Differential Rates of Syndesmotic Fixation in Operatively Treated Ankle Fractures by Subspecialty Training

Abstract

Category: Trauma Introduction/Purpose: Ankle fractures are a common orthopedic injury in the United States with annual incidence up to 187 per 100,000 persons. Approximately 23% of ankle fractures also involve injury to the syndesmotic ligaments and intraoperative assessment of syndesmotic instability represents a critical aspect of ankle fracture surgery. Recent studies have demonstrated that both Weber B and Weber C distal fibula ankle fractures can have concomitant syndesmotic injury necessitating trans-syndesmotic fixation. Through retrospective review of surgically treated ankle fracture cases, we sought to assess whether there were differences in the rates of intraoperative detection and surgical management of syndesmotic injuries based upon surgeon fellowship training and subspecialty experience. Methods: A multi-center retrospective cohort study of 219 surgically treated ankle fractures over a two year period was performed. Patient selection criteria was based on CPT codes while exclusion criteria included open trauma, pilon fracture, history of prior ankle fracture or pediatric patients. All preoperative radiographs were reviewed for Danis-Weber classification. All post-operative radiographs as well as operative reports were reviewed to confirm surgeon detection of syndesmotic injury and type of trans-syndesmotic fixation utilized. Surgeons were divided into three groups according to fellowship training: foot and ankle (Group 1), trauma (Group 2), and general / other (Group 3). There were 2 foot and ankle fellowship trained orthopedists, 5 trauma fellowship trained orthopedists, and 9 generalists whose fellowships included sports, hand, and spine. Patient demographics and medical risk factors were also recorded in the study. Results: 16.3% of 153 Weber B cases were treated with syndesmotic fixation: 24% of cases in Group 1, 17% of cases in Group 2, and 0% of cases in Group 3 had syndesmotic fixation. Comparing syndesmotic fixation in Groups 1 versus 3 using the Fisher's exact test resulted in p-value of < 0.0655 approaching statistical significance. 71.9% of 64 Weber C cases were treated with syndesmotic fixation: 91% of cases in Group 1, 69% of cases in Group 2, and 50% of cases in Group 3 had syndesmotic fixation. These differences were not statistically significant (p-value of < 0.1919). There were no statistically significant differences in demographics and medical risk factors among patients in the three groups. The study also included 2 Weber A cases. Conclusion: Our data shows an increased association of syndesmotic injury with Weber C compared to Weber B ankle fractures, similar to literature reports. While the data showed no statistically significant difference among the three surgeon groups, higher rates of syndesmotic injuries were intraoperatively detected and surgically treated by foot and ankle as well as trauma fellowship trained surgeons compared with general orthopedists or those with other fellowship background. Accordingly, fellowship training in foot and ankle and heightened experience in this subspecialty may facilitate recognition of syndesmotic injuries accompanying both Weber B and Weber C ankle fractures.