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TRANSCRIPT
1
Abstract 1
Background: Chronic syndesmotic injury may cause long-term pain and reduced ankle function. 2
Today, there is no consensus about the best surgical treatment of these injuries. We present the 3
technique and results of revision and fixation with a suture button and a quadricortical screw. 4
Methods: Eleven patients treated for chronic syndesmotic injury were included. The patients 5
completed questionnaires regarding ankle function, and computed tomography (CT) scans were 6
obtained to evaluate tibiofibular distance and osteoarthritis. Complications were registered. 7
Results: At mean 45 months follow-up, the mean American Orthopaedic Foot and Ankle Society 8
(AOFAS) ankle-hindfoot score was 87 points. There were 5 complications, including 3 hardware 9
related pain. The tibiofibular distance was significantly reduced with surgery. Seven patients had 10
progression of osteoarthritis. 11
Conclusions: Even though the majority of the patients had progression of radiological signs of 12
osteoarthritis, the functional outcome after revision and fixation with a suture button and a 13
quadricortical screw in chronic syndesmotic ruptures is good and comparable to the results 14
presented in other studies. 15
2
Key words 16
Chronic syndesmotic injury; Ankle sprain; Ankle fracture; Syndesmotic injury. 17
3
Level of evidence 18
Level 4, case series without control, technical note. 19
4
Text 20
Introduction 21
Injury to the distal tibiofibular syndesmosis is reported in 16-35% of the surgically treated ankle 22
fractures and 1-10% of the ankle sprains 1-4. The syndesmosis stabilizes the ankle joint during 23
weightbearing by maintaining the tibiofibular relationship. Simultaneously, it allows widening of the 24
mortise when ankle dorsiflexion to accommodate the increasing anterior width of the talar dome. 25
Unrecognized syndesmotic injury, malreduction of the fibula, hardware failure, or premature 26
removal of hardware may cause persistent widening of the syndesmosis 5. This may result in long-27
term instability, pain and reduced ankle function 6,7. Operative treatment is necessary to restore 28
stability and a well aligned ankle joint, and prevent the development of osteoarthritis 6,8. 29
Chronic syndesmotic injury has been defined as syndesmotic injury presenting more than 3 months 30
after trauma 9-11. At this time, significant fibrous tissue may be present, and reduction of the 31
syndesmosis necessitates thorough debridement 5,9,12. Several surgical methods for syndesmotic 32
stabilization are described in the literature, including suture button or screw fixation, anatomical 33
ligamentous reconstruction and arthrodesis 13-23. Today, no consensus regarding the best surgical 34
strategy for these injuries exists. 35
The aim of the study was to evaluate the surgical technique and results of revision and 36
transsyndesmotic fixation with a suture button and a quadricortical screw. 37
38
Methods 39
Twelve patients treated for chronic syndesmotic injury between January 2011 and January 2017 40
were identified by searching the surgical procedure according to Nomesco classification of surgical 41
procedures (NOMESCO, NCSP) in the electronic medical record system DIPS (DIPS AS, Bodø, Norway). 42
Chronic syndesmotic injury was defined as syndesmotic injury diagnosed more than 3 months after 43
5
initial trauma. All patients signed an informed consent, but 1 was excluded as he did not meet for 44
follow-up. Eleven patients were included in the study. 45
Preoperative patient characteristics, including initial injury, treatment and radiographic presentation, 46
are presented in Table 1. There were 5 men and 6 women. Six injuries involved the left ankle. Eight 47
patients had sustained an ankle fracture and 3 patients an ankle sprain. The patients presented at 48
the orthopedic outpatient clinic mainly because of persistent pain. The pain was most prominent at 49
weightbearing or during activities. Additionally, some of the patients had recurrent swelling, 50
stiffness, snapping on movement, or a subjective feeling of instability. The clinical examination 51
revealed varying degrees of pain when palpation of the anterior inferior tibiofibular ligament (AITFL), 52
and most of the patients had positive external rotation stress test or anterior impingement test. Plain 53
radiographs, computed tomography (CT) scans and / or magnetic resonance imaging (MRI) confirmed 54
the diagnosis and demonstrated increased distal tibiofibular distance or signs of syndesmotic 55
rupture. 56
The patients were treated with revision of the syndesmosis followed by syndesmotic fixation with a 57
suture button and a quadricortical screw. This was done in general anesthesia, in supine position and 58
with bloodless surgery. Revision was performed arthroscopically or open. Arthroscopic revision 59
included an anterolateral and anteromedial portal as described by van Dijk et al. 24. The tibiofibular 60
and ankle joint were explored and the extent of syndesmotic injury, fibrous tissue and degenerative 61
