Dual Suture Button Fixation With Buttress Plate for Ankle Syndesmotic Injury

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal. Methods: This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. Subjects were placed into either screw fixation or the Suture-button device group. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of the study were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively. Results: Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05).Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events, and only one subject (3%) in the suture-button group had adverse event. Conclusion: The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

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Kinematics after Syndesmotic Injury: Assessing the Magnitude of Talus and Fibula Rotation and Displacement

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00114 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0011

Author(s):

Jonathan Bartolomei ◽

Mark W. Bowers ◽

Kenneth J. Hunt

Keyword(s):

Repeated Measures ◽

External Rotation ◽

Deltoid Ligament ◽

Ankle Sprains ◽

Syndesmotic Injury ◽

Suture Button ◽

Clear Space ◽

Lateral Translation ◽

Radiographic Measurements

Category: Ankle; Sports; Other Introduction/Purpose: High ankle sprains, or injuries to the distal tibiofibular syndesmosis, are predictive of long-term ankle dysfunction. Our objectives were to evaluate ankle mortise stability, radiographically, and kinematically, using a cadaveric model with a simulated syndesmotic injury. We also measured the ability of a suture-button system to restore natural joint motion. Methods: Eight cadaveric specimens underwent serial sectioning of the anterior-inferior tibiofibular (AITFL), interosseous (IOL), posterior-inferior tibiofibular (PITFL), and deltoid ligaments. Specimens underwent external rotation and lateral translation testing after ligament release to obtain kinematic data (using a validated infrared LED motion capture system) and radiographic measurements. We then repeated external rotation and lateral translation testing after implementing a suture-button system. Repeated measures ANOVA with a Bonferroni/Dunn post-hoc test calculated the interspecimen comparisons. Results: Sectioning of each ligament, beginning with the AITFL, significantly increased talar external rotation. After releasing the AITFL and IOL, fibular external rotation increased significantly. Posterior displacement of the fibula began following the release of AITFL. Significant radiographic widening of the medial clear space and the syndesmosis occurred only after the release of the deltoid ligament. Syndesmotic and medial clear space widening was not significantly different from the intact state under lateral translation until after the release of the deltoid ligament. Placement of the suture-button system successfully reduced the medial clear space but was unable to restore the native stability of the ankle joint. Conclusion: This project addresses rotational and kinematic changes in the ankle after syndesmotic injury by quantifying the effect of ligamentous disruption on the tibiotalar articulation. The change in joint kinematics may explain why patients with moderate-to-severe syndesmosis injuries take longer to heal and develop long-term dysfunction. Significant talar rotation and posterior fibular displacement occur during external rotation, even with moderate syndesmosis injury, and before the disruption of the deltoid ligament. Stress radiography does not appear to be a reliable indicator of mild or moderate syndesmosis injuries.

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Hybrid Fixation Restores Tibiofibular Kinematics for Early Weightbearing after Syndesmotic Injury

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00097 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0009

Author(s):

Neel Patel ◽

Calvin Chan ◽

Conor Murphy ◽

Richard Debski ◽

Volker Musahl ◽

...

Keyword(s):

