Thoughts on Syndesmotic Fixation

Jennifer Spector, DPM:

Welcome back, everybody, to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. I'm Dr. Jennifer Spector, the assistant editorial director for Podiatry Today, and in this episode, we have Dr. Ali Rahnama with us, who we're very excited to speak to about syndesmotic fixation.

Dr. Rahnama is an assistant professor at the Georgetown University School of Medicine, currently on staff at MedStar Georgetown University Hospital, MedStar Washington Hospital Center and MedStar Orthopedic and Sports at Lafayette. He is a fellowship-trained surgeon, having participated in the traumatic and reconstructive foot and ankle surgery program with the Southeast Permanente Medical Group in the Greater Atlanta area.

Dr. Rahnama, we're so glad to have you with us today. Thank you so much for sharing your insights with our audience on this topic. When it comes to syndesmotic fixation, what do you feel are some of the biggest challenges or pitfalls that surgeons face when it comes to this?

Ali Rahnama, DPM:

When it comes to syndesmotic fixation and stabilization, I think two things are probably the most difficult, and surgeons oftentimes find themselves in an area of difficulty. Number one is achieving the appropriate reduction, and then number two, I would say, the problem of recurrent diastasis. So I think those are probably the two biggest challenges that face surgeons when it deals with this pathology, and knowing how to go into the case and being adequately prepared for the procedure, I think ultimately can help stave off some of these issues that folks might run into.

Jennifer Spector, DPM:

Are there any key components to that preparation? Are there any metrics or things about the case that people should really be focusing on as surgeons when they're getting ready for that case?

Ali Rahnama, DPM:

If we're talking about syndesmotic injuries as they relate to being a component of a fracture, meaning bimalleolar or trimalleolar type fracture, that also involves syndesmotic disruption, I think it's important to know the order of operations in which you're going to reduce and fixate the associated injuries and to know in what order to then come back and address the syndesmosis. Do we go after the syndesmosis first? Do we go after it last? Somewhere in the middle?

I would tell you for me, an associated fracture, for the most part I'm addressing the fractures and then most often, not always, but most often starting laterally with the fibula, making sure that the fibula is adequately out to length and that the reduction is appropriately keyed back into place, and then addressing the medial malleolus or even the posterior malleolus if there is a posterior malleolar injury before then coming back and addressing the syndesmotic injury.

The second thing that I would tell you is that one of the biggest things that I've evolved on when it comes to technique as it pertains to these injuries is that I remember as a resident really in the operating room with the King Tongs clamping down, and that is so wrong. And I'm lucky enough to have had Zedshan Husain as one of my biggest mentors in training in Detroit, and I remember he would tell you, "Whoa, whoa. You can't crank down on it so hard." And so I utilize minimal reduction or even just manually reducing it these days, and really, if you've done an adequate job of the debridement and the reduction, then really it should key right back into place, especially with fresh injuries.

Now, latent injuries are a whole different topic of discussion, and we could talk about some of the techniques and strategies on how to adequately achieve anatomic reduction with latent injuries as well, but I would tell you it really comes down to making sure that you've done everything appropriately to get a nice reduction.

Jennifer Spector, DPM:

Seems like the systematic approach really is key with these cases.

You already mentioned some of them, but are there any particular pearls or techniques that have had an impact on outcomes, in your experience? You mentioned being more gentle with the reduction, but anything else that you've picked up along the way?

Ali Rahnama, DPM:

Getting into the operating room, I really try to find a reproducible way to do the same thing over and over again, and I found that utilizing center-center technique when placing and putting in my syndesmotic hardware, whether it's flexible or rigid fixation for the syndesmosis, really helps me to adequately and appropriately reduce the syndesmosis and to place the hardware in the appropriate plane without it being too far anterior or posterior. That would be number one.

And then number two would be arthroscopic debridement of the syndesmosis and just the ankle joint in general prior to then subsequently reducing and then employing my fixation. And lots of folks have described the utilization of arthroscopy in ankle injuries, both in fractures and for syndesmotic injuries as well as for latent syndesmotic injuries, and this is going back into the '90s even. So plenty of folks, but Jack Schuberth or Arthur Manoli, so on and so forth, have described this, and I've utilized it and continue to utilize it and find it to be a huge factor in part of the procedure for me into making sure that the syndesmosis is adequately debrided, which would then subsequently lend itself to a better anatomic reduction.

Jennifer Spector, DPM:

So you've already mentioned about how surgeons can plan for success and some things that you can do in that proper preparation. Is there anything else that you'd like to add in that area, and are there any cases of syndesmotic reduction that come to mind that you've dealt with over the years that have stuck with you and lessons that you've learned from that?

Ali Rahnama, DPM:

Yeah. What I can tell you is that one of the biggest things for me is that coming particularly from a training background, working in inner-city, university-based hospitals, being very, very cost conscious, so on and so forth, we utilized a lot of rigid fixation for the syndesmosis. And one of the things that I could tell you is that now, particularly a little bit over the last 10 years or so, if you just read through the literature, there are at least five prospective randomized controlled trials evaluating the utilization of flexible versus rigid fixation for the syndesmosis, going back to Naviq in 2012 in AJSM, then the JOT paper in 2015, injury in '15, so on and so forth, down to Sanders in '19 and Anderson in '18.

All of these studies demonstrate the superiority of flexible fixation over rigid fixation, both when it comes to issues of malreduction, when it comes to issues of recurrent diastasis, when it comes to their functional outcomes. I just think flexible fixation is a lot more forgiving, and so it allows for you to maximize the likelihood of achieving anatomic reduction, and so I would implore those out there...

Now, if we're talking about diabetic ankle fractures, so on and so forth, absolutely, that's a different discussion and could probably be the topic of a podcast recording in and of itself, but I would tell folks that utilizing some of these things that are available to us can sometimes make all the difference.

Jennifer Spector, DPM:

Is there anything else on syndesmotic fixation that you don't feel like we had a chance to touch down on?

Ali Rahnama, DPM:

I would just tell folks, the planning is most of the time just as important as the execution, getting into the operating and doing the case. Do the planning. If you have an isolated syndesmotic injury, you think, I would implore you to get advanced imaging, whether it's an MRI or CT scan. You really don't want to get in there and be surprised.

And so I would tell you that the planning is half the battle, and that's one of the things that I really try to emphasize and harp on with my residents as well. And so at least once a week, sometimes twice a week, we get in my office and we review cases that are coming up and we have an open-forum-type discussion.

And not everybody's in academics, and not everybody has residents, but I think everybody, even the solo private practitioner, when getting ready for some of these cases, it's important to make sure you've crossed your T's and dotted your I's and you've done your homework and are ready to get in there and execute the plan based off of all of the facts.

Jennifer Spector, DPM:

Thank you so much for sharing your thoughts with us today. I'm sure the audience is benefiting greatly. We hope that the audience will also check out our other surgical content on Podcasts and on podiatrytoday.com. Be sure to check out our SoundCloud, Apple Podcasts, Spotify, and your favorite podcast platforms. We'll see you for the next episode.