changes was identified. A shaver was used to resect all hypertrophic fibrous tissue. Loose bone and 62
cartilage fragments were also resected. Open revision was performed with a lateral approach to the 63
lateral malleolus, exposing the AITFL and the ankle joint (Figure 1). The revision of the syndesmosis 64
allowed for reduction of the distal fibula in the fibular notch. The syndesmosis was reduced manually 65
or with the use of a clamp under visual and / or fluoroscopic guidance (Figure 2a and 2b). 66
Transsyndesmotic fixation was done with a suture button (TightRope; Arthrex, Naples, FL) and a 3.5 67
mm or 4.5 mm quadricortical screw (Synthes, West Chester, PA) (Figure 3). The transsyndesmotic 68
6
fixation was done open in all patients. All patients had postoperative radiographs (Figure 4). The 69
quadricortical screw was removed in local anesthesia 12 weeks postoperatively. Full weightbearing 70
was allowed after 6 weeks. 71
All patients had a minimum of 12 months postoperative follow-up. Primary outcome measure was 72
American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score 25 which devotes 40 73
points to pain, 50 points to function and 10 points to alignment. A total of 100 points is the best 74
result. Other functional outcome measures included the Foot and Ankle Ability Measure (FAAM) 75
Activities of Daily Living (ADL) 26, Manchester-Oxford Foot Questionnaire (MOxFQ) 27, Olerud-76
Molander Ankle (OMA) score 28, and Visual Analogue Scale (VAS) scores for pain during rest, walking, 77
and night. FAAM ADL is reported as a percentage score between 0 and 100 where a higher score 78
represents a higher level of physical function. The MOxFQ comprises the dimensions walking / 79
standing, pain and social interaction, and the total score is reported as a score between 0 and 100 80
where 100 being the most severe. The OMA score is a functional rating scale from 0 to 100 points 81
where 100 points being the best score. Complications were also registered. 82
CT scans were obtained preoperative and at follow-up. The CT scans were examined by a radiologist 83
and 2 orthopedic surgeons. The tibiofibular distance was measured on axial scans, 1 cm proximal to 84
the midpoint of the tibial plafond, at 3 standardized landmarks (Figure 5) 29-31. The measurements 85
were compared to the preoperative CT scans. The extent of ankle osteoarthritis was classified 86
according to the Kellgren and Lawrence grading scale (Table 2) 32. 87
The Statistical Package for Social Science (SPSS) software, version 25 (SPSS Inc, Chicago, IL, USA), was 88
used for statistical analyzes. Normally distributed data are presented as means and standard 89
deviations. Median values with full data range are presented when the data are non-normally 90
distributed. Paired samples T-test was used to analyze changes in means over time. Median values 91
were compared with Mann-Whitney U test. The Spearman’s Rank Order Correlation is a 92
7
nonparametric measure of correlation, and was used to analyze the relationship between continuous 93
data. The level of significance was set at p ≤0.05. 94
95
Results 96
At the time of syndesmotic reconstruction, the mean age was 37±18 years. The mean interval from 97
ankle injury to syndesmotic reconstruction was 28±16 months, and the mean time from syndesmotic 98
reconstruction to follow-up was 45±22 months. Table 3 demonstrates the surgical procedures and 99
postoperative complications. Additional procedures were executed when indicated. In two patients, 100
the plate and screws from the initial surgery were removed to achieve reduction. Malunion of 101
previous fibular fracture required osteotomy with plate and screw fixation in two patients. Deltoid 102
ligament reconstruction was performed in one patient. 103
The level of the transsyndesmotic fixation was measured on postoperative radiographs. The suture 104
buttons were placed median 1.43 (1.02-3.95) cm and the quadricortical screws median 2.77 (1.98-105
4.09) cm proximal to the tibial plafond. In 2 patients the suture button was placed proximal to the 106
screw. 107
The functional results at follow-up are presented in table 4. Eight patients presented with good or 108
excellent AOFAS score, defined as 80 points and more 25. Median VAS pain score was 1.0 (0-5.0) 109
during rest, 1.5 (0-5.0) during walking, and 0 (0-5.0) at night. No significant difference in functional 110
result was found when comparing the patients that had sustained an ankle fracture or an ankle 111
sprain (Table 5). All patients would recommend the surgery to others with the same injury. 112
Five patients experienced complications. Three patients had pain related to the hardware after 113
removal of the quadricortical screw, where 1 had removal of all metal, 1 had removal of the suture 114
button, and 1 were planned for removal of the suture button. They had a significant lower functional 115
outcome score at follow-up (Table 5). One patient had a postoperative infection and 1 had an 116
8
