Injury, Int. J.

Care Injured (2005) 36, 1121—1124

www.elsevier.com/locate/injury

Does position of syndesmotic screw affect

functional and radiological outcome in
ankle fractures?
S. Kukreti *, A. Faraj, J.N.V. Miles

Department of Orthopaedics, Hull Royal Infirmary, Anlaby road, Hull HU3 2JZ, UK

Accepted 18 January 2005

KEYWORDS Summary The optimum level of syndesmotic screw used in ankle fractures with a
Syndesmosis; tibiofibular diastasis is not clear in the literature. In a retrospective cohort study, we
Suprasyndesmotic evaluated the clinical and radiological outcomes in two groups of patients–—those who
screw; had a syndesmotic screw placed through the syndesmosis itself (transsyndesmotic, 17
Transsyndesmotic patients) and those who had a syndesmotic screw placed just above the syndesmosis
screw; (suprasyndesmotic, 19 patients). The study suggests that the two groups do not differ
Inferior tibiofibular significantly in terms of clinical and radiological outcomes.
synostosis (IFTJ); # 2005 Elsevier Ltd. All rights reserved.
Dorsiflexion (DF);
Plantarflexion (PF);
Activities of daily living
(ADL)

1. Introduction the optimal level for placing the syndesmosis screw

The inferior tibiofibular articulation (syndesmosis) is
formed by the incisural surface of lower end of the
tibia and adjoining medial wall of the fibula. Radi-
ologically the syndesmosis extends up to 2 cm from
the tibial plafond.7
Although biomechanical studies have provided
important information to guide the surgeon in
choosing when to stabilise the disrupted diastasis1,2
* Corresponding author. Present address: 33, West Court, West
Avenue, Roundhay, Leeds LS8 2JP, UK. Tel.: +44 113 2657297;
fax: +44 113 2657297.
E-mail address: emailsankuk@yahoo.co.uk (S. Kukreti).
is not clearly defined. In one cadaveric biomecha-
nical study,5 the screw exerted maximum resistance
to external rotation of ankle when it was placed
2 cm above the ankle joint but in another study,6 the
optimal level was at 5 cm above the ankle joint. The
AO manual of Principles of Fracture management4
states that the syndesmotic screw be placed just
proximal to the syndesmosis.
The purpose of this study was to evaluate the
clinical and radiological outcomes following place-
ment of a syndesmotic screw through the syndes-
mosis and above the syndesmosis. We define
transsyndesmotic screw to be within 2 cm from
the tibial plafond and suprasyndesmotic screw to

0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2005.01.014
1122 S. Kukreti et al.

Table 1 Patient demographics in suprasyndesmotic and transsyndesmotic groups

Number of patients Age in years mean (range) Gender distribution
Males Females
Suprasyndesmotic group 19 42.5 (18—74) 12 7
Transsyndesmotic group 17 53.8 (19—87) 10 7

