Abstract
Background
Avulsion fractures of fibula occur with ankle sprains. The purpose of this study was to compare the biomechanical characteristics of double-row suture versus compression screw techniques in treatment of lateral malleolar avulsion fracturelarger than 10 mm in size, which is typically not associated with an anterior talofibular ligament injury.
Methods
We simulated lateral malleolus avulsion fractures in six matched pairs of 12 human cadaveric ankles. These were then randomly divided into two groups: a double-row fixation group and a compression screw group. Biomechanical testing was performed after surgical fixation. The foot was rotated from the neutral position toward inversion at a rate of 1°/s until 12.5 N-m or structural failure was reached. The final rotation torque, rotation angle, stiffness, and displacement of the ossicles were recorded.
Results
No significant difference was found in the final rotation torque (7.60 ± 3.70 vs 7.23 ± 2.06 N-m, p = 0.87), rotation angle (43.61 ± 14.77° vs 40.93 ± 10.94°, p = 0.56), stiffness (0.19 ± 0.08 vs 0.13 ± 0.07, p = 0.33), or displacement (6.11 ± 5.23 vs 7.09 ± 5.93 mm, p = 0.77) between the two groups. Conclusions: The stability of the double-row suture fixation was equivalent to compression screw fixation in treating a lateral malleolar avulsion fracture larger than 10 mm in size with ligament injury, as determined by our biomechanical testing.
Keywords: Lateral malleolous, Avulsion fracture, Biomechanics, Double-row anchors fixation, Compression screw fixation
1. Introduction
Avulsion fractures of the distal fibula commonly occur with ankle sprains.1, 2, 3 The percentage of avulsion fractures found in patients with ankle inversion injury ranged from 26 % to 66 %.2,4,5 Because of the retracting force of the ligaments, the avulsed fracture may not be in contact with the distal fibula, making bone-to-bone healing more difficult.4 Prevous study indicated that the osseous union was obtained in only 65 % patients.2 Ossicles of avulsed fractures of the lateral malleolus can result in pain or chronic ankle instability.2,6,7 The indicence of osteochondral lesions of the talus was also higher in patients with an ossicle.7 Moreover, the presence of ossicles can result in a poor outcome after ankle lateral ligaments reconstruction.5 In clinical practice, Magnetic Resonance imaging and Ultrasound are used to assess whether an avulsion fracture is accompanied by lateral ankle ligaments injury. Surgical treatment is considered necessary after an avulsion of the lateral malleolus, particularly for those who have undergone long-term rehabilitation. resection, combined with the modified Broström procedure, is widely adopted for ossicles less than 10 mm in size. However, for larger ossicles, optimal treatment remains controversial and its effects are uncertain.8, 9, 10
Until now, few attempts have been reported to preserve ossicles.6,10,11 The use of compression screws for avulsed ossicles is associated with some limitations such as higher minimum requirements for the size and integrity of the ossicles. In addition, second operation may be needed to remove the internal fixation.
Double-row fixation has been used to treat avulsion fractures in other anatomical regions such as the acute bony Bankart lesions and avulsion fractures of the great tuberosity, and shows good results.12, 13, 14, 15, 16 We hypothesized that this technique could also be used for the fixation of avulsion fractures of the lateral malleolus.
In this study, we compared the strength of the double-row fixation technique versus compression screws for treating avulsion fractures of the lateral malleolus larger than 10 mm in size by assessing biomechanical variables. We hypothesized that the biomechanical strength characteristics of the double-row fixation technique would be comparable to compression screw fixation.
2. Materials and methods
2.1. Specimen preparation
The cadaveric specimens used in this study were obtained and approved for use by our institution's body donation program. The study was approved by the Ethics Committee of our Hospital. Six pairs of 12 freshly frozen human cadaveric ankles were collected within two days of death and stored at −20 °C until testing. All specimens were obtained from donors aged 18–80 years. Three of them were male and 3 of them were female. There was no evidence of injury history, previous surgeries, pathologies, or deformities in any of the specimens. Prior to the surgery and biomechanical testing, the cadaveric ankles were thawed at 5 °C for 24 h. The moisture of the specimens was maintained with saline spray during preparation and testing phases.