infection after removal of the quadricortical screw. After successful treatment, both these patients 117
scored high. 118
The tibiofibular distance was measured on all CT scans at follow-up and compared to the 119
preoperative CT scans. The difference in the anterior and central distances was significantly reduced 120
with surgery, with a mean difference of 2.4±2.1 mm (p=0.004) and 1.5±1.5 mm (p=0.010) 121
respectively. The mean difference in the posterior distance was increased with 0.1±2.3 mm, but this 122
was not significant. 123
Based on the Kellgren and Lawrence grading scale, progression of osteoarthritis on follow-up 124
compared to preoperative CT scans was evident in 7 patients. The grades of osteoarthritis are 125
presented in table 6. Neither the difference in tibiofibular distance nor the grade of osteoarthritis at 126
follow-up was significantly associated to functional outcome (table 7). 127
128
Discussion 129
Diagnosing and treating chronic syndesmotic injuries may be challenging. Undiagnosed injuries may 130
result in delayed treatment and development of degenerative soft tissue and osteoarthritis 5,6,8. The 131
goal of treatment is improvement of ankle function and absence of pain. The patients in the present 132
study reported a high functional outcome. 133
At mean 4 years follow-up, we found a mean AOFAS score of 87±11 points. This is in consistency with 134
previous studies on chronic syndesmotic injuries, reporting an AOFAS score of 83-95 13-16,19,21-23,33. 135
Ryan et al. 23 reported outcomes in 19 patients treated with arthroscopic debridement and 136
stabilization with 2 or 3 suture buttons after a minimum of 24 months follow-up. They found an 137
AOFAS score of 83±26 points. Similarly, Han et al. 33 and Harper et al. 13reported an AOFAS score of 138
87 and 91 points respectively after transcortical screw fixation with or without debridement of the 139
syndesmosis. A mean score of 91.6 in the general population has previously been reported 34. The 140
9
score is not validated and has been criticized for not being important for the patient outcome, but 141
has still been the most frequently used score in foot and ankle injuries 35. The FAAM ADL, MOxFQ and 142
OMA score have to our knowledge not previously been reported in studies addressing chronic 143
syndesmotic injuries. However, the FAAM ADL of 87±15 points in our study was acceptable 144
compared to the normative value of mean 92±12 points in 271 people >18 years old 36. The OMA 145
score demonstrated a high outcome compared to 3 years after surgical treatment for unstable ankle 146
fracture, respectively 79±19 and 76±24 points 37. Contrary to this, the mean MOxFQ for the 147
dimensions walking / standing, pain and social interaction in our study was 30±28, 30±20 and 19±18 148
points. The respective scores reported in 671 patients 9 months after foot and ankle surgery were 149
19±23, 19±19 and 13±18 points 38. 150
In our study, the patients with hardware related pain had the worst functional outcome at follow-up. 151
Totally, 5 of the 11 patients experienced a complication. Compared to previous studies reporting a 152
complication rate between 0% and 20% 13-23,33,39, this rate is high. In the study by Olson et al. 21 153
including 10 patients treated with distal tibiofibular arthrodesis and plate fixation, 2 of the patients 154
had pain from the metal that needed removal, where 1 patient also needed arthroscopic 155
debridement due to persistent pain. After transsyndesmotic screw fixation, Harper et al. 13 reported 156
1 patient with early screw loosening, and Schuberth et al. 14 reported 1 patient with tibiofibular 157
synostosis. In the study by Colcuc et al. 22, there were 2 cases with suture granuloma around the 158
suture button, and also Ryan et al. 23 reported 2 patients with pain from the suture button which 159
required removal. In our study, 3 patients had removal of metal due to pain. The definition of 160
complications varies greatly between studies which could explain the lower rate reported in previous 161
studies. 162
The CT scans at follow-up demonstrated a reduced anterior and central tibiofibular distance 163
compared to the preoperative CT scans. This is consistent with a successful reduction. Other 164
techniques have also presented with better postoperative reduction and good functional outcomes. 165
10
Schuberth et al. 14 compared pre- and postoperative plain radiographs after debridement and 2 or 3 166
transsyndesmotic screws in 6 patients. The mean change in total clear space was 4.4 mm, in total 167
fibular overlapping was 4.4 mm, and in medial clear space was 3.2 mm, indicating improvement in 168
ankle reduction. They also reported a significant increase in AOFAS score of 32 points at minimum 24 169
months follow-up. Similarly, Grass et al. 17 found improved reduction on plain radiographs after 170
peroneus longus ligamentoplasty and decreased tibiofibular distance measured centrally on axial CT 171
scan. The Karlsson score, where 100 points is the best, was 88 points at mean 16 months follow -up. 172
