofbothfibularcorticesand onetibialcortex, paralleltothe jointsurface,2–5cmabove itandangled atabout30◦ _anteriorly,_whenever_possible,_as allowedbythefractureline.

When a deltoid ligament rupture was observed, it was repairedwithabsorbablesurgicalsutures.Themedial malle-olus fracture was reduced and then fixed with a cortical screwforsmallfragments(3.5mm)associatedwitha1.5-mm Kirschnerwirebyusingthetensionbandtechniqueorbyusing twoparallel4-mmcancellousscrews,accordingtothesizeof thefragment.Aftersutureinlayers,thelimbwasimmobilized inacastandkeptelevated.

Patientswere discharged on theday aftersurgery, after radiographyinanteroposteriorandlateralviewsofthe oper-atedankle,withacast;patientsreceivedrecommendationsto keeptheirfootelevated,aswellastousetwocrutchesanda closeddressing.Inthefirstpostoperativeweek,thecastwas removed,adressingwasdone,andanewcastwasmadeat90◦_. Inthesecondpostoperativeweek,thestitcheswereremoved, anorthopedicwalkingbootwasprescribed,andphysical ther-apywasinitiated.Sixthweekspostoperatively,anewcontrol radiographwasperformed,andweight-bearingwaspermitted accordingtotolerance.Atthreemonths,incaseofirritative symptomsoftheSS,SSRwasperformed.Inthesixth post-operativemonth,patientsweredischargedfrom outpatient follow-up.

Thequantitative variables were described as mean and standarddeviations;categoricalvariablesweredescribed as single(n)andrelative(%)frequencies.TheShapiro–Wilktest wasusedtoassessthenormalityofdistribution.Toassessthe meandifferencebetweenthetypesofmaterial,thet-testfor independentsamplesortheMann–Whitneytestwereused. Toverify theexistenceofanassociationbetweenthetypes ofmaterialandcategoricalvariables,Fisher’sexacttestwas used.Thesignificancelevelwassetat5%.Thestatistical anal-yseswereperformedwithSPSSversion18.0.

Results

Thepatients wereevaluatedclinicallyandradiographically, andfractureconsolidationwasobservedinallpatientsaround

Table1–Demographicandclinicalcharacteristicsofthe sample.

Variable Removalofthescrew pa

No Yes

Operatedside 1.000

Right 10 67% 5 33%

Left 14 70% 6 30%

Gender 0.721

Male 9 64% 5 36%

Female 15 71% 6 29%

Lauge-Hansenclassification 0.174

SER2 2 67% 1 33%

SER3 12 86% 2 14%

SER4 10 56% 8 44%

Returntoactivities 1.000

No 6 67% 3 33%

Yes 18 69% 8 31%

Comorbidities 0.689

No 18 72% 7 28%

Yes 6 60% 4 40%

Physicaltherapy 0.652

No 4 57% 3 43%

Yes 20 71% 8 29%

Datapresentedasnand%.

a _p_-Value_for_Fisher’s_exact_test.

thesixthpostoperativeweek.Regardinggender,14weremale and21female;fivemale(36%)andsixfemale(29%)patients underwentSSR(Table1).

Regardingthetypeoftrauma,fivepatientshadtraffic acci-dents, onebyautomobileand four bymotorcycleaccident; ninesufferedsportsinjuries,ofwhomsixwerecausedby soc-cerplayingandthreebyskating;eighthadfallsfromaheight, onebyafallfromahorse,onebyafallfromastaircase,andsix byfallsfromtheirownheight;and13sufferedanklesprains. Amongthosewho underwentSSR,twohad suffereda soc-cerinjury,onewasinvolvedinamotorcycleaccident,three sufferedanklesprain,andthreefromfalls.

Regarding the operated side, 15 underwent right ankle surgery,fiveofwhom(33%)underwentSSR;20underwentleft anklesurgery,sixofwhom(30%)underwentSSR(Table1).

Inthepresentsample,threepatientsunderwentSER2-type trauma,andSSRwasperformedinone(33%);14sufferedSER3, andSSRwasperformedintwo(14%);and18sufferedSER4, and SSRwasperformedineight(44%).Intheevaluationof thereturntothelevelofactivitypriortosurgery,26patients (74%)returned tonormalactivities. Tenpatients (28%)had comorbidities,ofwhomfour(40%)underwentSSR.

Regarding physicaltherapy, seven(28%)didnotundergo physicaltherapy;ofthese,three(43%)underwentSSRandone (9%)presentedsuperficialinfection,whichwasmanagedwith surgicaldebridementandantibiotictherapy.

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Table2–Resultsofthegroupsinrelationtoage, physicalexaminationmeasurements,andclinical evaluationscales.

