Does the Arthrex TightRope® provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes® in 37 patients

Syndesmotic fixation in Weber B ankle fractures: A systematic review

Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.

Management of High Ankle Sprains Utilizing the Tightrope Surgical Procedure - A Novel Approach for a Rapid Return to Play

The distal tibiofibular joint is described as a syndesmosis. The syndesmosis is important to the structural integrity of the ankle joint by maintaining the proximity of the tibia, fibula, and talus. Syndesmotic or high ankle sprains, involving the syndesmotic ligaments, pose a significant rehabilitative challenge due to their intricate anatomy, prolonged recovery periods following injury, and high susceptibility to persistent disability. Traditional management strategies have often been conservative, marked by lengthy periods of immobilization and a gradual return to activity. Severe syndesmotic injuries with diastasis have been treated surgically with screw fixation which may require a second intervention to remove the hardware and carries an inherent risk of breaking the screw during rehabilitation. Another fixation technique, the Tightrope™, has gained popularity in treating ankle syndesmosis injuries. The TightRope™ involves inserting Fiberwire® through the tibia and fibula, which allows for stabilization of the ankle mortise and normal range of motion. The accelerated rehabilitation protocol promotes early weight-bearing and has been shown to expedite the return to sport. This emerging strategy has shown promise in reducing recovery time as it is now possible to return to sport in less than 2 months after a tightrope repair and accelerated rehabilitation, compared with 3-6 months post screw fixation. This clinical commentary delves into this novel approach, highlighting the procedure, rehabilitation protocols, and the implications for physical therapy practice.

Level of Evidence

V.

Dynamic Fixation versus Static Screw Fixation for Syndesmosis Injuries in Pronation External Rotation Ankle Fractures: A Retrospective Case Control Study

Introduction

The current standard treatment for ankle syndesmosis injury is static screw fixation. Dynamic fixation was developed to restore the dynamic function of the syndesmosis. The purpose of this study was to determine that which of static screw fixation and dynamic fixation is better for treatment of ankle syndesmosis injury in pronation-external rotation fractures.

Materials and methods

Thirty patients were treated with dynamic fixation (DF group) and 28 patients with static screw fixation (SF group). The primary outcome was Olerud-Molander Ankle Outcome Score. The secondary outcome were Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score, radiographic outcomes, complications and cost effectiveness. To evaluate the radiographic outcome, the tibiofibular clear space, tibiofibular overlap, and medial clear space were compared using the pre-operative and last follow-up plain radiographs. To evaluate the cost effectiveness, the total hospital cost was compared between the two groups.

Results

There was no significant difference in primary outcome. Moreover, there were no significant difference in secondary outcome including Visual Analogue Scale score and American Orthopedic Foot and Ankle Society score and radiographic outcome. Two cases of reduction loss and four cases of screw breakage were observed in the SF group. No complication in the DF group was observed. Dynamic fixation was more cost effective than static screw fixation with respect to the total hospital cost.

Conclusion

Although dynamic fixation provided similar clinical and radiologic outcome, dynamic fixation is more cost effective with fewer complications than static screw fixation in ankle syndesmosis injury of pronation-external rotation fractures.

Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace

PURPOSE

Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program.

MATERIALS AND METHODS

Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardised postoperative rehabilitation protocol was established. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively.

RESULTS

The average follow-up was 13 months. The total FAAM score for ADL was 95 ± 4.9 % (range, 83 - 100 %) and for sport activities 87 ± 13.6 % (range, 50 - 100 %). The rating of mean postoperative function for ADL was 94 ± 5.5 % (range, 80 - 100 %) and 90 ± 13 % (range, 35 - 100 %) for sportv. The difference between acute and chronic injuries was statistically higher (p < 0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p = 0.9296 and p = 0.1615, respectively). Twenty-seven patients (90 %) rated their overall current level of function as normal or nearly normal.

CONCLUSION

This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries.

Transosseous Fixation of the Distal Tibiofibular Syndesmosis: Comparison of Interosseous Suture and Endobutton Across Age Groups

Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.

Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study

Background: Syndesmotic injuries are common lesions associated with ankle fractures. Static and dynamic fixation are frequently used in syndesmotic injury-associated ankle fractures. The purpose of this study is to compare short- and mid-term quality of life, clinical outcomes, and gait after static stabilization with a trans-syndesmotic screw or dynamic stabilization with a suture button device. Methods: Here, 230 patients were enrolled in a retrospective observational study. They were divided in two groups according to the fixation procedure (Arthrex TightRope®, Munich, Germany) synthesis vs. osteosynthesis with a 3.5 mm trans-syndesmotic tricortical screw). They then underwent clinical assessment using the American Foot and Ankle Score (AOFAS) at 1, 2, 6, 12, and 24 months after surgery. Quality of life was assessed according to the EuroQol-5 Dimension (EQ-5D) at 2 and 24 months after surgery in the follow-up; gait analysis was performed 2 and 24 months postoperatively. Results: Significant differences were found at a two-month follow-up according to the AOFAS (p = 0.0001) and EQ-5D (p = 0.0208) scores. No differences were noted in the other follow-ups (p > 0.05) or gait analysis. Conclusion: The dynamic and static fixation of syndesmotic injuries in ankle fracture are both efficacious and valid procedures for avoiding ankle instability. The suture button device was comparable to the screw fixation according to functional outcomes and gait analysis.

Short and Middle Functional Outcome in the Static vs. Dynamic Fixation of Syndesmotic Injuries in Ankle Fractures: A Retrospective Case Series Study

BACKGROUND

Syndesmotic injuries are common lesions associated with ankle fractures. Static and dynamic fixation are frequently used in syndesmotic injury-associated ankle fractures. The purpose of this study is to compare short- and mid-term quality of life, clinical outcomes, and gait after static stabilization with a trans-syndesmotic screw or dynamic stabilization with a suture button device.

METHODS

Here, 230 patients were enrolled in a retrospective observational study. They were divided in two groups according to the fixation procedure (Arthrex TightRope^®, Munich, Germany) synthesis vs. osteosynthesis with a 3.5 mm trans-syndesmotic tricortical screw). They then underwent clinical assessment using the American Foot and Ankle Score (AOFAS) at 1, 2, 6, 12, and 24 months after surgery. Quality of life was assessed according to the EuroQol-5 Dimension (EQ-5D) at 2 and 24 months after surgery in the follow-up; gait analysis was performed 2 and 24 months postoperatively.

RESULTS

Significant differences were found at a two-month follow-up according to the AOFAS (p = 0.0001) and EQ-5D (p = 0.0208) scores. No differences were noted in the other follow-ups (p > 0.05) or gait analysis.

CONCLUSION

The dynamic and static fixation of syndesmotic injuries in ankle fracture are both efficacious and valid procedures for avoiding ankle instability. The suture button device was comparable to the screw fixation according to functional outcomes and gait analysis.

Acute Syndesmosis Injuries

Ankle syndesmosis injuries include isolated ligamentous rupture, as well as fractures with ligamentous injury. These injuries can significantly affect athletes in all sports, and lead to prolonged recovery and return to sport. Adequate evaluation and diagnosis of these injuries are imperative for treatment and return to play. Many can be treated nonoperatively, but operative treatment is indicated in fractures with syndesmosis disruption and ligamentous injuries with instability. Anatomic reduction and fixation of these injuries will allow functional rehab and return to sport.

Cost-effectiveness of on-demand removal of syndesmotic screwsx

Purpose

Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw.

Methods

Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs.

Results

Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p < 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness.

Conclusion

The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.