Previous studies addressing acute syndesmotic injuries have reported a significant effect of 173
tibiofibular distance on functional outcome 1,40-42. The small numbers in the present study prevents 174
any significant correlation between the tibiofibular distance and functional outcome. Still, a better 175
reduction suggests a high level of ankle function. 176
The correlation between the adequacy of the syndesmotic reduction and osteoarthritis after 4 years 177
was presented already in 1984 by Leeds and Ehrlich 6. Olson et al. 21 found no progression of 178
osteoarthritis after distal tibiofibular arthrodesis in 10 patients at mean 41 months follow-up. The 179
mean interval between the initial injury and the salvage procedure in their study was 9 (2-20) 180
months. Based on the Kellgren and Lawrence grading scale, progression of osteoarthritis was evident 181
in 7 patients after syndesmotic reconstruction in our study. Even though minor, the progression 182
might be related to latency of revision surgery, as the mean interval from injury to reconstruction 183
was 28±16 months. Also, the grade of osteoarthritis at follow-up was not correlated to functional 184
outcome. As the Kellgren and Lawrence grading scale is widely used, it was utilized despite being 185
based on radiographic assessment and not being ankle specific 32,43. 186
In previous studies, chronic syndesmotic injuries have been treated using different surgical methods, 187
and promising results are reported. A systematic review by Parlamas et al. 44 did not find support for 188
recommending one surgical method in the literature. They reported a pooled success rate of 87.9% 189
after screw fixation, 79.4% after arthrodesis and 78.7% after arthroscopic debridement. Lubberts et 190
11
al. 11 presented a systematic review including isolated syndesmotic injuries only. Also, they report 191
satisfactory results in all included studies, independent of surgical method used. The total 192
complication rate in their study was 10%. Transsyndesmotic fixation is the most frequent method, 193
but there is no consensus about type or number of devices today. 194
To our knowledge, no previous study has reported the surgical technique or results of revision and 195
fixation with a suture button and a quadricortical screw. Initial revision of the syndesmosis with 196
resection of interposed fibrous tissue is necessary to allow for reduction of the distal fibula in the 197
fibular notch 5,12. An arthroscopic approach is thought to be preferable because of less extensive 198
dissection and reduced risk of injury to the vascular supply of the bones 14,45. In the present study, all 199
patients were finally treated with open fixation of the syndesmosis and the advantages of an 200
arthroscopic approach on the soft tissues is not investigated. Additionally, arthroscopy allows for 201
revision of the medial clear space and removal of osteochondral defects and synovitis in the ankle 202
joint 9,10,14,46. Directly positioning of the fibula in the fibular notch necessitates an open approach. The 203
“self-centering effect” of the dynamic suture button allows for anatomic reduction of the fibula, and 204
a quadricortical screw adds additional securing of the fixation. A knotless suture button should be 205
preferred because of the otherwise risk of pain from the suture knot. 206
There are several limitations in our study. Firstly, there is a huge heterogenicity in our patient 207
material, including all patients with chronic syndesmotic injury regardless of type of injury. Secondly, 208
the type of treatment was not standardized, utilizing both arthroscopic and open revision and 3.5 209
mm and 4.5 mm screw. Also, some patients had concomitant procedures. Thirdly, our sample size is 210
small, and the low incidence of this injury prevents high quality studies. Multicenter studies should 211
be preferred in the future. 212
Strengths of the study are the long-term follow-up and the use of CT scans. CT scans taken both 213
preoperative and at follow-up were available for analyses. Additionally, bilateral CT scans should be 214
12
obtained at follow-up for comparison between the injured and non-injured ankle as significant 215
anatomic variations of the syndesmosis are reported 47,48. 216
217
Conclusion 218
The patients in this study were treated with revision and transsyndesmotic fixation with a suture 219
button and a quadricortical screw. We found a high functional outcome score which is comparable 220
with previous studies, even though the radiological signs of osteoarthritis increased in the majority of 221
the patients. Hardware related pain was the most frequently observed complication. We suggest that 222
the presented surgical method is a good alternative for treating chronic syndesmotic injuries. 223
224
Author Contribution Statement 225
All authors were fully involved in the study and preparation of the manuscript. 226
13
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335
Tables 336
18
Table 1. Patient characteristics including initial injury, treatment and radiographic presentation.