Removalofthescrew pa

No(n=24) Yes(n=11)

Mean SD Mean SD

Age 50.0 14.12 37.2 17.53 0.051

Differenceincalfdiameter 1.4 0.96 1.3 1.37 0.573 Differenceinanklewidth 0.5 0.31 0.6 0.46 0.552 Ankleextension 12.7 4.73 13.8 5.08 0.374 Ankleflexion 25.5 6.26 24.5 7.03 0.701 VASscale 2.0 1.53 2.3 1.90 0.699 AOFASscale 90.3 7.92 87.7 9.01 0.340 GSFSscale 1.5 0.88 1.6 1.03 0.532 PFSF36Norm-basedscalescores 52.9 3.68 54.6 2.44 0.201 RPSF36Norm-basedscalescores 46.8 6.79 48.5 7.36 0.497 BPSF36Norm-basedscalescores 54.5 4.25 56.4 2.16 0.090 GHSF36Norm-basedscalescores 55.4 6.75 57.1 5.72 0.466 VTSF36Norm-basedscalescores 61.9 5.37 65.0 3.68 0.092 SFSF36Norm-basedscalescores 47.4 8.00 46.3 8.76 0.743 RESF36Norm-basedscalescores 46.1 7.78 48.6 7.08 0.375 MH SF36Norm-basedscalescores 58.3 5.95 60.2 2.49 0.780 PCS SF36Summaryscores 50.4 4.87 52.1 4.01 0.387 MCSSF36Summaryscores 54.0 5.68 55.5 4.90 0.540

Datapresentedasmeanandstandarddeviation(SD).

a _p_-Value_for_the_{Mann–Whitney}_test.

inclinicaloutcomesbetweenthegroupsubmittedtoSSRin comparisontothegroupthatremainedwiththeSS.

Discussion

Thisstudyevaluatedthepostoperativeoutcomeofpatients submittedtoSSRwhencomparedwiththegroupofpatients whoremainedwithSS.Severalstudieswarnedagainst rou-tineimplantremovalafterfracturehealing,5,6,13,14_and_SSR_is

associatedwithpotentiallyhighcomplicationrates. Further-more,itcannotbepredictedwhetherremovalwillresultin functionalimprovement.15,16

Another argumentagainst routinescrewremoval isthe large amount of resources needed (operating room and time) and economic costs involved (regarding, for exam-ple, secondary surgery, surgery time, and treatment of complications).5,17

Severalauthorshavereportedthephenomenonof recur-rentSDafterSSR;in2011,Hsuetal.4_reported_a_DS_recurrence

of15%.4,18–20 _In_the_present_series,_no_cases_of_SD_after_SSR

wereobserved.

Inthepresent series, theprimary complaintofpatients fortheindicationofSSRwaslocalirritationsymptoms pro-ducedbySSlocatedinthesubcutaneouslayer.Nodifference betweenthecomplaintswasobservedafterSSR;thisfinding isinagreementwithSchepersetal.5_and_Boyle_et_al.,21_who

demonstratedthatthereisnostatisticaladvantageinSSR. Among patients who underwent SSR, the most posi-tiveeffectsobservedwereanklemobilityimprovementand painreductionindailyactivities. Despitethe improvement reportedbythesepatients,nostatisticallysignificant differ-encewasobservedbetweenthetwogroups.Thus,itcanbe

deductedthatinthegroupofpatientswhounderwentSSR, thereissomebiasinfavoroftheprocedure,incasesinwhich thepatienthim/herselfoptedforSSR.7,21

The time indicated for the SSR varies in the literature between threeand sixmonths.18,19 _At_this _medical_center,

SSRswereperformedatthreemonths,withnoserious out-comesinthepresentseries.

In recentliterature,differentclinical assessment instru-ments have been used to evaluate clinical outcomes in patientswithanklefractures.Generally,theAOFASscale,VAS, SF-36,GSFS,andphysicalexaminationoftheankleROMare used.TheOlerudandMolander22_scores_have_also_been_used

incurrentliterature.21,23_However,_this_score_was_not_included

inthepresentstudy;inturn,theAOFASscorewaspreferred,as itallowsanassociatedobjectiveandsubjectiveevaluation.In thepresentstudy,theresultsofthedifferentinstrumentsused werestatisticallysimilarbetweenthetwogroupsanalyzed.

Themainlimitationofthepresentstudyisitsretrospective natureandthesmallsample,duetothefactthatourhospital attendstohighlycomplexpatients,manywithmultiple frac-tures,whichwerenotincludedintheanalysis.Furthermore, inthepresentstudy,theuseofprophylacticantibioticsduring SSRwasnotincludedintheanalysisbecause,atthetimeof surgery,itwasnotaroutinepracticeatthishospitaltouse prophylacticantibioticsinthistypeofsurgery.

Conclusion

SSRdoesnotsignificantlyaltertheclinicaloutcomeofpatients surgicallytreatedwithSSduetoSER-typefractures.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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