Investigating the Radiological Outcomes of Syndesmosis Injuries in Ankle Fracture Patients After Suture Button Fixation

Concomitant syndesmotic injury occurs in 10% of ankle fractures. Anatomic reduction and maintenance of this reduction is critical in ensuring ankle stability and preventing long-term complications. This is a retrospective cohort study aimed at evaluating the mid-term radiological outcomes of syndesmotic injuries in ankle fracture patients after surgical fixation with suture button device. The study group included 33 patients. Plain radiographs including anteroposterior, lateral and mortise views of the affected ankle were performed preoperatively, postoperatively and at 3-month follow-up. Anteroposterior views were used to measure the amount of tibiofibular overlap and tibiofibular clear space. Paired Student's t test and linear model regression were performed. Between the immediate postoperative and 3-month follow-up period, there was a mean decrease in tibiofibular overlap of 0.841 (±2.07) mm (p = .0259). There was a mean increase in tibiofibular clear space of 0.621 (±1.46) mm (p = .0201). In addition, we found significant correlation between fracture type and change in tibiofibular clear space (p = .047). Our study showed that there is statistically significant widening of the syndesmosis after suture button fixation at 3-month follow-up as evidenced by reduced tibiofibular overlap and increase in tibiofibular clear space. However, they remain within the maximum threshold for acceptable syndesmotic widening of 1.5 mm. Further correlation between radiological outcomes and patient function is needed to determine clinical significance of these changes.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape

AIMS

The ideal management of acute syndesmotic injuries in elite athletes is controversial. Among several treatment methods used to stabilize the syndesmosis and facilitate healing of the ligaments, the use of suture tape (InternalBrace) has previously been described. The purpose of this study was to analyze the functional outcome, including American Orthopaedic Foot & Ankle Society (AOFAS) scores, knee-to-wall measurements, and the time to return to play in days, of unstable syndesmotic injuries treated with the use of the InternalBrace in elite athletes.

METHODS

Data on a consecutive group of elite athletes who underwent isolated reconstruction of the anterior inferior tibiofibular ligament using the InternalBrace were collected prospectively. Our patient group consisted of 19 elite male athletes with a mean age of 24.5 years (17 to 52). Isolated injuries were seen in 12 patients while associated injuries were found in seven patients (fibular fracture, medial malleolus fracture, anterior talofibular ligament rupture, and posterior malleolus fracture). All patients had a minimum follow-up period of 17 months (mean 27 months (17 to 35)).

RESULTS

All patients returned to their pre-injury level of sports activities. One patient developed a delayed union of the medial malleolus. The mean return to play was 62 days (49 to 84) for isolated injuries, while the patients with concomitant injuries returned to play in a mean of 104 days (56 to 196). The AOFAS score returned to 100 postoperatively in all patients. Knee-to-wall measurements were the same as the contralateral side in 18 patients, while one patient lacked 2 cm compared to the contralateral side.

CONCLUSION

This study suggests the use of the InternalBrace in the management of unstable syndesmotic injuries offers an alternative method of stabilization, with good short-term results, including early return to sports in elite athletes. Cite this article: Bone Joint J 2022;104-B(1):68-75.

Suture Button versus Screw Fixation for Distal Tibiofibular Injury and Expected Value Decision Analysis

Patient preference for fixation technique of syndesmotic injury in the presence of an ankle fracture is not known. This study followed a five-step process for expected value decision analysis: decision tree, outcome probabilities, expected patient values, foldback analysis, and sensitivity analysis. Outcome variables were "well" (cases that did not require further procedures or suffer any complications related to surgery), surgical site infection (SSI), loss of reduction (LOR), hardware removal (HWR), and malreduction. The systematic review included 22 studies including 358 patients who underwent suture button fixation and 739 who underwent screw fixation. Outcome probabilities for suture button fixation were 76.4% well, 6.2% SSI, 5.4% LOR, 10.4% HWR, and 1.6% malreduction. Outcome probabilities for screw fixation were 47.1% well, 4.3% SSI, 8.1% LOR, 30.7% HWR, and 9.8% malreduction. After the survey and foldback analysis, overall utility values for suture button and screw fixation were 7.46 and 4.78, respectively. One-way sensitivity analysis revealed that the overall utility value for suture button fixation was greater than the utility value of screw fixation under all circumstances except when the rate of malreduction for suture button fixation was theoretically elevated to 85%. Level of evidence: therapeutic, level IV.

Tratamento da lesão da sindesmose tibiofibular distal associada às fraturas do tornozelo com suture button

Objetivo Avaliar os resultados obtidos do tratamento cirúrgico das fraturas maleolares do tornozelo associadas a lesão da sindesmose tibiofibular distal (STFD) submetidas a procedimento cirúrgico convencional de fixação da fratura e fixação da STFD pelo suture button (SB).

Métodos Avaliou-se retrospectivamente 49 pacientes com uma média de idade de 45 anos e seguimento médio de 34,1 meses. A avaliação clínica e funcional foi baseada na escala visual analógica (EVA) e na escala American Foot and Ankle Society Score (AOFAS, na sigla em inglês) para tornozelo e retropé, retorno às atividades da rotina e retorno ao esporte.

Resultados As médias pós-operatórias das escalas AOFAS e EVA foram, respectivamente, 97,06 (índice de confiança [IC 95%: 95,31 – 98,81] e 0,16 [IC 95% 0,04 – 0,29]. Todos os pacientes retornaram às atividades prévias do cotidiano, sendo que apenas 12 apresentaram algum sintoma residual. Não se verificou instabilidade pós-operatória em nenhum paciente. Ao todo, 46 pacientes retornaram às atividades desportivas e, destes, apenas 1 não retornou ao nível prévio à lesão. Apenas dois pacientes apresentaram alterações relacionadas ao SB. Não houve relato de insatisfação.

Conclusão Em fraturas maleolares do tornozelo com lesão da STFD, a fixação da sindesmose com o SB demonstrou excelentes resultados pós-operatórios.

Nível de Evidência IV, série de casos retrospectiva.

Clinical outcomes of Tightrope system in the treatment of purely ligamentous Lisfranc injuries

Background

Purely ligamentous Lisfranc injuries are mainly caused by low energy damage and often require surgical treatment. There are several operative techniques for rigid fixation to solve this problem clinically. This study evaluated the effect of using the Tightrope system to reconstruct the Lisfranc ligament for elastic fixation.

Methods

We retrospectively analyzed 11 cases with purely ligamentous Lisfranc injuries treated with the Tightrope system from 2016 to 2019, including 8 male and 3 female. X-ray was performed regularly after operation to measure the distance between the first and second metatarsal joint and the visual analogue scale (VAS) score was used to evaluate pain relief. American orthopedic foot & ankle society (AOFAS) and Maryland foot score were recorded at the last follow-up.

Results

The average follow-up time was 20.5 months (range, 17–24). There was statistically significant difference in the distance between the first and second metatarsal joint and VAS score at 3 months, 6 months, and the last follow-up when compared with preoperative values (P < 0.05).Mean of postoperative AOFAS mid-foot scale and Maryland foot score were 92.4 ± 4.3, 94.1 ± 3.5, respectively. The Tightrope system was not removed and the foot obtained better biomechanical stability. No complications occurred during the operation.

Conclusion

Tightrope system in the treatment of purely ligamentous Lisfranc injuries can stabilize the tarsometatarsal joint and achieve satisfactory effect.

Biomechanical comparison of screw, tightrope and novel double endobutton in the treatment of tibiofibular syndesmotic injuries

BACKGROUND

Adequate reduction and stabilization of the syndesmosis are significant to prevent early degeneration of the ankle joint and get better clinical outcomes. However, the routine surgical methods have diffierent limitations. The purpose of this study was to develop a novel double Endobutton fixation to treat the distal tibiofibular syndesmotic injuries, and determine whether the novel double Endobutton fixation demonstrates a better biomechanical property compare with the intact syndesmosis, the screw fixation and the Tightrope fixation.