be more than 2 cm but within 5 cm from the tibial
plafond.
2. Materials and methods
This was a retrospective cohort study in which case
notes of 60 patients over a period from 1989 to 2001
were reviewed. All patients had ankle fracture with
syndesmotic disruption which was treated by open
reduction and internal fixation including syndesmo-
tic screw insertion. The position of the screw was
according to the surgeon’s preference. The patients
were sent a letter explaining to them the nature of
study and were given a date to attend a clinic to be
reviewed if they consented. Of the 60 patients, 36
were reviewed during July and August 2001. The
mean duration of follow-up was 35.4 months (range:
9—126 months). Eight patients had moved out of the
area and were not contactable. Eleven refused to
attend.
The patient demographics in both suprasyndes-
motic and transsyndesmotic groups are shown in
Table 1. None of the patients were diabetic.
All patients had AO type C ankle fractures, the
distribution of which is shown in Table 2.
All patients had a syndesmotic screw placed
under fluoroscopic control with the ankle fully dor-
siflexed. A 3.5 mm cortical screw was used in all
patients. Only one cortex of the tibia was engaged in
all but seven patients (three in the suprasyndesmo-
tic group and four in the transsyndesmotic group).
No screws were used in compression mode.
Postoperative management consisted of non-
weight bearing in a below knee plaster till removal
of the syndesmotic screw. This was on average 8
weeks (range: 32—97 days) for both groups. Three
patients in transsyndesmotic group did not have the
screw removed. These were elderly patients (68-,
83- and 84-years-old at time of operation) with low
physical demands.
Table 2 Distribution of AO ankle fracture types in
suprasyndesmotic and transsyndesmotic groups
C1 C2 C3 Total
Suprasyndesmotic group 12 6 1 19
Transsyndesmotic group 9 6 2 17
Total 21 12 3 36
The patients were evaluated with regard to the
following parameters:
clinical:
(1) rest pain localised at the inferior tibiofibular
joint,
(2) pain at the inferior tibiofibular joint during
single stance twisting,
(3) pain at the inferior tibiofibular joint on com-
pression,
(4) range of movement (ROM);
radiological (anteroposterior mortise and lateral
view of the ankle):
(1) talar tilt/shift,
(2) osteoarthritis of the ankle,
(3) inferior tibiofibular synostosis;
functional:
(1) activities of daily living,
(2) time off work,
(3) overall satisfaction.
3. Statistical analysis
The comparison of suprasyndesmotic and transsyn-
desmotic groups was evaluated on the basis of P-
value (P < 0.05 significant) using SPSS package [SPSS
Inc., Chicago]. This was based on chi-square with
continuity correction where appropriate, or on Fish-
er’s exact test where chi-square is inappropriate
because of small sample size. For continuous mea-
sures Mann—Whitney U-test was used.
4. Results
The mean duration of follow-up from the time of
operation was 35.4 months (range: 9—126 months).
In the suprasyndesmotic group, the mean was 32
months (range: 9—75 months) and in the transsyn-
desmotic group, the mean was 39.2 months (range:
9—126 months).
The clinical and radiological results are outlined
in Table 3.
4.1. Range of movement
This was measured with a goniometer. The normal
ankle dorsiflexion is 208 and plantarflexion is 508.3
Position of syndesmotic screw 1123

Table 3 Comparison of clinical and radiological parameters in supra and transsyndesmotic groups and their statistical
significance
Suprasyndesmotic Transsyndesmotic P-value
group–—number group–—number
of patients (%) of patients (%)
Rest pain at ITFJ 1 (5.3) 1 (5.9) 1.00
Single stance twist pain IFTJ 5 (26.3) 2 (11.8) 0.41
Pain on IFTJ compression 3 (15.8) 3 (17.6) 1.00
DF restriction a 13 (68.4) 10 (58.8) 0.55
PF restriction a 8 (42.1) 7 (41.2) 0.97
Talar shift 1 (5.3) 3 (17.6) 0.10
Talar tilt 2 (10.5) 2 (11.8) 1.00
Osteoarthritis 4 (21.1) 4 (23.5) 1.00
IFTJ synostosis 5 (26.3) 8 (47.1) 0.34
ADL restriction 4 (21.1) 2 (11.8) 0.66
Overall satisfaction 16 (84.2) 15 (88.2) 1.00
a
Chi-square test, all others Fisher’s exact test, because of small expected values.

