Ayak Bilek Kırıklarında Postoperatif Sindesmoz Malredüksiyonları
Özet
Ayak bileği kırıklarında postoperatif sindesmoz malredüksiyonları, karmaşık anatomi ve intraoperatif değerlendirme zorlukları nedeniyle cerrahi sonrası sıkça karşılaşılan ve fonksiyonel sonuçları olumsuz etkileyen önemli bir problemdir. Distal tibio-fibular eklemdeki 2 mm'lik minimal bir uyum kaybı dahi eklem biyomekaniğini bozarak travma sonrası artrit riskini belirgin şekilde artırmaktadır. Malredüksiyonların saptanmasında iki boyutlu direk radyografiler minimal deplasmanları, fibula rotasyonunu ve lateral translasyonu tespit etmede yetersiz kalırken; bilgisayarlı tomografi (BT) bu dizilim bozukluklarının belirlenmesinde altın standart kabul edilmektedir. Hatalı anatomik yerleşim; redüksiyon klempinin veya sindesmoz vidasının yanlış konumlandırılması, aşırı kompresyon uygulanması ve hastanın anatomik insisura morfolojisi gibi faktörlerden kaynaklanmaktadır. Cerrahide malredüksiyon oranlarını düşürmek amacıyla eklemin direkt gözle görülerek açık redükte edilmesi ya da intraoperatif BT kullanımı gibi yöntemler uygulansa da BT'de saptanan dizilim bozuklukları tamamen önlenememektedir. Cerrahi stabilizasyonda geleneksel rijit vidaların yanı sıra, mikro harekete izin veren ve rutin çıkarılma gerektirmeyen esnek sütür-düğme implantları da malredüksiyon oranlarını azaltmada başarılı bir alternatif sunmaktadır.
Postoperative syndesmosis malreductions in ankle fractures are a common problem that adversely affects functional outcomes due to complex anatomy and difficulties in intraoperative evaluation. Even a minimal 2 mm loss of alignment in the distal tibiofibular joint disrupts joint biomechanics and significantly increases the risk of post-traumatic arthritis. While two-dimensional direct radiographs are insufficient in detecting minimal displacements, fibular rotation, and lateral translation during the detection of malreductions, computed tomography (CT) is accepted as the gold standard for determining these misalignments. Faulty anatomical placement stems from factors such as the incorrect positioning of the reduction clamp or syndesmotic screw, application of excessive compression, and the patient's specific anatomical incisura morphology. Although methods like open reduction under direct visualization or intraoperative CT utilization are applied to decrease malreduction rates in surgery, misalignments detected on CT cannot be completely prevented. In surgical stabilization, along with traditional rigid screws, flexible suture-button implants, which allow micro-motion and do not require routine removal, also offer a successful alternative in reducing malreduction rates.
Referanslar
Gardner MJ, Demetrakopoulos D, Briggs SM, et al. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot and Ankle International. 2006;27(10):788-792. doi:10.1177/107110070602701005
Schon JM, Brady AW, Krob JJ, et al. Defining the three most responsive and specific CT measurements of ankle syndesmotic malreduction. Knee Surgery Sports Traumatology Arthroscopy. 2019;27(9):2863-2876. doi:10.1007/s00167-019-05457-8
Boszczyk A, Kwapisz S, Krümmel M, et al. Correlation of Incisura Anatomy With Syndesmotic Malreduction. Foot and Ankle International. 2018;39(3):369-375. doi:10.1177/1071100717744332
Cherney SM, Spraggs-Hughes AG, McAndrew CM, et al. Incisura Morphology as a Risk Factor for Syndesmotic Malreduction. Foot and Ankle International. 2016;37(7):748-754. doi:10.1177/1071100716637709
Cosgrove CT, Putnam SM, Cherney SM, et al. Medial Clamp Tine Positioning Affects Ankle Syndesmosis Malreduction. Journal Orthopaedic Trauma. 2017;31(8):440-446. doi: 10.1097/BOT.0000000000000882.