Each specimen was transected at the tibia, approximately 18 cm above the fibular tip, leaving the soft tissues intact. The soft tissues 8 cm from the fibular tip and the surrounding parts within 5 cm of the posterior surface of the calcaneus were removed. The exposed tibia, fibula, and calcaneus were then fixed with self-curing denture acrylic.
The specimen for double-row fixation technique was chosen at random, and the paired contralateral ankle was used for compression screw fixation. All surgical procedures were performed by a single senior surgeon.
2.2. Surgical technique
First, we made a curved incision anterior to the tip of the fibula. The surrounding soft tissue was then removed but the ligaments were left intact. To simulate an avulsion fracture with a maximum diameter of 10 mm at the lateral malleolus, a hole was drilled with a 1.5 mm Kirschner wire at the superior edge of the anterior talofibular ligament (ATFL) insertion. Then, we identified a point on the inferior plane of the distal fibula that was 10 mm from the superior edge of the ATFL insertion, as the other end of the ossicle. The fracture line was determined by drilling a row of holes perpendicular to the bone surface with a 1.5 mm Kirschner wire.Then, an osteotome was used to creation of fibular avulsion fracture. The attachment ligaments of the ossicle were recorded (Fig. 1).
Fig. 1.
A bony avulsion fracture on the distal fibula was created using an osteotome. The fracture line was determined by drilling a row of holes perpendicular to the bone surface with a Kirschner wire. Then, an osteotome was used to creation of fibular avulsion fracture. The attachment ligaments of the ossicle were recorded. 1. Fibula; 2. bony avulsion fracture; 3. anterior talofibular ligament; 4. calcaneofibular ligament; 5. posterior talofibular ligament.
2.2.1. Compression screws
Compression lag technique was used to fixed the avulsion fracture. After the fracture was fixed by a reducing cramp, two threaded cancellous screws (diameter: 2.5 mm; length: 23 mm, Trauhui Inc., Changzhou, Jiangsu, China) were placed perpendicular to the fracture line and 0.5 cm apart in the ossicle (Fig. 2).
Fig. 2.
Compression screw fixation technique. Compression lag technique was used to fixed the avulsion fracture. After the fracture was fixed by a reducing cramp, two threaded cancellous screws (diameter: 2.5 mm; length: 23 mm) were placed perpendicular to the fracture line and 0.5 cm apart in the ossicle. 1. Fibula; 2. bony avulsion fracture; 3. anterior talofibular ligament; 4. calcaneofibular ligament; 5. Two threaded cancellous screws (diameter: 2.5 mm; length: 23 mm).
2.2.2. Double-row suture fixation
A bioabsorbable 3.0 mm single-row anchor (Bio-sutureTak, Arthrex Inc., FL, USA) was inserted into the medial edge of the fibular fracture surface which was parallel to the shaft of the fibula. A 2.0 mm Kirschner wire was then used to drill two bone tunnels in the ossicle. Each end of the No. 2 suture (FiberWire, Arthrex Inc., FL, USA) in the 3.0 mm anchor was passed separately through the bone tunnels in the ossicle with a suture hook. The two ends of the suture were then passed through the eyelet of a 2.9 mm knotless anchor (Pushlock, Arthrex Inc., FL, USA). After adjusting the tension of the suture, the knotless anchor was then inserted into the lateral side of the malleolus 5 mm proximal to the fracture line, to fix the two ends of the suture with the ankle in a neutral dorsiflexion and lightly everted position. At that point, the ossicles and the lateral ankle ligaments were fixed to the fibula (Fig. 3).
Fig. 3.