METHODS

Twenty-four normal fresh-frozen ankle specimens with a mean age of 42 ± 8 (range, 28-62) years were randomly divided equally into four groups: (1) the intact group, (2) the screw group, (3) the Tightrope group, (4) the Endobutton group. 3D printer technology was used to establish the personalized distal tibiofibular syndesmotic navigation modules to determine the accurate bone tunnel. Axial loading was applied in five ankle positions: neutral position, dorsiflexion, plantar flexion, varus and valgus. Rotation torque was applied in two ankle rotation of the neutral position: internal and external.

RESULTS

In most situations, the displacements of the intact group were larger than the screw group, the Tightrope group and the Endobutton group (P < .05), and the displacements of the screw group were smaller than other three groups (P < .05). The displacements of the double Endobutton group were slightly larger than the Tightrope group but no significant differences were found between these two groups except in the dorsiflexion position of axial loading experiments (P < .05). The novel double Endobutton fixation was steadier than intact syndesmosis and more micromotional than screw fixation.

CONCLUSION

Our study demonstrated that the novel double Endobutton can be considered as the better fixation in treatment of distal tibiofibular syndesmotic injuries.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Changes in the Syndesmotic Reduction After Syndesmotic Suture-Button Fixation for Ankle Malleolar Fractures: 1-Year Longitudinal Evaluations Using Computed Tomography

BACKGROUND

Evaluation over time is important in assessing the reduction of the syndesmosis after suture-button fixation for ankle malleolar fractures. The purposes of this study were to evaluate time-dependent change in the syndesmotic reduction immediately after suture-button fixation for ankle malleolus fractures and 1 year after surgery using computed tomography, and to investigate the reliability of the measurement values to evaluate the reduction of syndesmosis.

METHODS

We assessed 28 patients who underwent suture-button fixation for ankle fractures. Syndesmotic reduction was assessed within 2 weeks of the fracture surgery and 1 year after surgery using axial computer tomographic images. Side-to-side differences in the anterior, central, and posterior tibiofibular distances, anteroposterior fibular translation, fibular rotation, and syndesmosis area were measured.

RESULTS

The mean anterior tibiofibular distance and anteroposterior fibular translation were 1.8 mm and 1.5 mm, respectively, after syndesmotic fixation. They decreased to 1.2 mm and 0.6 mm, respectively, at 1 year after surgery (P = .03 and P = .01, respectively). The other measurement values did not change over time. The minimum detectable change in the distance of measurements was 1 mm or less.

CONCLUSION

The anterior tibiofibular distance and anteroposterior fibular translation had decreased 1 year after fixation in ankle malleolar fractures with syndesmotic suture button. Even if the fibula is posteriorly malreduced by the time computed tomography is performed immediately after surgery, the fibula may return to a good position 1 year after surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Biomechanical evaluation of syndesmotic fixation techniques via finite element analysis: Screw vs. suture button

BACKGROUND AND OBJECTIVE

Tibiofibular syndesmotic injuries may cause degenerative changes, reduction in ankle function and compromising ankle stability. Different fixation techniques try to restore its functionality. Screw-fixation is the gold-standard. Recently, suture-button fixation has aroused the attention because it allows for physiologic micromotion while maintaining an accurate reduction. The aim of this study is to compare the biomechanical behaviour of both fixation techniques using the finite element method.

METHODS

A three-dimensional finite element model of the tibiofibular joint was reconstructed simulating the intact ankle and the injured syndesmosis. Then, different methods of syndesmosis fixation were analysed: screws (number of cortices, number of screws and distance between screws) and suture buttons (single, double parallel and double divergent with a sensitivity analysis on the pretension forces) configuration. Ligaments and cartilages were included and simulated as spring elements. Physiological loads during stance phase were simulated.

RESULTS

Syndesmosis widening and von Mises stresses were computed. Syndesmosis widening in the injured configuration compromised joint stability (2.06 mm), whereas using a single quadricortical screw (0.18 mm) stiffened the joint. Syndesmosis widening using suture-buttons were closer to syndesmosis widening of the intact ankle configuration (0.97 mm). Von Mises stresses were higher for the titanium screws than for the suture buttons.

CONCLUSIONS

A detailed biomechanical comparison among different syndesmotic fixation was performed. Suture buttons have advantages with regard to syndesmosis widening in comparison to screw fixation. This fact supports the good long-term clinical results obtained with suture buttons fixation. The proposed methodology could be an efficient tool for preoperative planning.

The Impact of Suture Button Removal in Syndesmosis Fixation

The suture button (SB) device was introduced to negate the need for routine hardware removal in the treatment of syndesmosis injuries. However, a considerable SB removal rate has been reported, and the impact of removal is unknown. This study aimed to evaluate the radiographic and clinical outcomes after removal of SB for syndesmosis fixation. A total of 36 patients who underwent removal surgery after syndesmosis fixation using SB were identified. The mean postoperative time to removal was 12.2 months. On a plain radiograph, tibiofibular clear space (TFCS) was measured and compared at three follow-up time points. In patients with computed tomography (CT) imaging (n = 18), the anterior-to-posterior (A/P) ratio was measured to evaluate changes in quality of reduction. Additionally, clinical outcomes were assessed. There were no significant differences in TFCS between the three follow-up periods. None of the patients exhibited recurrent diastasis after SB removal. Although CT analysis demonstrated malreduction in six patients (33.3%), five of six patients had a subsequent spontaneous reduction of the syndesmosis. Clinically, all patients described the resolution of symptoms related to painful hardware at the final follow-up. Our results demonstrate that SB removal at one year following syndesmosis fixation leads to improved clinical symptoms without negatively impacting the quality of syndesmosis reduction.

Functional outcome of fusion versus ligament reconstruction in patients with a syndesmosis injury: A narrative review

Injury to distal tibiofibular syndesmosis is commonly associated with ankle fractures. The surgical treatment especially in isolated chronic syndesmosis instability is still debated. This article has reviewed literature identified from PubMed, EMBASE and Cochrane from year 2000 onwards and compared the functional outcomes between syndesmosis fusion and ligament reconstruction based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen studies were included. All the included papers described a good-to-excellent post-operative functional outcome without major complications. No significant difference between the two surgical interventions could be concluded. Further studies of better quality shall be conducted in the future.

Suture-button Versus Screw Fixation in Adolescent Syndesmotic Injuries: Functional Outcomes and Maintenance of Reduction

BACKGROUND

Fixation of the tibiofibular syndesmosis is often performed with a trans-syndesmotic screw (SS) or suture-button (SB). SB fixation has been shown to have lower rates of postoperative syndesmotic malreduction, late diastasis, and implant removal, though some studies have found complications related to infection and implant subsidence. The purpose of this study was to compare maintenance of reduction, complications, implant removal and functional outcomes of SB versus SS fixation in adolescents.

METHODS

A retrospective chart review identified patients who underwent syndesmotic fixation from 2010 to 2019 at a single institution. Loss of syndesmotic reduction (diastasis) was defined as either a >2 mm increase in tibiofibular clear space or >2 mm decrease in tibiofibular overlap, and corresponding incongruence of the ankle mortise (medial clear space 1 millimeter greater than superior clear space). Functional outcomes were collected at a minimum of 1 year postsurgery using the Foot and Ankle Ability Measure (FAAM).

