Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Background

Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury.

Purpose

To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex).

Study Design

Case series; Level of evidence, 4.

Methods

Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed.

Results

Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports.

Conclusion

Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Biomechanical profile of varying suture button constructs in cadaveric specimens: a systematic review and meta-analysis

Background

Suture button fixation of syndesmotic injuries allows for more physiologic motion of the ankle joint while maintaining adequate reduction and may avoid the need for additional surgeries, given the lower risk of syndesmotic diastasis and implant failure. Few studies have examined the optimal number and configuration of suture buttons for syndesmotic disruption. The purpose of this systematic review and meta-analysis is to compare different suture button configurations from the cadaveric literature and to assess their relative effect on the stability of the syndesmotic reduction and functional movement of the ankle.

Methods

A literature search in the databases MEDLINE via PubMed, Embase via Elsevier, Scopus via Elsevier, and SPORTDiscus via EBSCO were searched through December 2022 to identify studies related to cadaveric modeling of the syndesmosis. Only cadaveric studies with suture button fixation and studies in English were included. The quality of cadaveric studies was assessed using the Quality Assessment for Cadaveric Studies (QUACS) tool. Revman 5.3 software was used to perform the meta-analysis.

Results

The meta-analysis included 5 studies and 86 limbs. The systematic review included 15 studies. When comparing single and double suture button configurations, no difference was found between groups with regard to fibular rotation (MD =-0.9; 95% CI: -2.09 to 0.27; I2=79%; P=0.13) and both groups had similar rotational stability. The double suture button technique did demonstrate less sagittal fibular translation compared to the single suture button (MD =0.48; 95% CI: 0.02-0.94; I2=66%; P=0.04). When comparing two suture buttons in parallel and divergent configurations, studies did not find any differences with regard to strength or stability.

Conclusions

There were no significant differences in biomechanical parameters when comparing single and double suture button constructs. While single button suture constructs result in minimal fibular rotation, double suture button constructs minimize fibular translation. This review may serve as a guide for clinicians when approaching these injuries.

Editorial Commentary: Buttoning Up After Recurrent Anterior Shoulder Instability: The Eden-Hybinette Procedure Is an Effective Salvage After Failed Latarjet

Operative management of anterior glenohumeral dislocation can confer significant improvements in subjective shoulder function, pain, and overall stability. Although the coracoid-based Latarjet procedure has long been considered the ultimate treatment for complex anterior shoulder instability with glenoid or bipolar bone loss, few authors have considered the unimaginable question: what do you do when a patient fails Latarjet? A modified arthroscopic technique of the Eden-Hybinette procedure allows for revision anterior glenoid augmentation of critical glenoid bone loss with autologous tricortical iliac crest, while suture button fixation may obviate hardware complications previously seen with bicortical screw fixation. Although distal tibial allograft provides excellent congruity, viable articular cartilage, and no harvest site morbidity, financial costs and graft availability must also be considered. With favorable patient-reported outcomes, excellent rates of radiographic union, and reliable return to sport, the Eden-Hybinette procedure with suture button-based construct offers a viable alternative for patients with advanced glenoid bone loss (>20%) or revision scenarios.