Double-row suture technique. A bioabsorbable 3.0 mm single-row anchor was placed into the distal end of the fibula. A 2.0 mm Kirschner wire was then used to drill two bone tunnels in the ossicle. Each end of the No. 2 suture was passed through the bone tunnels with a suture hook, respectively. The two ends of the suture were then passed through the eyelet of a 2.9 mm knotless anchor. After adjusting the tension of the suture, the knotless anchor was then inserted into the lateral side of the malleolus 5 mm proximal to the fracture line, to fix the two ends of the suture. At that point, the ossicles and the lateral ankle ligaments were fixed to the fibula. 1. Fibula; 2. bony avulsion fracture; 3. anterior talofibular ligament; 4. calcaneofibular ligament; 5. No. 2 suture (FiberWire, Arthrex Inc., FL, USA).
2.3. Biomechanical testing
The biomechanical testing system is shown in Fig. 4. The potted calcaneus, as well as the tibia and fibula of each specimen, were rigidly fixed to a custom fixture using two screws. The fixture holding the tibia and fibula was mounted onto a stationary pedestal. The fixture holding the calcaneus was then mounted onto a rotatable pedestal with a universal force/torque sensor (electronic universal testing machine; DDL20, Changchun, China).
Fig. 4.
Biomechanical Testing Procedure. The potted calcaneus, as well as the tibia and fibula of each specimen, were rigidly fixed to a custom fixture using two screws. The fixture holding the tibia and fibula was mounted onto a stationary pedestal. The fixture holding the calcaneus was then mounted onto a rotatable pedestal with a universal force/torque sensor. During the test, the structural stiffness, failure torque and failure angle were recorded.
A digital video camera (video extender; VE-7100, Shanghai, China) was then focused on two points on each ankle: the midpoint of the fracture line on the lateral surface of the ossicle and the points corresponding to the fracture line on the opposite side. The horizontal axis corresponded forward to the right side of the camera while the longitudinal axis corresponded forward to the lower side of the camera.
The foot was positioned at 15° internal rotation and 20° plantar flexion to simulate the lower leg loading position.17,18 Each ankle was movement from 0° to 10° supination for 10 cycles as pretension. In the formal test, the protonation speed was controlled at 1°/s to 12.5 N-m or the structure failed, to simulate the structural failure caused by protonation when walking on a slope. During the test, the structural stiffness, failure torque, failure angle, were recorded. The precise time of failure was obtained from the sudden reduction of measured torque; this was used to extract displacement data of the ossicle immediately before torque failure. Stiffness was determined by the torque-pronation angle curve of the last 5° or movement.17,18 The displacement of the points on the ossicles just before structure failure was recorded.
2.4. Statistical analysis
A priori power analysis was used to calculate the sample sizes before the test. According to previous study, a minimum clinically important difference was selected to be 2.0 mm and a standard deviation of 1.0 mm was assumed.19 As the power and signifaicance level were set at 0.8 and 0.05, respectly, 5 specimens in each group were needed. All values were reported as means and standard deviations (SD). Differences were considered statistically significant at values of P < 0.05. All statistical analyses were conducted using SPSS 19.0 (IBM Corporation, Armonk, New York, USA).
3. Results
3.1. Compression screws
Six specimens were included in the compression screw group, including three from the right leg and three from the left leg. Beause of the various sizes of the ankle joint, the ATFL was attached to the ossicle in one specimen and the CFL was attached to the tip of the fibular. The ATFL and CFL were attached to the ossicle in the other specimens. The mechanism of failure for all specimens in this group involved the disengagement of screws.
3.1.1. Double-row suture fixation
In the double-row suture fixation group, six specimens were included, of which three were from the right leg and three were from the left leg. In one specimen, the ATFL was attached to the ossicle and the CFL was attached to the tip of the fibular. In the others, the ATFL and CFL were attached to the ossicle. The mechanism of failure for two specimens was disengagement of the suture from the bony tunnel. No obvious structural damage was found in the other specimens, which was presumed to reflect internal ligament tearing.