Screw Fixation ◽

External Rotation ◽

Syndesmotic Injury ◽

Hybrid Fixation ◽

Fixation Methods ◽

Suture Button ◽

Tibiofibular Ligament ◽

Lateral Translation ◽

Posterior Translation ◽

Single Suture

Category: Ankle Introduction/Purpose: Injury to the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM) of the syndesmosis is a predictive measure of residual symptoms after an ankle injury. Unstable syndesmotic injuries are typically treated surgically with constructs consisting of cortical screw and/or suture button fixation. Previous studies have shown contradicting findings regarding the effects of different surgical fixation methods on tibiofibular kinematics. Thus, the objective of this study was to quantify tibiofibular joint motion with different syndesmotic screw and suture button fixation constructs after disruption of the syndesmosis compared to the intact ankle during simulated weight bearing. Methods: Five fresh-frozen human cadaveric specimens were tested using a six degree-of-freedom robotic testing system. After subtalar joint fusion, the tibia and calcaneus were rigidly fixed to a robotic manipulator, while complete fibular length was maintained and fibular motion was unconstrained. A constant 200 N compressive load was applied to the ankle while an additional 5 Nm external rotation and 5 Nm inversion moment applied independently to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Fibular motion with respect to the tibia was tracked using an optical tracking system. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: intact ankle, complete injury (AITFL, PITFL, and IOM transected), single tricortical screw fixation double tricortical screw fixation, hybrid fixation (single tricortical screw and single suture button), suture button fixation, and divergent suture button fixation. Repeated measures ANOVA was performed for statistical analysis. Results: The external rotation moment produced significant differences in fibular motion between the injury and fixation states compared to the intact state. A complete syndesmotic injury caused significantly increased fibular lateral translation, posterior translation, and external rotation in all ankle positions except 30° plantarflexion compared to the intact ankle. Single suture button and single screw fixation resulted in significantly higher fibular lateral translation at 10° dorsiflexion compared the intact ankle, while single suture button fixation also resulted in significantly higher external rotation at 10° dorsiflexion compared the intact ankle. Fibular posterior translation was significantly higher with hybrid, suture button, and divergent suture button fixation at 0° flexion and with single tricortical screw and double screw fixation at 10° dorsiflexion compared to the intact ankle (Figure 1). Conclusion: Complete injury to the syndesmosis results in significantly higher fibular lateral translation, external rotation, and posterior translation compared to the intact ankle. Hybrid or divergent suture button fixation would be recommended to restore tibiofibular motion without over-constraint. However, none of the fixation methods were able to restore AP translation in all ankle positions. Thus, it is important to evaluate syndesmotic stability in the sagittal plane at different ankle positions. Findings of this study suggest that physicians should evaluate fibular AP translation in a neutral position when using suture button fixation constructs and in dorsiflexion when using tricortical screw fixation constructs.

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A Prospective, Randomized Suture-button vs Screw Syndesmotic Fixation

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00185 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0018

Author(s):

Eric Giza ◽

Todd Oliver ◽

Christopher Kreulen ◽

Ashoke Sathy ◽

Wade Faerber ◽

...

Keyword(s):

Adverse Events ◽

Clinical Outcomes ◽

Screw Fixation ◽

Hardware Removal ◽

Syndesmotic Injury ◽

Short Term ◽

Suture Button ◽

Syndesmotic Screw ◽

Fixation Group ◽

Vas Scores

Category: Ankle, Arthroscopy, Sports Introduction/Purpose: Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal. Methods: This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. At the time of surgical intervention, subjects were placed into either the screw fixation or the Suture-button device group by opening a randomized envelope in the operating room. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of thestudy were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively. Results: Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05). Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events; four required repeat surgery for symptomatic syndesmotic screw removal, one for revision fixation, and four did not return to surgery despite hardware failure. One subject(3%) in the suture-button group required hardware removal. Conclusion: The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

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Three-Dimensional Analysis of Fibular Motion After Fixation of Syndesmotic Injuries With a Screw or Suture-Button Construct

Foot & Ankle International ◽

10.1177/1071100716666865 ◽

2016 ◽

Vol 37 (12) ◽

pp. 1350-1356 ◽

Cited By ~ 27

Author(s):

Jeremy M. LaMothe ◽

Josh R. Baxter ◽

Conor Murphy ◽

Susannah Gilbert ◽

Bridget DeSandis ◽

...

Keyword(s):