RESULTS

Seventy-seven adolescents (45 SS, 32 SB) were included (mean age: 16±1.5 y). Forty-five patients had Weber C fibula fractures, 27 Weber B fractures, and 5 had isolated syndesmotic injuries or small posterior malleolus fractures. Fifty-one patients (66%) had functional outcomes available. There was no significant difference in mean FAAM Sports score between the 2 groups (SB=94.8%, SS=89.8%) at mean follow-up of 4.0±2.1 years. Syndesmotic implant removal occurred in 36/45 patients (80%) in the SS group compared with 4/32 patients (13%) in the SB group. There was 1 case of syndesmotic malreduction requiring revision surgery in the SS group, and no cases of postoperative malreduction or diastasis in the SB group. Nine patients in the SB group and 8 in the SS group weighed over 100 kilograms, with no cases of diastasis in these larger patients. There were 4 superficial infections and 1 deep infection in the screw group, with 1 superficial infection in the SB group.

CONCLUSIONS

While both SB and screw fixation maintained syndesmotic reduction, SB fixation led to lower rates of implant removal surgery. SB fixation was equally effective at preventing recurrent diastasis in adolescents weighing over 100 kilograms, and functional outcomes were at least equivalent to screw-fixation at mean follow-up of 4.0 years.

LEVEL OF EVIDENCE

Level III.

Anatomic Repair vs Closed Reduction of the Syndesmosis

BACKGROUND

The goal of the study was to compare radiographic and functional outcomes between conventional closed syndesmotic reduction and screw fixation with open reduction, direct repair of the anterior inferior tibiofibular ligament (AiTFL) and screw fixation. We hypothesized that open reduction with restoration of the AiTFL would provide an improved reduction with better radiographic and functional outcomes.

METHODS

Fifty consecutive patients with OTA 44-C ankle fractures were enrolled. Treatment was nonrandomized and based on surgeon preference. Patients were treated with either open reduction, suture-anchor AiTFL repair, and screw fixation (ART group), or conventional closed reduction of the syndesmosis followed by screw fixation (CR group). The primary outcome measure was anteroposterior (AP) displacement of the fibula on CT scan at 3 months postoperatively. Secondary outcome measures included the Maryland Foot Score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score, and the Foot and Ankle Outcome Score (FAOS).

RESULTS

Mean AP difference between injured and noninjured ankles was decreased in the ART group compared with the CR group (0.7 ± 0.3 mm vs 1.5 ± 0.3 mm, P = .008). No differences were observed between groups in overall scores for secondary outcome measures. The ART group displayed a significant difference in Maryland Foot Shoe subscore at 12 months (ART = 9.5 vs CR = 8.3, P = .03) and FAOS Quality of Life subscore at 12 months (64.1 compared to 38.3, P = .04).

CONCLUSION

Open anatomic syndesmotic repair resulted in improved radiographic outcomes compared with closed reduction. Cosmesis was worse at 6 weeks compared to the CR group; however, quality of life and shoewear were improved in the ART group at 1 year postoperatively.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Comparison of Open Anterior Syndesmotic Repair Augmented With Suture-Tape and Trans-syndesmotic Screw Fixation: A Biomechanical Study

The treatment of syndesmotic injuries with ankle fractures is controversial. The purpose of this study was to compare the biomechanical properties of open anterior syndesmotic repair with those of screw fixation. Ten matched pairs of human cadaver specimens were subjected to open syndesmotic repair or screw fixation. Each specimen underwent initial intact physiologic loading, consisting of 10 cycles of external torsional loading with a peak torque of 7.5 Nm at 0.05 Hz. Injuries of the anterior inferior tibiofibular ligament, tibiofibular interosseous membrane, and deltoid ligament were applied to each specimen. Postfixation cyclic loading consisted of 50 cycles of combined axial and external rotation loading with peak torques of 750 N and 7.5 Nm at a rate of 0.05 Hz. After postfixation loading, each specimen underwent failure loading by external rotation at 0.25 degrees/second. Failure torque and failure angle were measured. The paired t test and Wilcoxon signed-rank test were used to analyze the data. Mean failure torques were 95.63 Nm in the open anterior syndesmotic repair augmented with suture-tape group and 108.61 Nm in the screw group. Mean failure angles were 34.93 degrees in the open anterior syndesmotic repair augmented with suture-tape group and 43.55 degrees in the screw group. These data were not statistically significantly different between the groups (p= .7682 and .4133, respectively). Open anterior syndesmotic repair augmented with suture tape for ankle syndesmotic injury provides similar torsional strength to that of screw fixation. Therefore, this technique can be considered as an alternative treatment option for syndesmosis injury.

A comparison of double single suture-button fixation, suture-button fixation, and screw fixation for ankle syndesmosis injury: A retrospective cohort study

Different methods have been used throughout the years for syndesmotic injury but there is no consensus on the ideal treatment. Some methods are expensive and some have more complications. The aim of this study is to compare single suture endobutton with double suture endobutton and screw fixation for syndesmotic injury.Sixty nine patients with syndesmotic injury with fibular fractures whom were treated with a single interosseous suture endobutton system (ZipTightTM, Zimmer Biomet), a double interosseous suture endobutton system (ZipTightTM, Zimmer Biomet) and 1 syndesmotic screw (TST, Istanbul, Turkey) were included in this study. Functional and radiological results from patient records between 2015 and 2018 were retrospectively evaluated.Twenty patients were treated with the double interosseous suture endobutton, 23 were treated with the single interosseous suture endobutton, and 26 were treated with traditional AO screw fixation. Three patients from the screw fixation group (11.5%) required revision surgery (P < .05). All the radiologic and clinical outcomes were statistical similar in all 3 groups.Our findings showed that the interosseous suture endobutton system is at least as safe as the screw fixation technique for treatment of syndesmosis joint injuries and can be used as an alternative to the screw method. The interosseous suture endobutton system eliminates the need for a second surgery to remove the hardware, which minimizes the probability of re-diastasis. Since our results showed no statistical difference between single and double interosseous suture endobutton systems, the less costly single endobutton system may be the better alternative.

Surgical Site Infections After Routine Syndesmotic Screw Removal: A Systematic Review

OBJECTIVES

To investigate the incidence of surgical site infections (SSIs) after routine removal of syndesmotic screws (SSs) placed to stabilize syndesmotic injuries.

DATA SOURCES

A systematic literature search was performed in the PubMed, Cochrane, and EMBASE databases for studies published online before February 2020, using the key words and synonyms of "syndesmotic screw" ("ankle fractures" or "syndesmotic injury") and "implant removal."

STUDY SELECTION

Studies were eligible for inclusion when they described >10 adult patients undergoing elective/scheduled removal of the SS.

DATA EXTRACTION

The 15 included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Baseline characteristics of the studies, the study population, the intervention, the potential confounders, and the primary outcome (% of SSIs) were extracted using a customized extraction sheet.

DATA SYNTHESIS

The primary outcome was presented as a proportion of included patients and as a weighted mean, using inverse variance, calculated in RStudio. Furthermore, potential confounders were identified.

CONCLUSIONS

The percentage of SSIs ranged from 0% to 9.2%, with a weighted mean of 4%. The largest proportion of these infections were superficial (3%, 95% confidence interval: 2-5), compared with 2% deep infections (95% confidence interval: 1-4). These rates were comparable to those of other foot/ankle procedures indicating that the individual indication for SS removal (SSR) should be carefully considered. Future studies should focus on valid indications for SSR, the influence of prophylactic antibiotics on an SSI after SSR, and complications of retaining the SS to enable a fair benefits/risks comparison of routine versus on-demand removal of the SS.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Injury mechanism affects the stability of suture-button syndesmosis fixation

BACKGROUND

Ankle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure syndesmosis injury, Weber-B, and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation.

METHODS

We retrospectively reviewed 63 patients with ankle syndesmosis injury who underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope was evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure syndesmosis injury, Weber-B, and Weber-C type fractures were performed.