3.1.2. Double-row suture fixation vs compression screws
No significant differences were found in the final rotation torque (7.60 ± 3.70 vs 7.23 ± 2.06 N-m, p = 0.87), rotation angle (43.61 ± 14.77° vs 40.93 ± 10.94°, p = 0.56), stiffness (0.19 ± 0.08 vs 0.13 ± 0.07, p = 0.33), or displacement (6.11 ± 5.23 vs 7.09 ± 5.93 mm, p = 0.77) between double-row suture fixation and compression screws group.
4. Discussion
This study demonstrates that the double-row suture fixation surgical procedure for avulsed fractures of the lateral malleolus has comparable strength and stability as compression screw fixation.
For aucte avulsed fracture of the lateral malleolus, because of the retracting force of the ligaments, the avulsed fracture may not be in contact with the distal fibula, making bone-to-bone healing more difficult.4 Therefore, chronic ankle instability are more common in acute ankle inversion sprain patients with lateral malleolar avulsion fracture.
Although fibular ossicles are commonly seen in the clinic, the treatment approach to this condition remains controversial. Since ossicles are attached by the ligaments and displaced from the fibular tip, conservative treatments such as immobilization or rehabilitation do not elicit adequate fixation to allow the fusion of ossicles to the fibular. While such strategies can lead to non-union of the bones, surgical treatments can reestablish a more normal anatomy.
Ossicle resection combined with the modified Broström procedure has been widely used, especially in cases involving small ossicles <10 mm in size.5,20, 21, 22, 23 For large ossicles, usually considered to be > 9–10 mm in diameter,24 controversy remains about the best approach and expected outcomes. In a previous study, Kim et al.5 reported a lack of improvement in anterolateral stability in cases with large ossicles following ossicle resection and the modified Broström procedure. The authors found that the resection of a large ossicle can result in a lack of remnant ligamentous tissue and leave a permanent gap between the ATFL and the insertion in the fibular, thus leading to poor anterolateral stability. Therefore, the reconstruction of ligaments following ossicle resection or ossicle fixation may need to be prioritized for cases involving large ossicles. Most ossicles are partially or completely embedded within the fibers of the ATFL and are often accompanied by ruptures of the posterior talofibular and CFL.5,25 On the other hand, Diallo et al. reported cases in which ossicles were attached to both the ATFL and CFL, thus demonstrating that a large ossicle might be simultaneously attached to multiple ligaments.4 In such cases, ossicle-conserving surgery will likely be more advantageous in terms of reducing the complexity of the surgery and reducing unnecessary trauma to the surrounding ligaments.
In ossicle-conserving surgery, the tightness and the strength of the fixation play a decisive role in determining bony union and postoperative symptoms.25
Screws have been used to fix ossicles.4,6,8 For example, Kose et al. fixed the ossicle of a patient with two headless compression screws.8 Nine months after surgery, the patient was free of pain and returned to her previous level of daily activity; the range of motion was normal compared with the contralateral side. In another study, El Ashry et al. also fixed the ossicle of a 12-year-old patient with two headless screws. The fracture healed three months after surgery and the patient returned to his preinjury activity level over eight months.6 Diallo et al. treated ten patients with bony avulsion fractures of the fibula following acute ankle sprains with screw fixation. After a mean follow-up period of 2.4 years, all patients were clinically and radiographically stable and satisfied with their outcomes.4 The advantage of screw fixation was ease to perform percutaneous or throuth mini-open techniques. However, due to the limited reported cases, such approaches to preserving ossicles have not yet been thoroughly tested.
