Влијание на времетраењето, репозицијата и нивото на фиксацијата на синдезмозата на скочниот зглоб врз функционалниот исход кај малеоларните фрактури

Abstract

Malleolar fractures with ankle syndesmosis disruption are common injuries whose incidence will continue to increase in the future. Dillemas surrounding these injuries include the timing of positioning screw removal, the level of the lag screw placement and the syndesmotic reduction; all of them being subjected to individual practice and expert opinions. The research focused on this subject still represents small series using various treatment protocols and different outcome measures. The aim of the presented research is to evaluate the effect of the duration and level of syndesmotic fixation as well as the quality of reduction of the syndesmosis on the functional outcome in malleolar fractures with ankle syndesmotic disruption. The prospective research in a period of 2.5 years was conducted at the University clinic of Traumatology – Skopje. Follow up period was 6 months. Inclusion and exclusion criteria were defined; the operative treatment and rehabilitation were conducted in accordance with the Institution protocol. The groups of the patients were definded with regard to the duration od the syndesmotic fixation, level of the lag-screw placement and the quality of syndesmotic reduction as measured by antero-posterior tibiofibular ratio. Functional outcome was measured with The American Orthopedic Foot and Ankle Society Ankle Hindfoot Score and The Olerud Molander Score. The statistical analysis was undertaken by means of desctiptive and nonparametrical methods, and statistically significant were considered p<0.05 values. The study included total of 68 patients with a nonsignificant male predominance (57.35%) and the mean age of 48 years (range 20-72). Comorbidities were noted in 80.9% of the study group and the cardiovascular diseases were predominant. The average Body Mass index of the study group was 22.69 kg/m2. Trimalleolar fracture was present in 54.41%; according to AO classification, type B fracture was present in 44 (67.71%) examinees, the others has type C fracture. The average American Orthopedic Foot and Ankle Society Ankle Hindfoot Score was 85.73 points while average Olerud Molander score was 93.97 points. With regard to the duration of the syndesmotic fixation, the groups with intact, removed and broken screw were formed, with 36 (52.94%), 20(29.41%) and 12 (17.65%) examinees respectively and with American Orthopedic Foot and Ankle Society Ankle Hindfoot Score of 85.42, 85.75 and 86.67 points (p=0.29); the average Olerud Molander Score was 84.25, 79.72 and 96.25 points respectively (p=0.000026). With regard to the level of syndesmotic screw placement the examinees were stratified into following gropus: below 2cm, 2-4cm and above 4 cm (9, 33 and 26 examinees respectively) and demonstrated the scores of 86.19, 87.22 and 84.97 American Orthopedic Foot and Ankle Society Ankle Hindfoot Score points (p=0.82), and 84.04, 84.44 and 83.79 points (p=0.99) of Olerud Molander Score, respectively. Based on the quality of sundesmotic reduction, the examinees were divided into anatomical and nonanatomical group, each counting 51 (75%) and 17 (25%) examinees respectively, with an average 90.11 and 70.18 points of American Orthopedic Foot and Ankle Society Ankle Hindfoot Score respectively; Olerud Molander score was 88.92 and 69.71 points for anatomical and nonanatomical group respectively, with p value below 0.0001 for both scores. In conclusion, the results of the present study demonstrated that the duration and level of the syndesmotic fixation has no effect on the functional outcome; however, the patients with removed screw have the lowest subjective score as measured by Olerud Molander system 6 months post injury. Anatomical reduction resulted in a significantly better outcome. These results do not spport the routine positioning srew removal and do emphasise the importance of the anatomical reduction of the syndesmosis.