RESULTS

Syndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 to 4.04 mm, the tibiofibular overlap was increased from 3.05 to 6.44 mm, and the medial clear space was reduced from 8.12 to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS 3.82 to 4.45 mm, p < 0.01 and TFO 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05).

CONCLUSIONS

Suture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored.

TRIAL REGISTRATION

This trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020.

LEVEL OF EVIDENCE

III.

Cortical suture button fixation vs. bicortical screw fixation in the Latarjet procedure: a biomechanical comparison

BACKGROUND

The Latarjet procedure traditionally has been performed with 2 screws in an open manner. Recently, cortical suture button fixation for coracoid transfer has been used in hopes of mitigating complications seen with screw placement. The aim of this study was to evaluate a cortical suture button and technique currently available in the United States compared with screw fixation in the Latarjet procedure in a cadaveric model.

METHODS

We randomly assigned 9 matched pairs of fresh-frozen cadaveric shoulders (N = 18) to undergo the Latarjet procedure with either screw fixation or cortical suture button fixation. After fixation, all shoulders underwent biomechanical testing with direct loading on the graft vas a material testing system. Cyclic testing was performed for 100 cycles to determine axial displacement with time; each graft was then monotonically loaded to failure.

RESULTS

The maximum cycle displacement was significantly less for screw fixation vs. cortical suture button fixation (3.1 ± 1.3 mm vs. 8.9 ± 2.1 mm, P < .0001). The total load at failure was 481.1 ± 88.8 N for screws and 175.5 ± 95.8 N for cortical suture buttons (P < .0001). Bony damage to the surrounding anatomy was more extensive at failure in the screw-fixation group.

CONCLUSION

At time zero, the cortical button fixation and technique did not resist direct loads to the graft as much as traditional screw fixation, although bony damage to the surrounding anatomy was more extensive in screw fixation than button fixation. In the event of unanticipated loading, this could place a patient at higher risk of graft migration, which could lead to unintended early outcomes. These results support the need for implants and techniques specifically tailored to the Latarjet procedure and should bring into question the adoption of a cortical button and technique not specific to the procedure.

Syndesmotic malreduction may decrease fixation stability: a biomechanical study

Background

This study aims to investigate the malreduction of syndesmosis and its effects on stability.

Methods

The biomechanical tests, including the three-dimensional (3D) displacement of the syndesmotic incisura, fibular rotation angle, and torque resistance, were performed on six cadaver legs. These specimens were first tested intact (intact group), then cut all the syndesmotic ligaments and fixed in anatomical position (anatomical model group) and test again. After that, syndesmosis was fixed in 1 cm malreduction (anterior and posterior displacement group) to do the same test.

Results

In internal or external load, there were significant differences in torque resistance and fibular rotation angle (internal t = 2.412, P = 0.036; external t = 2.412, P = 0.039) between the intact and post-malreduction groups. In internal rotation load, there were significant differences in sagittal displacement between the intact and post-malreduction groups (P = 0.011), and between the anatomical and post-malreduction groups (P = 0.020). In external rotation load, significant differences existed between the intact and ant-malreduction group (P = 0.034) in sagittal (anterior-posterior) displacement. Significant differences also existed between the intact and post-malreduction groups (P = 0.013), and between the anatomical and post-malreduction groups (P = 0.038) in coronal (medial-lateral) displacement.

Conclusions

Malreduction in different conditions does affect the stability of the syndesmotic fixation. The result of the study may reveal the biomechanical mechanism of poor clinical outcome in syndesmosis malreduction patients and pathological displacement patterns of the ankle under syndesmotic malreduction conditions.

Level of evidence

III

Improved Reduction of the Tibiofibular Syndesmosis With TightRope Compared With Screw Fixation: Results of a Randomized Controlled Study

OBJECTIVE

To compare the rate of malreduction after high fibular fractures associated with syndesmosis injury treated with open reduction and internal fixation, with either 2 screws or 1 knotless TightRope device.

DESIGN

Prospective randomized controlled multicenter trial.

SETTING

Eleven academic and community hospitals including Level 1 and Level 2 trauma centers across Canada.

PATIENTS/PARTICIPANTS

One hundred three patients with OTA/AO 44-C injuries with demonstrated radiographic syndesmosis diastasis or instability after malleolar bony fixation were followed for 12 months after treatment.

METHODS

Open reduction of the syndesmosis was performed in all cases. Fixation was randomized to either TightRope (1 knotless TightRope, group T) or screw fixation (two 3.5-mm cortical positional screws placed across 3 cortices, group S). Surgical techniques and rehabilitation were standardized. All surgeons were trained or experienced in the use of the TightRope device. Follow-up was performed at 2 and 6 weeks, 3, 6, and 12 months.

MAIN OUTCOME MEASURE

Rate of malreduction based on bilateral ankle computed tomography scan results at 3 months after fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ-5D, the Olerud-Molander Ankle Score, the Foot and Ankle Disability Index, and the Work Productivity Activity Impairment Questionnaire. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only.

RESULTS

Overall, the rate of malreduction using screw fixation was 39% compared with 15% using TightRope fixation (P = 0.028, χ). Analysis of computed tomography results was performed using a 2-mm translation or 10-degree rotation threshold for malreduction and included fibular translation (anterior, posterior); syndesmosis distance (anterior, posterior, and mid); medial compression; and rotation (fibular and articular). Patients in group T had greater anterior translation (5.4 ± 1.8 mm) compared with the contralateral limb (4.3 ± 1.3 mm, P < 0.01) or group S (4.6 ± 1.5 mm, P = 0.05). Group T syndesmoses also had greater diastasis compared with control limb (4.1 ± 1.3 vs. 3.3 ± 1.4 mm, P < 0.01) and less fibular medialization compared with group S (1.04 ± 1.8 vs. 0.3 ± 1.8 mm, P = 0.05). Functional outcome measures demonstrated significant improvements over time, but no differences between fixation groups. Foot and Ankle Disability Index scores at each time interval were 44 ± 22 (T) versus 45 ± 24 (S) (6 weeks), 76 ± 14 versus 73 ± 17 (3 months), 89 ± 10 versus 86 ± 13 (6 months), and 93 ± 9 versus 90 ± 14 (12 months) (all P > 0.2). The reoperation rate was higher in the screw group compared with TightRope (30% vs. 4%, P = 0.02) with the difference driven by the rate of implant removal.

CONCLUSIONS

Based on our results, the TightRope device seems to compare favorably with two, 3.5-mm, 3-cortex screw fixation for syndesmosis injuries.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Hemitrapeziectomy and Suture Button Suspensionplasty in the Treatment of First Carpometacarpal Joint Eaton-Littler Stage 2-3 Arthrosis

Background  Degenerative arthritis of the first carpometacarpal (CMC) joint is a common degenerative condition in the hand. Many different surgical procedures have been applied for years. However, in the studies there is no consensus about the superiority of one technique to another. Questions/Purposes  In this study, we evaluated the results of the patients with first CMC Eaton-Littler stage 2-3 arthrosis who were operated to prevent first metacarpal joint lateral subluxation and migration with arthroscopic hemitrapeziectomy and suture button suspensionplasty. Patients and Methods  Between 2011 and 2014, 21 patients (16 female, five male) were evaluated retrospectively. Mean age was 52.3 years. The preoperative and postoperative assessments were performed with visual analog scale (VAS) and disabilities of the arm, shoulder, and hand score (DASH) scores. The Kapandji's thumb opposition score was used to assess thumb range of movement. The patients were assessed after arthroscopy according to Badia classification. Results  Mean follow-up period was 50.1 months. According to Badia classification, seven patients were found to be type 2 and 14 patients were type 3. The mean preoperative Kapandji's score was 7.6 and the mean postoperative Kapandji's score was 9.2. The mean VAS values were 8.2 preoperatively and 1.9 postoperatively. The mean preoperative DASH value was 23.4 and the mean postoperative DASH value was 5.5. The mean preoperative grip strength was 66.2 and the mean postoperative grip strength was 75.1. The mean preoperative pinch strength was 14.8 and the mean postoperative pinch strength was 20.2. Conclusion  Arthroscopic hemitrapeziectomy and suture button suspensionplasty is a minimal invasive technique and can be performed with low morbidity in the treatment of first CMC joint Eaton-Littler stage 2-3 arthrosis. By this technique, the patients' existing instability and pain problems can be solved. Complications, such as loosening of the suture button at the first metacarpal at the postoperative period due to direct trauma to the first CMC joint, could be avoided using a new suture button. Type of Study/ Level of Evidence  Therapeutic IV.

