Analysis of the Stress and Displacement Distribution of Inferior Tibiofibular Syndesmosis Injuries Repaired with Screw Fixation: A Finite Element Study

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Abstract

Background

Studies of syndesmosis injuries have concentrated on cadaver models. However, they are unable to obtain exact data regarding the stress and displacement distribution of various tissues, and it is difficult to compare models. We investigated the biomechanical effects of inferior tibiofibular syndesmosis injuries (ITSIs) and screw fixation on the ankle using the finite element (FE) method.

Methodology/Principal Findings

A three-dimensional model of a healthy ankle complex was developed using computed tomography (CT) images. We established models of an ITSI and of screw fixation at the plane 2.5 cm above and parallel to the tibiotalar joint surface of the injured syndesmosis. Simulated loads were applied under three conditions: neutral position with single-foot standing and internal and external rotation of the ankle. ITSI reduced contact forces between the talus and fibula, helped periarticular ankle ligaments withstand more load-resisting movement, and increased the magnitude of displacement at the lower extreme of the tibia and fibula. ITSI fixation with a syndesmotic screw reduced contact forces in all joints, decreased the magnitude of displacement at the lower extreme of the tibia and fibula, and increased crural interosseous membrane stress.

Conclusions/significance

Severe syndesmosis injuries cause stress and displacement distribution of the ankle to change multidirectional ankle instability and should be treated by internal fixation. Though the transverse syndesmotic screw effectively stabilizes syndesmotic diastasis, it also changes stress distribution around the ankle and decreases the joint's range of motion (ROM). Therefore, fixation should not be performed for a long period of time because it is not physiologically suitable for the ankle joint.

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Most cited references 30

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Persistent disability associated with ankle sprains: a prospective examination of an athletic population.

Charles Scoville, D. Taylor, Jason G. Williams … (1998)

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.

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Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction.

Rose Galvin, Irum Awan, John Cunningham … (2012)

Ankle syndesmotic injuries are complex and require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint and prevent long-term complications. The aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using TightRope versus syndesmotic screw fixation. Cohort study; Level of evidence, 2. This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial computed tomography (CT) scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. A greater than 2-mm widening of syndesmosis compared with the untreated contralateral ankle was considered significant malreduction. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores. Forty-six of 55 eligible patients participated in the study; 23 patients were in the TightRope group and 23 in the syndesmotic screw group. The average age was 42 years in the TightRope and 40 years in the syndesmotic screw group, and the mean follow-up time was 2.5 years (range, 1.5-3.5 years). The average width of normal syndesmosis was 4.03 ± 0.89 mm. In the TightRope group, the mean width of syndesmosis was 4.37 mm (SD, ±1.12 mm) (P = .30, t test) compared with 5.16 mm (SD, ±1.92 mm) in the syndesmotic screw group (P = .01, t test). Five of 23 ankles (21.7%) in the syndesmotic screw group had syndesmotic malreduction, whereas none of the TightRope group showed malreduction on CT scans (P = .04, Fisher exact test). Average time to full weightbearing was 8 weeks in the TightRope group and 9.1 weeks in the syndesmotic screw group. There was no significant difference between the TightRope and syndesmotic screw groups in mean postoperative AOFAS score (89.56 and 86.52, respectively) or FADI score (82.42 and 81.22, respectively). Regression analysis confirmed malreduction of syndesmosis as the only independent variable that affected the clinical outcome (regression coefficient, -12.39; t = -2.43; P = .02). The results of this study indicate that fixation with TightRope provides a more accurate method of syndesmotic stabilization compared with screw fixation. Syndesmotic malreduction is the most important independent predictor of clinical outcomes; therefore, care should be taken to reduce the syndesmosis accurately.

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Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention.

Amanda Gross, Feng-Ying C Lin, Paul S Weinhold (2006)

Syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. The purpose of this clinical commentary is to review the mechanisms of syndesmotic injuries, clinical examination methods, diagnosis, and management of the injuries. Cadaveric studies of the syndesmosis and deltoid ligaments are also reviewed for further understanding of stress transmission and the roles of different structures in stabilizing the distal syndesmosis. External rotation and excessive dorsiflexion of the foot on the leg have been reported as the most common mechanisms of injury. The injury is most often incurred by individuals who participate in skiing, football, soccer, and other sport activities played on turf. The external rotation and squeeze tests are reliable tests to detect this injury. The ability of imaging studies to assist in an accurate diagnosis may depend on the severity of the injury. The results of cadaveric studies indicate the importance of the deltoid ligament in maintaining stability of the distal tibiofibular syndesmosis and the congruency of the ankle mortise. Intervention programs with early rigid immobilization and pain relief strategies, followed by strengthening and balance training are recommended. Heel lift and posterior splint intervention can be used to avoid separation of the distal syndesmosis induced by excessive dorsiflexion of the ankle joint. Application of a rigid external device should be used with caution to prevent medial-lateral compression of the leg superior to the ankle mortise, thereby inducing separation of the distal syndesmosis articulation. Surgical intervention is an option when a complete tear of the syndesmotic ligaments is present or when fractures are observed.

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Author and article information

Contributors

Carlos M. Isales: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2013

Publication date (Electronic): 3 December 2013

Volume: 8

Issue: 12

Electronic Location Identifier: e80236

Affiliations

[1 ]Department of Orthopaedic Trauma, Hong-Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, China

[2 ]Department of Orthopaedic Trauma, Nanfang Hospital, Southern Medical University, Guangzhou, China

[3 ]Xijing Hospital, The Fourth Military Medical University, Xi'an, China

Georgia Regents University, United States of America

Author notes

* E-mail: smu-liuqh@ 123456163.com (ZL); yubinol@ 123456163.com (BY)

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: QHL BY GXP. Performed the experiments: QHL BY KZ. Analyzed the data: QHL ZL YZ KZ. Contributed reagents/materials/analysis tools: GXP. Wrote the paper: QHL BY.

Article

Publisher ID: PONE-D-13-19856

DOI: 10.1371/journal.pone.0080236

PMC ID: 3848989

PubMed ID: 24312464

SO-VID: 3e47eba5-5bf7-44d1-a864-5134f5d59126

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 10 May 2013

Date accepted : 1 October 2013

Page count

Pages: 13

Funding

This work was supported by the Natural Science Foundation of China (No. 81071233)( http://www.nsfc.gov.cn/Portal0/default152.htm) and the Shaanxi Province Science Technology Research and Development Projects (No. 2011K12-05-13)( http://www.sninfo.gov.cn:8083/xzzx.jsp). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Analysis of the Stress and Displacement Distribution of Inferior Tibiofibular Syndesmosis Injuries Repaired with Screw Fixation: A Finite Element Study

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Abstract

Background

Methodology/Principal Findings

Conclusions/significance

Related collections

PLOS Climate

Most cited references 30

Persistent disability associated with ankle sprains: a prospective examination of an athletic population.

Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction.

Ankle syndesmosis injuries: anatomy, biomechanics, mechanism of injury, and clinical guidelines for diagnosis and intervention.

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Cited by 6

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