Anatomical reconstruction of the anterior inferior tibiofibular ligament for chronic disruption of the distal tibiofibular syndesmosis

Background: The diagnosis of subtle injuries to the distal tibiofibular syndesmosis remains elusive. Conventional radiographs miss a large subset of injuries that present without frank diastasis. This study evaluated the impact of torque application on the assessment of syndesmotic injuries when using weightbearing computed tomography (CT) scans. Methods: Seven pairs of male cadavers (tibia plateau to toe-tip) were included. CT scans with axial load application (85 kg) and with (10 Nm) or without torque to the tibia (corresponding to external rotation of the foot and ankle) were taken during 4 test conditions. First, intact ankles (native) were scanned. Second, 1 specimen from each pair underwent anterior inferior tibiofibular ligament (AITFL) transection (condition 1A), while the contralateral underwent deltoid transection (condition 1B). Third, the lesions were reversed on the same specimens and the remaining intact deltoid or AITFL was transected (condition 2). Finally, the distal tibiofibular interosseous membrane (IOM) was transected in all ankles (condition 3). Measurements were performed to assess the integrity of the distal tibiofibular syndesmosis on digitally reconstructed radiographs (DRRs) and on axial CT scans. Results: Torque impacted DRR and axial CT scan measurements in almost all conditions. The ability to diagnose syndesmotic injuries using axial CT measurements improved when torque was applied. No significant syndesmotic morphological change was observed with or without torque for either isolated AITFL or deltoid ligament transection. Discussion: Torque application had a notable impact on two-dimensional (2-D) measurements used to diagnose syndesmotic injuries for both DRRs and axial CT scans. Because weightbearing conditions allow for standardized positioning of the foot while radiographs or CT scans are taken, the combination of axial load and torque application may be desirable. Clinical Relevance: Application of torque to the tibia impacts 2-D measurements and may be useful when diagnosing syndesmotic injuries by DRRs or axial CT images.

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

The Bone & Joint Journal ◽

10.1302/0301-620x.104b1.bjj-2021-0542.r2 ◽

2022 ◽

Vol 104-B (1) ◽

pp. 68-75

Author(s):

Nick J. Harris ◽

Gareth Nicholson ◽

Ippokratis Pountos

Keyword(s):

Elite Athletes ◽

Contralateral Side ◽

Return To Play ◽

Anatomical Reconstruction ◽

Medial Malleolus ◽

Anterior Talofibular Ligament ◽

Return To Sports ◽

Tibiofibular Ligament ◽

Anterior Inferior Tibiofibular Ligament ◽

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.

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Suture-Button Fixation and Mini-Open Anterior Inferior Tibiofibular Ligament Augmentation Using Suture Tape for Tibiofibular Syndesmosis Injuries

The Journal of Foot & Ankle Surgery ◽

10.1053/j.jfas.2017.07.007 ◽

2018 ◽

Vol 57 (1) ◽

pp. 159-161 ◽

Cited By ~ 8

Author(s):

Atsushi Teramoto ◽

Hiroaki Shoji ◽

Yuzuru Sakakibara ◽

Tomoyuki Suzuki ◽

Kota Watanabe ◽

...

Keyword(s):

Tibiofibular Syndesmosis ◽

Suture Button ◽

Tibiofibular Ligament ◽

Ligament Augmentation ◽

Anterior Inferior Tibiofibular Ligament ◽

Mini Open ◽

Suture Tape

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Three-Dimensional Analysis of Ankle Instability after Tibiofibular Syndesmosis Injuries

The American Journal of Sports Medicine ◽

10.1177/0363546507308235 ◽

2007 ◽

Vol 36 (2) ◽

pp. 348-352 ◽

Cited By ~ 55

Author(s):

Atsushi Teramoto ◽

Hideji Kura ◽

Eiichi Uchiyama ◽

Daisuke Suzuki ◽

Toshihiko Yamashita

Keyword(s):

Ankle Joint ◽

Ankle Instability ◽

External Rotation ◽

Tracking System ◽

Three Dimensional ◽

Traction Force ◽

Tibiofibular Syndesmosis ◽

Tibiofibular Ligament ◽

Distal Tibiofibular Syndesmosis ◽

Fresh Frozen

Background Rupture of the distal tibiofibular syndesmosis commonly occurs with extreme external rotation. Most studies of syndesmosis injuries have concentrated only on external rotation instability of the ankle joint and have not examined other defects. Hypothesis Syndesmosis injuries cause multidirectional ankle instability. Study Design Controlled laboratory study. Methods Ankle instability caused by distal tibiofibular syndesmosis injuries was examined using 7 normal fresh-frozen cadaveric legs. The anterior tibiofibular ligament, interosseous membrane, and posterior tibiofibular ligament, which compose the distal tibiofibular syndesmosis, were sequentially cut. Anterior, posterior, medial, and lateral traction forces, as well as internal and external rotation torque, were applied to the tibia; the diastasis between the tibia and fibula and the angular motion among the tibia, fibula, and talus were measured using a magnetic tracking system. Results A medial traction force with a cut anterior tibiofibular ligament significantly increased the diastasis from 1.1 to 2.0 mm ( P = .001) and talar tilt angles from 9.6° to 15.2° ( P < .001). External rotation torque significantly increased the diastasis from 0.5 to 1.8 mm ( P= .009) with a complete cut; external rotation torque also significantly increased rotational angles from 7.1° to 9.4° ( P = .05) with an anterior tibiofibular ligament cut. Conclusion Syndesmosis injuries caused ankle instability with medial traction force and external rotation torque to the tibia. Clinical Relevance Both physicians and athletes should be aware of inversion instability of the ankle joint caused by tibiofibular syndesmosis injuries.

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