Distal Tibiofibular Syndesmosis Dysfunction: A Systematic Literature Review of Dynamic Versus Static Fixation Over the Last 10 Years

The goal of the present work was to perform a systematic review of the literature of the past 10 years regarding dynamic and static fixation of the distal tibiofibular syndesmosis to determine any clinical differences between the 2 procedures. A literature search of the PubMed MEDLINE database was conducted to identify relevant studies related to distal tibiofibular syndesmosis. Studies before January 1, 2007, were excluded to limit the project to the recent literature. Clinical outcomes, device removal rates, time to weightbearing after the initial procedure, and the cost effectiveness of each device were explored. In these 26 studies, 350 patients were treated using a dynamic technique and 845 were treated using a static technique. The weighted American Orthopedic Foot and Ankle Score was 91.70 (standard error [SE] 1.87) for dynamic fixation patients and the weighted average was 86.48 (SE 2.17) for static fixation patients (p = .068). A secondary procedure to remove the fixation device was performed in 7.7% of dynamic fixation patients and in 39.4% of static fixation patients when studies with 100% device removal were excluded (p < .0001). The mean time to weightbearing was 5.96 (SE 0.72) weeks for patients who underwent dynamic fixation and 10.45 (SE 0.99) weeks for those who had static fixation (p = .0002). The cost for dynamic fixation was found to be less than that for static fixation when secondary procedures for device removal were considered. Based on similar clinical functional scores, lower secondary procedure rates, faster time to full weightbearing, and lower costs to patients, dynamic fixation of the distal tibiofibular syndesmosis may be a superior option compared with static fixation.

To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: A meta-analysis

BACKGROUND

To compare the efficacy between fixation with suture-button and screw in the treatment of syndesmotic injuries: a meta-analysis.

METHODS

We comprehensively searched PubMed, Embase, and the Cochrane Library and performed a meta-analysis of randomized controlled trials (RCTs) and retrospective comparative studies (RTCs). We performed using Review Manager 5.2.

RESULTS

Three RCTs and six retrospective studies were conducted, including a total of 397 patients. The significant differences of the fixation of suture-button were reported for AOFAS scores (at 3, 6 and 12 months follow-up), full-weight time, reoperation, malreduction and the rate of failure of fixation. There were no significant differences between the groups regarding complications of infection, VAS, OMAS, range of motion, TFCS, TFO and MCS.

CONCLUSIONS

Neither the functional outcome nor complications significantly differed between the fixation methods, but suture-button might lead to a quicker return to work. This analysis needs to be confirmed and updated by larger sample data and rigorously designed RCTs.

Lower complication rate and faster return to sports in patients with acute syndesmotic rupture treated with a new knotless suture button device

PURPOSE

Suture button devices for tibiofibular syndesmosis injuries provide semirigid dynamic stabilization, but complications including knot irritation have been reported. No randomized trials of the new knotless suture button devices have been performed. We hypothesized that knotless suture button devices eliminate knot irritation and facilitate quicker return to sports. This study was performed to compare the clinical outcomes, complication rates, and time to return to sports between a new knotless suture button device and syndesmotic screw fixation.

METHODS

This study included 54 patients treated for ankle syndesmotic injury from 2012 to 2014 with a knotless suture button device or syndesmotic screw fixation. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society score, Foot and Ankle Disability Index, Olerud and Molander score, and visual analog scale for pain and function. Secondary outcome measures were the complication rate and time required to return to sports. Patients underwent clinical and radiological evaluations preoperatively and three times during the 1-year postoperative follow-up.

RESULTS

54 of 62 eligible patients were analyzed, median age 37 (18-60) and underwent the 1-year follow-up. The screw fixation and knotless suture button groups comprised 26 and 28 patients, respectively. The complication rate was significantly lower (p = 0.03) and time to return to sports was significantly shorter in the knotless suture button than screw fixation group (average, 14 versus 19 weeks, respectively; p = 0.006). No significant differences were identified in clinical outcomes or visual analog scale scores for pain and function between the groups. Age, injury mechanism, and body mass index did not significantly affect the time required to return to sports activities. The type of fixation was the only independent variable that reached statistical significance (p = 0.006).

CONCLUSION

Syndesmotic screw fixation and the new knotless suture button device both resulted in good clinical results. Lower complication rate and the earlier time to return to sports make the new knotless suture button device recommendable especially for highly active patients.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Costs and Radiographic Outcomes of Rotational Ankle Fractures Treated by Orthopaedic Surgeons With or Without Trauma Fellowship Training

INTRODUCTION

We evaluated the radiographic outcomes and surgical costs of surgically treated rotational ankle fractures in our health system between providers who had completed a trauma fellowship and those who had not.

METHODS

We grouped patients into those treated by trauma-trained orthopaedic surgeons (TTOS) and non-trauma-trained orthopaedic surgeons (NTTOS). We graded the quality of fracture reductions and calculated implant-related costs of treatment.

RESULTS

A total of 208 fractures met the inclusion criteria, with 119 in the TTOS group and 89 in the NTTOS group. Five patients lost reduction during the follow-up period. The adequacy of fracture reduction at final follow-up did not differ (P = 0.29). The median surgical cost was $2,940 for the NTTOS group and $1,233 for the TTOS group (P < 0.001).

DISCUSSION

We found no notable differences in radiographic outcomes between the TTOS and NTTOS groups. Cost analysis demonstrated markedly higher implant-related costs for the NTTOS group, with the median surgical cost being more than twice that for the TTOS group.

LEVEL OF EVIDENCE

Level III.

Cost-Effectiveness Analysis of Syndesmotic Screw Versus Suture Button Fixation in Tibiofibular Syndesmotic Injuries

OBJECTIVES

To evaluate the cost effectiveness of suture buttons compared with syndesmotic screws for repair of tibiofibular syndesmotic injuries.

METHODS

A decision tree model was constructed to describe outcomes after syndesmosis repair using suture buttons and syndesmotic screws from the perspective of a capitated health care system. Outcomes were uneventful healing, removal of symptomatic implants, deep infection, and persistent diastasis requiring revision. Weighted literature averages were used to estimate variables for a baseline model. Outcomes were measured in quality adjusted life years. Procedure and implant costs were derived from Medicare reimbursement rates and the University Health System Consortium. An incremental cost-effectiveness ratio threshold of $50,000 per quality-adjusted life years was used to evaluate cost effectiveness.

RESULTS

The baseline model did not identify suture buttons to be cost effective. Sensitivity analysis demonstrates the model to be exquisitely sensitive to small changes in reoperation rates and implant price. At median University Health System Consortium implant prices, if the removal rate for symptomatic screws is below 13.7%, then screws are cost effective. If the screw removal rate is greater than 17.5%, then a suture button is cost effective. Within this interval, detailed analysis of the model suggests that screws may be the cost-effective strategy, but that determination should be taken with caution.