Ebraheim NA, Taser F, Shafiq Q, et al. Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments. Surgical and Radiologic Anatomy. 2006;28(2):142-149. doi:10.1007/s00276-006-0077-0
Dattani R, Patnaik S, Kantak A, et al. Injuries to the tibiofibular syndesmosis. Journal of Bone and Joint Surgery Br. 2008;90(4):405-410. doi:10.1302/0301-620X.90B4.19750
Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surgical and Radiologic Anatomy. 2003;25(5-6):379-386. doi:10.1007/s00276-003-0156-4
Bai L, Zhou W, Cheng Z, et al. A Radiological Study for Assessing Syndesmosis Malreduction: Its Validity and Limitation. The Journal of Foot and Ankle Surgery. 2020;59(6): 1181-1185. doi:10.1053/j.jfas.2020.04.014
Stenquist DS, Kwon JY. Strategies to Avoid Syndesmosis Malreduction in Ankle Fractures. Foot and Ankle Clinics. 2020;25(4):613-630. doi:10.1016/j.fcl.2020.08.001
Tartaglione JP, Rosenbaum AJ, Abousayed M, et al. Classifications in Brief: Lauge-Hansen Classification of Ankle Fractures. Clinical Orthopaedics Related Research. 2015;473(10):3323-3328. doi: 10.1007/s11999-015-4306-x.
Marmor M, Hansen E, Han HK, et al. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot and Ankle International. 2011;32(6):616-622. doi:10.3113/FAI.2011.0616
Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. Journal of Orthopaedic Trauma. 2012;26(7):439-443. doi:10.1097/BOT.0b013e31822a526a
Ebraheim NA, Lu J, Yang H, et al. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot and Ankle International. 1997;18(11):693–698. doi:10.1177/107110079701801103
Miller AN, Barei DP, Iaquinto JM, et al. Iatrogenic syndesmosis malreduction via clamp and screw placement. Journal of Orthopaedic Trauma. 2013;27(2):100-106. doi:10.1097/BOT.0b013e31825197cb
Knops SP, Kohn MA, Hansen EN, et al. Rotational malreduction of the syndesmosis: reliability and accuracy of computed tomography measurement methods. Foot and Ankle International. 2013;34(10):1403-1410. doi:10.1177/1071100713489286
Abbasian M, Biglari F, Sadighi M, et al. Reliability of Postoperative Radiographies in Ankle Fractures. The Archives of Bone and Joint Surgery. 2020; 8(5): 598-604. doi:10.22038/abjs.2020.43134.2173
Bafna KR, Jordan R, Yatsonsky D, et al. Revision of Syndesmosis Screw Fixation. Foot and Ankle Specialist . 2020;13(2):138-143. doi:10.1177/1938640019843328
Yüce A, Mısır A, Yerli M, et al. The Effect of Syndesmotic Screw Level on Postoperative Syndesmosis Malreduction. Journal Foot and Ankle Surgery. 2022;61(3):482-485. doi:10.1053/j.jfas.2021.09.022
Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Reviews. 2018;3(1):24-29. doi:10.1302/2058-5241.3.170017
Miller AN, Carroll EA, Parker RJ, et al. Direct visualization for syndesmotic stabilization of ankle fractures. Foot and Ankle International. 2009;30:419-426. doı:10.3113/FAI-2009-0419
Gardner MJ, Brodsky A, Briggs SM, et al. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clinical Orthopaedics Related Research. 2006;447:165-171. doi:10.1097/01.blo.0000203489.21206.a9
Manjoo A, Sanders DW, Tieszer C, et al. Functional and Radiographic Results of Patients with Syndesmotic Screw Fixation: Implications for Screw Removal. Journal of Orthopaedic Trauma. 2010;24:2–6. doi:10.1097/BOT.0b013e3181a9f7a5
Baek JH, Kim TY, Kwon YB, et al. Radiographic Change of the Distal Tibiofibular Joint Following Removal of Transfixing Screw Fixation. Foot and Ankle International. 2018;39(3):318-325. doi:10.1177/1071100717745526
Song DJ, Lanzi JT, Groth AT, et al. The Effect of Syndesmosis Screw Removal on the Reduction of the Distal Tibiofibular Joint: A Prospective Radiographic Study. Foot and Ankle International. 2014;35(6) 543–548. doi:10.1177/1071100714524552
Bauer AS, Bluman EM, Wilson MG, et al. Injuries of the distal lower extremity syndesmosis. Current Orthopaedic Practice. 2009;20(2):111-116.
Westermann RW, Rungprai C, Goetz JE, et al. The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. Journal of Bone and Joint Surgery Am. 2014;96(20):1732-1738. doi:10.2106/JBJS.N.00198