Patient
Initial ankle
fracture Primary treatment
Syndesmotic
screw removal
Secondary
treatment
Plain
radiographs CT scan MRI
1
No fracture Arthroscopic revision x4 . . Partial syndesmotic rupture
2 Unimalleolar Cast . . Malunion with syndesmotic
incongruence
3
Unimalleolar Cast . . Calcification of the syndesmosis Syndesmotic rupture
4 Trimalleolar ORIF, syndesmotic screw fixation Yes . Increased distal tibiofibular
distance
5 Unimalleolar ORIF, syndesmotic screw fixation Yes . Increased MCS Increased distal tibiofibular
distance
6 Unimalleolar ORIF, syndesmotic screw fixation Yes . Increased MCS
7 Trimalleolar ORIF (no syndesmotic screw fixation) . . Increased distal tibiofibular
distance
8 Unimalleolar ORIF, syndesmotic screw fixation Yes Arthroscopic
revision x2
Increased distal tibiofibular
distance
9 No fracture Walker . . Partial rupture of AITFL
10 Trimalleolar External fixation . . Increased distal tibiofibular
distance
11 No fracture Arthroscopic revision . . Partial rupture of AITFL
The initial ankle injury with primary and secondary treatment, before the diagnosis of chronic syndesmotic injury. Radiographic presentation, including plain radiographs, CT scan and MRI,
which confirmed the diagnosis of chronic syndesmotic injury.
Abbreviations: CT = Computed tomography. MRI = Magnetic resonance imaging. ORIF = Open Reduction Internal Fixation. MCS = Medial clear space. AITFL = Anterior inferior tibiofibular
ligament.
337
19
338
Table 2. The Kellgren and Lawrence grading scale for osteoarthritis.
Grade Description
None No features
Doubtful Doubtful joint space narrowing, possible osteophytic lipping
Minimal Definite osteophytes, possible narrowing of joint space
Moderate Moderate multiple osteophytes, definite narrowing of joint
space, some sclerosis, possible deformity of bone ends
Severe Large osteophytes, marked narrowing of joint space, severe
sclerosis and definite deformity of bone ends
The grading of osteoarthritis as classifies according to Kellgren and Lawrence [32].
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Table 3: Surgical procedures and postoperative complications.
Patient Syndesmotic reconstruction
Additional
procedures
Syndesmotic
screw removal Complications
Treatment of
complications
1 Open revision and fixation,
4.5 mm screw and suture button Yes
2 Open revision and fixation,
4.5 mm screw and suture button Fibulaosteotomy Yes Pain from metal
Removal of
metal
3 Open revision and fixation,
4.5 mm screw and suture button Yes
Postoperative
infection
Revision, VAC
and antibiotics
4 Arthroscopic revision, open fixation,
4.5 mm screw and suture button Yes
5 Arthroscopic revision, open fixation,
4.5 mm screw and suture button
Removal of plate
and screws Yes Pain from metal
Removal of
suture knot
6 Arthroscopic revision, open fixation,
4.5 mm screw and suture button
Removal of plate
and screws Yes
7 Arthroscopic revision, open fixation,
4.5 mm screw and suture button
Deltoid ligament
reconstruction Yes
8 Arthroscopic revision, open fixation,
4.5 mm screw and suture button Yes
9 Open revision and fixation,
3.5 mm screw and suture button Yes Pain from metal
Planned
removal of
suture button
10 Arthroscopic revision, open fixation,
4.5 mm screw and suture button Fibulaosteotomy Yes
Infection after
syndesmotic
screw removal
Antibiotics
11 Open revision and fixation,
4.5 mm screw and suture button Yes
The surgical procedures including syndesmotic reconstruction, additional procedures, and syndesmotic screw removal.
Postoperative complications and treatment.