CONCLUSIONS

Moving away from the practice of routinely removing all syndesmotic screws has changed the financial landscape of syndesmosis repair. At their median cost, suture buttons are likely to be cost effective over screws for symptomatic screw removal rates greater than 17.5%. Cost effectiveness is sensitive to changes in implant removal rates and the number of devices used per patient.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What's new in ankle fractures

The diagnosis and treatment of ankle fractures has evolved considerably over the past two decades. Recent topics of interest have included indications for operative treatment of isolated lateral malleolus fractures, need for fixation of the posterior malleolus, utilization of the posterolateral approach, treatment of the syndesmosis, and the potential role of fibular nailing. In this update, we concisely review these topics and what to expect in the future literature.

Management of syndesmotic injuries of the ankle

Injuries to the tibioperoneal syndesmosis are more frequent than previously thought and their treatment is essential for the stability of the ankle mortise.

Recognition of these lesions is essential to avoid long-term morbidity.

Diagnosis often requires complete history, physical examination, weight-bearing radiographs and MRI.

Treatment-oriented classification is mandatory.

It is recommended that acute stable injuries are treated conservatively and unstable injuries surgically by syndesmotic screw fixation, suture-button dynamic fixation or direct repair of the anterior inferior tibiofibular ligament.

Subacute injuries may require ligamentoplasty and chronic lesions are best treated by syndesmotic fusion.

However, knowledge about syndesmotic injuries is still limited as recommendations for surgical treatment are only based on level IV and V evidence.

Cite this article: EFORT Open Rev 2017;2:403–409. DOI: 10.1302/2058-5241.2.160084

A systematic review of suture-button versus syndesmotic screw in the treatment of distal tibiofibular syndesmosis injury

BACKGROUND

Now, using a suture-button device to treat distal tibiofibular syndesmotic injuries is overwhelming due to its advantages over screw fixation. Current systematic review was conducted to make a comparison between suture-button fixation and traditionally screw fixation in the treatment of syndesmotic injuries. The outcomes included functional outcomes, implant removal, implant failure, malreduction, post-operative complications (except implant failure and malreduction), and cost-effectiveness aspects.

METHOD

A literature search in the electronic databases of Medline, Embase, the Cochrane Library, Web of Science was conducted to identify studies until March 2017. The references of the included articles were also checked for potentially relevant studies. Only English articles were included. We followed the Preferred Reporting Items for Systematics reviews and Meta-Analysis (PRISMA) guidelines in this review.

RESULTS

Finally, 10 studies were identified, encompassing a total of 390 patients. The mean American Orthopaedic Foot and Ankle Society ankle score (AOFAS) score of 150 patients treated with the suture-button device was 91.06 points, with an average follow-up of 17.58 months, and the mean AOFAS score of 150 patients treated with syndesmotic screws was 87.78 points, with an average follow-up of 17.73 months. Implant removal was reported in 5 of 134 (3.7%) patients treated with the suture-button device, and in 54 of 134 (40.2%) patients treated with the syndesmotic screw. No patient in the suture-button fixation group had implant failure, however the rate of implant failure in the screw fixation group was 30.9%. Malreduction was reported in 1 of 93 (1.0%) patients treated with the suture-button device, and in 12 of 95 (12.6%) patients treated with the syndesmotic screw. The rate of post-operative complications in the suture-button fixation group was 12.0% and 16.4% in the screw fixation group. There was only one publication demonstrated about cost-effectiveness aspects, it showed that patients treated with the suture-button device spent on average $1482 less and had a higher quality of life by 0.058 quality-adjusted life-year compared with patients who received fixation with 2 syndesmotic screws in supination-external rotation type 4 injuries.

CONCLUSION

Based on our research, though the suture-button fixation group had similar functional outcome (measured on the AOFAS score) and post-operative complication rate compared with the syndesmotic screw fixation group, the suture-button device could lead to better objective range of motion (ROM) measurements and earlier return to work. Besides, the suture-button fixation group had lower rate of implant removal, implant failure, and malreduction. However, high-quality randomized controlled trials with more uniformity in outcome reporting are desirable to determine the long-term effects and cost-effectiveness of the suture-button device.

Five-Year Outcomes After Treatment for Acute Instability of the Tibiofibular Syndesmosis Using a Suture-Button Fixation System

Background:

Suture-button repair is a widely accepted surgical treatment for acute and isolated ankle syndesmosis injuries. To our knowledge, midterm results have not previously been reported.

Purpose:

To evaluate the clinical, qualitative, and quantitative radiological midterm outcomes of suture-button repair after acute isolated ankle syndesmosis injuries.

Study Design:

Retrospective case series; Level of evidence, 4.

Methods:

Clinical outcomes were measured using the Foot and Ankle Disability Index (FADI) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Three-tesla magnetic resonance imaging (MRI) was performed bilaterally at the ankle. Besides morphological sequences for evaluation of the syndesmosis and degenerative changes of the ankle using the Ankle Osteoarthritis Scoring System (AOSS), the MR protocol included a coronal 2-dimensional multislice multiecho sequence for quantitative cartilage T2-weighted mapping. Spearman correlations and paired t tests were used for statistical analysis.

Results:

This retrospective study included 19 consecutive patients (mean age, 29.7 ± 11.5 years) with acute isolated syndesmosis injuries treated with a suture-button system between January 2006 and June 2014, with a mean follow-up of 5.1 ± 2.6 years. Postoperatively, the median FADI score was 136 (range, 78-136), and the median AOFAS score was 100 (range, 87-100). Seventeen (89.5%) patients reported to have reached their preinjury level of sports activities. MRIs of 16 patients were obtained and all showed intact anterior and posterior syndesmotic ligaments; however, in most patients, the previously injured syndesmotic ligament was thickened compared with the uninjured ankle. Average width of the anterior (P = .81) and posterior (P = .60) syndesmosis was not significantly different between the ipsilateral (3.2 ± 1.2 and 4.4 ± 0.9 mm) and contralateral ankles (3.0 ± 0.6 and 4.2 ± 0.7 mm). The median AOSS score was 1.5 (range, 0-11) for the ipsilateral ankle and 0 (range, 0-6) for the contralateral ankle. T2 values of articular cartilage did not significantly differ between the involved and the uninjured ankle (P = .68). Five patients needed hardware removal due to persistent skin irritation, and 1 patient suffered from reinstability of the ankle resulting in revision surgery 2 years after the index surgery.

Conclusion:

Suture-button fixation is an excellent treatment for acute and isolated syndesmosis injuries, resulting in stable ankles without early or advanced osteoarthritic changes at midterm follow-up.

Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report

Background/aim

The distal tibiofibular joint is described as a syndesmosis. Traditionally, severe syndesmotic injuries with diastasis have been treated surgically with screw fixation. This case series details an ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol that reduces the amount of time to return to professional rugby league in the UK. The aim of this study was to describe players’ journey from injury, through diagnosis to surgery, rehabilitation and return to participation, detailing time scales and methods used at each stage to highlight the change in current practice.

Methods

Players were identified via a single orthopaedic surgeon in the UK who specialises in ankle syndesmosis repair. Between January 2010 and September 2015, adult men playing full-time professional rugby league in the UK Super League with ankle syndesmosis injuries were identified.

Results

Eighteen players from six different clubs were included. The most common mechanism of injury was forced dorsiflexion/eversion. The average return to participation was 64 days (SD 17.2, range 38–108). This compares favourably to reports of between 120 and 180 days following screw fixation.

Conclusion

Ankle syndesmosis tightrope repair and an accelerated rehabilitation protocol is as safe as traditional methods. The accelerated rehabilitation protocol promotes early weight-bearing and has shown to expedite the return to sport for professional Rugby League players. It is possible to return to sport 2 months after a tightrope repair and accelerated rehabilitation, compared with 3–6 months post screw fixation. This is extremely encouraging for the professional sporting population.