Sagittal Plane ◽

External Rotation ◽

Stress Test ◽

Coronal Plane ◽

Medial Malleolus ◽

Syndesmotic Injury ◽

Intact Specimen ◽

Suture Button ◽

Single Suture ◽

Rotation Stress

Background: Suture-button constructs are an alternative to screw fixation for syndesmotic injuries, and proponents advocate that suture-button constructs may allow physiological motion of the syndesmosis. Recent biomechanical data suggest that fibular instability with syndesmotic injuries is greatest in the sagittal plane, but the design of a suture-button construct, being a rope and 2 retention washers, is most effective along the axis of the rope (in the coronal plane). Some studies report that suture-button constructs are able to constrain fibular motion in the coronal plane, but the ability of a tightrope to constrain sagittal fibular motion is unknown. The purpose of this study was to assess fibular motion in response to an external rotation stress test in a syndesmotic injury model after fixation with a screw or suture-button constructs. Methods: Eleven fresh-frozen cadaver whole legs with intact tibia-fibula articulations were secured to a custom fixture. Fibular motion (coronal, sagittal, and rotational planes) in response to a 6.5-Nm external rotation moment applied to the foot was recorded with fluoroscopy and a high-resolution motion capture system. Measures were taken for the following syndesmotic conditions: intact, complete lateral injury, complete lateral and deltoid injury, repair with a tetracortical 4.0-mm screw, and repair with a suture button construct (Tightrope; Arthrex, Naples, FL) aimed from the lateral fibula to the anterior medial malleolus. Results: The suture-button construct allowed significantly more sagittal plane motion than the syndesmotic screw. Measurements acquired with mortise imaging did not detect differences between the intact, lateral injury, and 2 repair conditions. External rotation of the fibula was significantly increased in both injury conditions and was not restored to intact levels with the screw or the suture-button construct. Conclusion: A single suture-button placed from the lateral fibula to the anterior medial malleolus was unable to replicate the motion observed in the intact specimen when subjected to an external rotation stress test and allowed significantly more posterior motion of the fibula than when fixed with a screw in simulated highly unstable injuries. Clinical Relevance: Fixation of a syndesmotic injury with a single suture-button construct did not restore physiological fibular motion, which may have implications for postoperative care and clinical outcomes.

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Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial

The Bone & Joint Journal ◽

10.1302/0301-620x.102b2.bjj-2019-0692.r2 ◽

2020 ◽

Vol 102-B (2) ◽

pp. 212-219 ◽

Cited By ~ 4

Author(s):

Benedikte W. Ræder ◽

Wender Figved ◽

Jan E. Madsen ◽

Frede Frihagen ◽

Silje B. Jacobsen ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Controlled Trial ◽

Long Term Results ◽

Secondary Outcome ◽

Syndesmotic Injury ◽

Range Of Movement ◽

Suture Button ◽

Randomized Controlled ◽

Syndesmotic Screw

Aims In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. Methods A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years. Results The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (–0.1 mm vs 1.2 mm; p = 0.016). Conclusion Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212–219.

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Effect of Complete Syndesmotic Disruption and Deltoid Injuries and Different Reduction Methods on Ankle Joint Contact Mechanics

Foot & Ankle International ◽

10.1177/1071100717696360 ◽

2017 ◽

Vol 38 (6) ◽

pp. 694-700 ◽

Cited By ~ 18

Author(s):

Jeremy LaMothe ◽

Josh R. Baxter ◽

Susannah Gilbert ◽

Conor I. Murphy ◽

Sydney C. Karnovsky ◽

...

Keyword(s):

Contact Mechanics ◽

Ankle Joint ◽

Contact Area ◽

Repeated Measures ◽

Screw Fixation ◽

Biomechanical Model ◽

Posttraumatic Arthritis ◽

Syndesmotic Injury ◽

Suture Button ◽

Joint Contact

Background: Syndesmotic injuries can be associated with poor patient outcomes and posttraumatic ankle arthritis, particularly in the case of malreduction. However, ankle joint contact mechanics following a syndesmotic injury and reduction remains poorly understood. The purpose of this study was to characterize the effects of a syndesmotic injury and reduction techniques on ankle joint contact mechanics in a biomechanical model. Methods: Ten cadaveric whole lower leg specimens with undisturbed proximal tibiofibular joints were prepared and tested in this study. Contact area, contact force, and peak contact pressure were measured in the ankle joint during simulated standing in the intact, injured, and 3 reduction conditions: screw fixation with a clamp, screw fixation without a clamp (thumb technique), and a suture-button construct. Differences in these ankle contact parameters were detected between conditions using repeated-measures analysis of variance. Results: Syndesmotic disruption decreased tibial plafond contact area and force. Syndesmotic reduction did not restore ankle loading mechanics to values measured in the intact condition. Reduction with the thumb technique was able to restore significantly more joint contact area and force than the reduction clamp or suture-button construct. Conclusion: Syndesmotic disruption decreased joint contact area and force. Although the thumb technique performed significantly better than the reduction clamp and suture-button construct, syndesmotic reduction did not restore contact mechanics to intact levels. Clinical Relevance: Decreased contact area and force with disruption imply that other structures are likely receiving more loads (eg, medial and lateral gutters), which may have clinical implications such as the development of posttraumatic arthritis.