Abbreviations: VAC = Vacuum assisted closure.
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Table 4: Functional results at follow-up.
Mean SD Min. Max.
Respondents
(total n = 11)
AOFAS score 87 11 63 100 11
- Pain score 31 7 20 40
- Function score 46 4 38 50
- Alignment score 10 2 5 10
FAAM ADL 87 15 57 100 9
MOxFQ 27 22 0 67 10
- Walking / standing domain 30 28 0 82
- Pain domain 30 20 0 60
- Social interaction domain 19 18 0 50
OMA score 79 19 35 100 10
Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-hindfoot score.
FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living. MOxFQ = Manchester-Oxford
Foot Questionnaire. OMA score = Olerud-Molander Ankle score. SD = Standard deviation.
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Table 5: Left: Functional outcome for patients that had sustained an ankle fracture or an
ankle sprain. Right: Functional outcome for patients that experienced pain related to
the hardware and not.
Injury
P-value
Pain from hardware
P-value Fracture Sprain Yes No
AOFAS score 87 87 0.757 78 88 0.013
FAAM ADL 92 87 0.362 63 93 0.039
MOxFQ 25 30 0.819 55 13 0.029
OMA score 85 75 0.491 58 85 0.189
The scores are presented as median values. Mann-Whitney U test was used to test
differences between the groups. P-value ≤ 0.05 is significant.
Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-
hindfoot score. FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living.
MOxFQ = Manchester-Oxford Foot Questionnaire. OMA score = Olerud-Molander Ankle
score.
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Table 6: Grades of osteoarthritis preoperative and at follow-up.
Preoperative Follow-up
Patient 1 None None
Patient 2 Doubtful Doubtful
Patient 3 Minimal Minimal
Patient 4 Doubtful Moderate
Patient 5 Minimal Moderate
Patient 6 Doubtful Minimal
Patient 7 Doubtful Minimal
Patient 8 None Doubtful
Patient 9 None None
Patient 10 Moderate Severe
Patient 11 None Minimal
Osteoarthritis is graded according to the Kellgren and Lawrence
grading scale (33).
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Table 7: Left: Correlation between reduction in anterior, central and posterior tibiofibular distance
and outcome. Right: Correlation between grade of osteoarthritis at follow-up and outcome.
Difference in tibiofibular distance Osteoarthritis at
follow-up Anterior Central Posterior
rs p-value rs p-value rs p-value rs p-value
AOFAS 0.234 0.488 0.326 0.327 0.120 0.726 -0.071 0.835
FAAM ADL -0.076 0.847 0.151 0.698 -0.034 0.932 0.150 0.700
MOxFQ 0.043 0.907 0.018 0.960 0.195 0.589 -0.047 0.896
OMAS 0.207 0.565 0.000 1.000 -0.098 0.789 0.478 0.162
Spearmans’s Rank-Order Correlation was used for the analyses. The numbers demonstrate the
correlation coefficients (rs) and the subsequent p-values. P-value ≤ 0.05 is significant.
Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-hindfoot score.
FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living. MOxFQ = Manchester-Oxford
Foot Questionnaire. OMA score = Olerud-Molander Ankle score.
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Figures 345
Figure 1 346
347
348
Figure 2a 349
350
26
351
Figure 2b 352
353
354
Figure 3 355
356
357
27
Figure 4 358
359
360
Figure 5 361
362
363
28
Legends 364
Figure 1. A direct lateral approach was used to access the AITFL and the ankle joint for open revision. 365
The figure demonstrates a normal right ankle with intact AITFL. 366
Figure 2a and 2b. After revision, the syndesmosis was reduced manually or with a clamp. The figures 367
demonstrate the joint after arthroscopically revision and the tibiofibular distance before (a) and after 368
reduction (b) syndesmotic reduction. 369
Figure 3. The peroperative fluoroscopy demonstrates the fixation of the syndesmosis in a reduced 370
position with a suture button and a 4.5 mm quadricortical screw. 371
Figure 4. The postoperative radiograph displays the surgical technique including syndesmotic fixation 372
with a suture button and a quadricortical screw. 373
Figure 5. The bilateral axial CT scan demonstrates the postoperative measurement of the tibiofibular 374
distance of the right ankle (left). The distance was measured on axial scans, 1 cm proximal to the 375
midpoint of the tibial plafond, at 3 standardized landmarks; representing anterior, central and 376
posterior distances. 377