Syndesmosis Stabilisation: Screws Versus Flexible Fixation

Orthopedic surgery is not short of situations where there is controversy regarding optimum management. Treating ankle syndesmosis injuries is an example where practice varies widely and there are many questions that remain unsatisfactorily answered. When addressing the type of syndesmosis stabilization that is required it is essential to ascertain the extent of instability. Only then can a logical approach to restoring the ankle mortise be achieved. Fixation of fibula shaft fractures and posterior malleolus fractures can restore sufficient stability to render syndesmosis stabilization unnecessary. The indications and techniques for stabilizing the distal tibiofibular joint are reviewed with clinical examples.

Current trends in the diagnosis and management of syndesmotic injury

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

Tightrope fixation of syndesmotic injuries in Weber C ankle fractures: a multicentre case series

BACKGROUND

No general consensus has yet been established for the gold standard treatment of ankle syndesmotic complex injuries. Recent literature has documented the success of ankle tightrope fixation for heterogeneous ankle fracture patterns, resulting in syndesmotic complex injuries. We present a multicentre case series assessing the clinical, radiological and functional outcomes of patients with Weber C ankle fractures treated with the Arthrex TightRope^® fixation system.

METHOD

We performed a retrospective analysis of all adult patients with Weber C ankle fractures who were treated with the Arthrex TightRope^® fixation system at four centres over a 3-year period. All patients were followed up for a mean of 14 months (range 12-26). Outcomes measures were assessed subjectively using functional scores (AOFAS and Olerud and Molander) and objectively using radiological measurements, complication rates and revision surgery rates.

RESULTS

Thirty-six patients met our eligibility criteria. The mean age at operation was 31 years (range 18-65). There were 20 males and 16 females. No patients were lost to follow-up. The ankle tightrope maintained satisfactory reduction in the ankle mortise in 97% of cases. Of these 35 successfully treated cases, no evidence of re-displacement on follow-up radiographs of the syndesmotic complex was observed at an average of 10.8 months (range 6-12). Post-operative mean medial clear space was 3.1 mm, and mean tibio-fibular overlap was 10.1 mm. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.8 (range 67-98) at a mean follow-up of 14 months (range 12-26). The overall complication rate was 6% (one failure requiring revision surgery and one medial sided skin irritation requiring removal of suture button). No infections or wound complications occurred.

CONCLUSION

Tightrope fixation is a safe alternative to screw fixation for syndesmotic complex injuries in Weber C ankle fractures. We have shown that it has low complication rates and a high patient satisfaction.

A 24-Month Follow-Up of a Custom-Made Suture-Button Assembly for Syndesmotic Injuries of the Ankle

In the present retrospective analysis, we introduce a custom suture-button fixation device for acute ankle syndesmotic injuries that allows for early weightbearing without another planned operation for hardware removal. We evaluated 87 consecutive ankles in 87 patients (49 males [56.32%] and 38 females [43.68%]). Of the 87 patients, 15 (17.24%) withdrew or were lost to follow-up, leaving 72 patients (82.76%) in the present study. Their mean age was 35.2 (range 17 to 67) years. Nineteen patients (26.39%) presented with a pure syndesmotic disruption, and 53 (73.61%) had associated malleolar fractures. The American Orthopaedic Foot and Ankle Society scale score improved significantly from 31.2 ± 4.2 preoperatively to 88.5 ± 5.3 at an average of 24 months postoperatively (p < .0043). Revision was undertaken because of implant failure in 4 ankles (5.56%). Two revisions (2.78%) were performed in 2 ankles because of early weightbearing in the first 2 weeks after surgery. The third patient (1.39%) underwent revision at 5 weeks postoperatively. This syndesmotic reduction failure was attributed to failure of the threads, which was noted at the second surgery. The fourth patient (1.39%), a 66-year-old male, underwent revision at 5 months postoperatively because of persistent infection. An 18-month postoperative radiograph was available for all patients. The medial clear space had significantly decreased, from 8.2 ± 3.1 mm preoperatively to 3.5 ± 2.2 mm at 18 months postoperatively (p < .0344). Likewise, the tibiofibular clear space had decreased significantly, from a mean of 8.8 ± 3.7 mm preoperatively to a mean of 3.7 ± 2.2 mm at 18 months postoperatively (p < .0322). In conclusion, suture-button fixation described in the present report delivered satisfactory functional outcomes and anatomic reduction at minimum of 18 months after surgery.

The use of TightRope fixation for ankle syndesmosis injuries: our experience

PURPOSE

Ten percentage of all ankle fractures sustain an associated syndesmotic injury. TightRope is a relatively new technique for syndesmosis fixation, characterized by a non-absorbable FibreWire held tight between two cortical metal buttons. The purpose of this study was to evaluate the results obtained with the use of this device.

METHODS

From January 2011 to December 2015, 54 patients with ankle diastases were treated. Eighteen patients were excluded from the study. Fractures of the fibula or tibia requiring fixation were internally fixed using standard AO techniques. Preoperative and the most recent postoperative ankle radiographs were reassessed for measurements of the tibiofibular clear space (TFCS), medial clear space (MCS) and tibiofibular overlap (TFO). Clinical outcomes were assessed at the time of follow-up using the American Orthopaedic Foot and Ankle Society (AOFAS) score, a self-administered Foot and Ankle Disability Index (FADI) score and patients satisfaction.

RESULTS

The mean follow-up was 28, 64 months. Mean values for MCS, TFCS and TFO were 1.51-1.53 and 0.25 cm, respectively. The mean AOFAS score was 93.11, and the mean FADI score was 130.11. Twenty-nine (80.6 %) patients reported their outcome as excellent or very good.

CONCLUSIONS

TightRope technique can achieve flexible fixation of the syndesmosis and permit full range of motion of the tibiofibular joint. Patients can start rehabilitation exercise at an early stage after operation. The results of this study indicate that TightRope fixation is a valid option for syndesmotic injuries.

A systematic review on dynamic versus static distal tibiofibular fixation

BLACKGROUND

In the last couple of years dynamic fixation for syndesmosis injuries, using a suture-button technique, raised more interest due to its advantages over the static fixation. In the current systematic review suture-button fixation is compared to the traditionally applied static fixation in unstable ankle fractures accompanied with distal tibiofibular syndesmosis injury, including the functional outcome, post-operative complications, reoperation rate, recurrent diastasis and financial aspects.

METHODS

A computerized literature search using PubMed/MEDLINE and EMBASE was conducted in search of suitable articles between January 2006 and February 2016. A total of 4 suture-button studies, 5 suture-button vs. static fixation studies and 1 study discussing the financial aspects were identified.

RESULTS

The AOFAS of 104 patients treated with the suture-button device was 91.08 points with an average study-follow up of 24.85 months. The AOFAS of 106 patients treated with a static fixation device was 87.95 with an average follow-up of 24.78 months. Removal of the suture-button device was reported in 10.5% of 229 patients and removal of the screws in 38.5%.

CONCLUSIONS

Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. They can accurately stabilize the ruptured syndesmosis without device breakage or loss of reduction.

LEVEL OF EVIDENCE

1A economic/decision.

Football injuries of the ankle: A review of injury mechanisms, diagnosis and management

Football is the most popular sport worldwide and is associated with a high injury rate, most of which are the result of trauma from player contact. Ankle injuries are among the most commonly diagnosed injuries in the game. The result is reduced physical activity and endurance levels, lost game time, and considerable medical cost. Sports medicine professionals must employ the correct diagnostic tools and effective treatments and rehabilitation protocols to minimize the impact of these injuries on the player. This review examines the diagnosis, treatment, and postoperative rehabilitation for common football injuries of the ankle based on the clinical evidence provided in the current literature.