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Outcomes and Complications Following Treatment of Chronic Subtle Syndemotic Injury with Arthroscopic Debridement and Fixation with Suture Button

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00418 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0041

Author(s):

Chamnanni Rungprai ◽

Yantarat Sripanich

Keyword(s):

Chronic Pain ◽

Ankle Sprain ◽

Functional Outcomes ◽

Arthroscopic Debridement ◽

Syndesmotic Injury ◽

Mild Pain ◽

Suture Button ◽

Sf 36 ◽

Recovery Times ◽

Arthroscopic Examination

Category: Ankle; Arthroscopy Introduction/Purpose: The syndesmotic injury can be occurred 10-18 percent associated with acute ankle sprain. This injury is commonly missed due to a difficulty to diagnosis in acute setting leading to chronic pain, swelling, and inability to return to previous level of activities and sports. Anterior ankle arthroscopic examination has been proposed to be successful technique to establish the diagnosis of this subtle injury. The purpose of this study is to demonstrate outcomes and complications of the patients who isolated syndesmotic injury and treated with anterior ankle arthroscopic debridement and fixation with suture button. Methods: A prospective case series of 62 patients who had ankle sprain with chronic pain on syndesmosis between 2015 and 2019 were enrolled in this study. All patients were failed from conservative treatment including bracing, ankle range of motion and strengthening exercises, low-does laser, and ultrasound treatment for at least 6 months after initial injury. The syndesmotic injury was considered when patients had chronic pain and swelling and athletic taping test was positive, and MRI demonstrated AITFL torn or fluid was ascended more than 10mm from ankle joint line. All patients were confirmed by intra-operatively ankle arthroscopy with a 3-mm shaver could pass through the syndesmotic joint. Syndesmotic joint was debridement and was fixed by suture button. Pre- and post-operative SF-36, FAAM, and VAS were obtained and compared using a paired t-test. Operative times, complications, and recovery times including time to return to ADL, work, and sports were recorded. Results: There were significant improvements of all functional outcomes (FAAM, SF-36, and VAS (p < 0.001 all)) with an average follow-up of 20.8 months. An average operative time was 30.2 minutes. Patients reported no previous pain after the operation (VAS 0/10, 54/62) and mild pain (VAS 1-2/10, 8/62). There were 6 patients with osteochondral injury intraoperatively and 9 patients with enlargement of anteroinferior tibiofibular ligament (AITFL). Recovery times included returned to ADL 4.9 weeks, to work 6.8 weeks, and to sports 5.8 months. Four patients had saphenous nerve irritation from the medial button and this was fully recovery at 4.8 months post-operatively and 2 patients has mild pain on fibular. There were no migration or disruption of suture button and no wound complications. Conclusion: Isolated sublte syndesmotic injury after ankle injury was successfully confirmed by anterior ankle arthroscopic examination and arthroscopic debridement and suture button fixation demonstrated significant improvement of functional outcomes as measured with FAAM, SF-36, and VAS. and patients were able to return previous activities. This technique is effective, safe, and feasible for treatment in patients with isolated subtle syndesmotic injury.

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Chronic Syndesmotic Injury: Revision and Fixation With a Suture Button and a Quadricortical Screw

Foot & Ankle Specialist ◽

10.1177/1938640020916128 ◽

2020 ◽

pp. 193864002091612

Author(s):

Ingrid Kvello Stake ◽

Mette Renate Andersen ◽

Elisabeth Ellingsen Husebye

Keyword(s):

Case Series ◽

Technical Note ◽

Syndesmotic Injury ◽

Suture Button ◽

Computed Tomography Scans ◽

The Mean ◽

American Orthopaedic ◽

Ankle Function

Background. Chronic syndesmotic injury may cause long-term pain and reduced ankle function. Today, there is no consensus about the best surgical treatment of these injuries. We present the technique and results of revision and fixation with a suture button and a quadricortical screw. Methods. Eleven patients treated for chronic syndesmotic injury were included. The patients completed questionnaires regarding ankle function, and computed tomography scans were obtained to evaluate tibiofibular distance and osteoarthritis. Complications were registered. Results. At mean 45 months follow-up, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score was 87 points. There were 5 complications, including 3 hardware-related pain. The tibiofibular distance was significantly reduced with surgery. Seven patients had progression of osteoarthritis. Conclusions. Even though the majority of the patients had progression of radiological signs of osteoarthritis, the functional outcome after revision and fixation with a suture button and a quadricortical screw in chronic syndesmotic ruptures is good and comparable to the results presented in other studies. Levels of Evidence: Level IV: Case series without control, technical note

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