Although the open technique was used in our current research, the double-row suture repair technique is an endoscopic procedure which is widely used for bony Bankart lesions, an avulsion fracture of the greater tuberosity.12, 13, 14, 15, 16 There, the double-row repair technique can reduce the osseous fragment within the capsulolabral and ligamentous complex using double rows of suture anchors.26 Compared with percutaneous cannulated screw fixation, this technique is believed to achieve better anatomical restoration, including both stable osseous fixation and capsulolabral repair or plication.27 For avulsion fractures of the greater tuberosity, the double-row technique can be used in comminuted fractures where cannulated screws cannot be used; this approach shows superior strength in biomechanical studies, especially at a low abduction angle.16,28,29
In this study, we found no significant differences in the final failure torque, failure angle, stiffness, and ossicle displacement between the two groups. The similar torque failure angle and stiffness indicate that the double-row fixation technique provides similar strength and stability compared to the existing compression screw fixation technique. According to Hasegawa et al., displacement of an ossicle impedes bony union.25 In the present study, the two experimental groups showed similar outcomes in the displacement of the ossicles; which means that the likelihood of bony union is comparable for patients being treated with either approach. However, in clinical practice, as many patients were chronic instability, the bone surface of the ossicle and fibula should be prepared by cortical debridement or flattening to increase the chance of bony union.
There are several advantages of double-row suture fixation when compared to compression screw fixation. First, the double-row fixation technique does not require a second operation to remove hardware; this is more cost-effective, and reduces the risk of iatrogenic complications. On the contrary, in some hospitals, including our hospital, the hardware was removed according to the patients’ request. In addition, because the sutures of a double-row fixation wrap around the ossicle and the adjacent soft tissues, the tension can be transmitted to a wider area, thus reducing the likelihood of the ossicle splitting.30 Therefore, the requirement for bone size and integrity can be lower, thus rendering this technique more available to a wider patient population.
In our experiment, we used a 2.0 mm diameter Kirschner wire to construct the bone tunnels. However, the diameter of these bony tunnels can be made smaller, as long as they accommodate the sutures. Furthermore, operators can even opt to pass the sutures through the soft tissue surrounding the ossicle rather than the ossicle itself, thereby wrapping sutures around the ossicle to fix it to the fibula. This practice further reduces the possibility of intraoperative damage to the ossicles.
5. Limitations
The study has some limitations that need to be considered. Firstly, the specimens used in the present study were from donors aged between 18 and 80 years; differences in bone mineral density between the groups may have increased bias. In response, the use of matched pairs of ankles help minimize the impact of sampling errors. Secondly, the man-made avulsion fracture used in this study may differ from the physiological mechanisms of avulsion fracture; also, the diameter was limited to 10 mm. These factors may reduce the generalizability of our findings. At the same time, the consistency of this approach was necessary to reduce heterogeneity and thus improves the comparability of the groups.
6. Conclusion
The stability of the double-row suture fixation was equivalent to compression screw fixation in treating a lateral malleolar avulsion fracture larger than 10 mm in size with ligament injury, as determined by our biomechanical testing. It is worth noting that this study does not demonstrate the superiority of either method.
Ethical approval
Ethical approval for this study was obtained from the Ethics Committee of Huashan Hospital (2020–1123).
Authorship statement
All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication.
Category 1: Conception and design of study: Y.H. Hua, H.Y. Li, S.Y. Chen acquisition of data: W.K. Xuan, H. Li analysis and/or interpretation of data: H.Y. Li, W·K. Xuan.
Category 2: Drafting the manuscript: H.Y. Li, W.K. Xuan revising the manuscript critically for important intellectual content: Y.H. Hua, S.Y. Chen, H·Li.
Category 3: Approval of the version of the manuscript to be published (the names of all authors must be listed): H.Y. Li, W.K. Xuan, H. Li, Y.H. Hua, S·Y. Chen.
Declaration of Competing interest
A conflict of interest occurs when an individual's objectivity is potentially compromised by a desire for financial gain, prominence, professional advancement or a successful outcome. AP-SMART Editors strive to ensure that what is published in the Journal is as balanced, objective and evidence-based as possible. Since it can be difficult to distinguish between an actual conflict of interest and a perceived conflict of interest, the Journal requires authors to disclose all and any potential conflicts of interest.
The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Acknowledgment
This work was supported by a grant awarded to Ying-Hui Hua from the National Natural Science Foundation of China (NSFC81871823) and Hong-Yun Li from the National Key Research and Development Program of China (2020YFC20070405).
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