In the suprasyndesmotic group, 6 patients had full
active ROM while 14 (73.7%) had some restriction. Of
the 14 who had restriction, 9 had restriction of both
dorsi and plantarflexion; 5 had restriction of dorsi-
flexion only.
Dorsiflexion was comparable to the opposite nor-
mal ankle in 6 patients; restricted in 13 (mean
restriction: 5.88). Plantarflexion was comparable
to the opposite normal ankle in 11 patients;
restricted in 8 patients (mean: 7.48).
In the transsyndesmotic group, four patients had
full ROM, while 13 (76.5%) had some restriction. Of
the 13 who had restriction, 4 had restriction of both
dorsi and plantarflexion; 6 had restriction of only
dorsiflexion and 3 only plantarflexion.
Dorsiflexion was comparable to the opposite nor-
mal ankle in 7 patients; restricted in10 patients(mean
restriction: 7.68). Plantarflexion was comparable
to the opposite normal ankle in 10 patients; restricted
in 7 patients (mean restriction: 7.18) (Table 4).
On the basis of the Mann—Whitney U-test, no
significant difference was found in restriction of
dorsiflexion and plantarflexion between suprasyn-
desmotic and transsyndesmotic groups.
inferior tibiofibular synostosis. All three patients in
the transsyndesmotic group who did not have the
syndesmotic screw removed, had radiological synos-
tosis. Of these three, two had no pain on stance or on
inferior tibiofibular compression, although one of
them had early radiological OA. The third patient
had severe OA both radiologically and clinically.
Inferior tibiofibular synostosis did not correlate
significantly with
(a) restriction of dorsiflexion in both transsyndes-
motic (P = 0.3) and suprasyndesmotic groups
(P = 1),
(b) single stance twist pain in suprasyndesmotic
group (P = 0.2) and transsyndesmotic group
(P = 1),
(c) pain on IFTJ compression in suprasyndesmotic
group (P = 1) and transsyndesmotic group
(P = 0.58).
There was no statistically significant difference
between suprasyndesmotic or transsysndesmotic
screw placement with regards to clinical and radi-
ological outcomes.

4.2. Inferior tibiofibular synostosis

5. Discussion
In the suprasyndesmotic group, five patients (26.3%)
and in the transsyndesmotic group, eight patients had As far as we know there has been no study comparing
clinical and radiological outcomes following supra-
Table 4 Comparison of mean restriction of ankle syndesmotic or transsyndesmotic screw insertion in
dorsiflexion and Plantarflexion in suprasyndesmotic ankle fractures with an inferior tibiofibular diasta-
and transsyndesmotic groups sis, so the optimal screw position remains to be
Suprasyn- Transsyn- P-value defined clearly.
desmotic desmotic Our study suggests that there does not appear to
group (8) group (8) be any significant difference between the suprasyn-
Dorsiflexion 5.8 7.1 1.0 desmotic and transsyndesmotic screw groups with
Plantarflexion 7.4 7.1 0.85 regard to clinical and radiological parameters. How-
ever, the small number of patients in our study could
1124
result in a Type II error. Transsyndesmotic screw
insertion may lead to higher incidence of inferior
tibiofibular synostosis (heterotopic ossification).4
Although the synostosis may occur due to the injury
itself, the bone reamings as a result of drilling used
to insert the screw, may be contributory.4 However,
our study could not show a significant difference in
inferior tibiofibular synostosis between the two
groups. Interestingly, all three elderly patients with
a retained transsyndesmotic screw had radiologic
inferior tibiofibular synostosis which suggests that
persistent presence of screw though the syndesmo-
sis could lead to inferior tibiofibular synostosis.
An inferior tibiofibular synostosis could lead to
restriction of dorsiflexion, based on the anatomical
fact that the wider anterior part of talus engages the
ankle mortise on dorsiflexion.7 However, there did
not appear to be a significant correlation between
inferior tibiofibular synostosis and restriction of
dorsiflexion in either the transsyndesmotic or the
suprasyndesmotic group.
The study is open to criticism in being retro-
spective in design and the patients were not ran-
domly assigned to groups, so it must be considered
to be an observational study.
6. Conclusion
There does not appear to be any significant differ-
ence between the suprasyndesmotic and transsyn-
S. Kukreti et al.
desmotic screw position with regard to clinical and
radiological outcomes, in ankle fractures.
Acknowledgement
The authors thank Sue Yu. Clinical Audit Assistant in
Orthopaedics, Hull Royal Infirmary.
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