scholarly journals Complications and Early Radiographic Outcomes of Flatfoot Deformity Correction With Metallic Midfoot Opening Wedge Implants

2019 ◽  
Vol 4 (3) ◽  
pp. 247301141986897
Author(s):  
Tyler W. Fraser ◽  
Anish R. Kadakia ◽  
Jesse F. Doty
Keyword(s):  
Bone Grafting ◽  
Weight Bearing ◽  
Osteotomy Site ◽  
Opening Wedge ◽  
Common Component ◽  
Future Studies ◽  
Radiographic Outcomes ◽  
Medial Cuneiform ◽  
Forefoot Varus

Background: Forefoot varus is a common component of flatfoot deformity that is often surgically addressed. Multiple options exist to plantarflex the medial column, with midfoot fusion and the Cotton osteotomy being the most common. This study analyzes radiographic outcomes and complications when a titanium wedge is used for structural support in a dorsal opening wedge Cotton osteotomy of the medial cuneiform. Methods: Between December 2016 and May 2018, 32 feet in 31 patients were treated with medial column titanium wedges for residual forefoot varus in association with flatfoot corrections. All participants had preoperative and weight-bearing postoperative radiographs examined for analysis of radiographic correction. The average age of the patients was 41.1 (range: 12-70). The average follow-up time for patients was 12.2 months (8-24). Results: All radiographic parameters were statistically significantly improved from preoperative to postoperative ( P < .05). There were no instances of nonunion of the medial cuneiform osteotomy. There was 1 implant that loosened and was revised to a larger implant that healed uneventfully. No wedges were removed for continued pain at the osteotomy site. Conclusion: This study suggests that metal wedges are both safe and effective for use in medial column correction based on early follow-up data. Future studies comparing titanium wedges versus traditional bone grafting for Cotton osteotomies may provide further analysis of radiographic correction, operative time, procedure cost, and outcomes. There were no instances of pain over the titanium wedge site. Radiographic outcomes are similar to those reported for opening wedge Cotton osteotomies including bone grafting and wedge plates with screws. Future studies will help determine the long-term maintenance of correction and hardware survivorship. Level of Evidence: Level IV, case series.

scholarly journals Radiographic Outcomes and Complications of Medial Column Correction in Adult Acquired Flatfoot Deformity Using A Titanium Wedge

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0017
Author(s):  
Tyler W. Fraser ◽  
Jesse F. Doty ◽  
Anish R. Kadakia
Keyword(s):  
Weight Bearing ◽  
Wedge Osteotomy ◽  
Osteotomy Site ◽  
Opening Wedge ◽  
Common Component ◽  
Radiographic Outcomes ◽  
Medial Cuneiform ◽  
Significant Correction ◽  
Forefoot Varus

Category: Hindfoot, Midfoot/Forefoot, Flatfoot Introduction/Purpose: Forefoot varus is a common component of flatfoot deformity that is often surgically addressed. There are multiple options to plantarflex the medial column of the foot, with midfoot fusion and the Cotton osteotomy being the most common. This study analyzes radiographic outcomes and complications when a titanium wedge is used for structural support in a dorsal opening wedge Cotton osteotomy of the medial cuneiform. Methods: Between December 2016 and May 2018, 32 feet in 31 patients were treated with medial column titanium wedges for residual forefoot varus in association with flatfoot corrections. All participants had preoperative and weight-bearing postoperative radiographs examined for analysis of radiographic correction. The average age of the patients was 41.1 years (Range: 12-70). The average follow-up time for patients was 8.1 months (6-17 months). All patients underwent a six-month non-operative treatment course prior to operative intervention. The average time from the initial visit with the primary surgeon (JFD, ARK) to the day of surgical intervention was 211 days (29-1296 days). The choice to use a titanium wedge, versus an alternative method of correction of the medial column, was at the discretion of the primary surgeon (JFD, ARK). Results: A dorsal opening wedge medial cuneiform osteotomy was performed in all patients. All radiographic parameters showed statistically significant correction from preoperative to postoperative. All cases had multiple concomitant procedures performed to address the flatfoot deformity, so it is difficult to isolate the effect of the medial cuneiform osteotomy. 30/31 cases went on to successful union of the osteotomy within the study follow-up period. There were no instances of hardware pain requiring implant removal. There was 1 case of plantar gapping at the osteotomy site and implant loosening that required revision to a larger titanium wedge which healed uneventfully. No implants had supplemental fixation or additional bone graft placement at the osteotomy site. Conclusion: To our knowledge, this represents the first reported series on the use of structural titanium wedges with an opening wedge osteotomy of the medial cuneiform. There is limited data regarding the use of metal wedges for flatfoot correction. Nearly every patient in our series underwent concomitant procedures as part of the flatfoot reconstruction. This makes it difficult to isolate the effect of the deformity correction provided solely by the medial column correction. Our study suggests that metal wedges are both safe and effective for use in medial column correction, and future studies comparing titanium wedges to traditional techniques are needed.

scholarly journals Medial Cuneiform Opening Wedge Osteotomy for Correction of Flexible Flatfoot Deformity: Trabecular Titanium vs. Bone Allograft Wedges

2019 ◽  
Vol 2019 ◽  
pp. 1-7 ◽  
Author(s):  
Giovanni Romeo ◽  
Alberto Bianchi ◽  
Vincenzo Cerbone ◽  
Matteo Maria Parrini ◽  
Francesco Malerba ◽  
...  
Keyword(s):  
Surgical Techniques ◽  
Bone Allograft ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
Metallic Implant ◽  
Radiographic Outcomes ◽  
Clinical Scores ◽  
Medial Cuneiform ◽  
Forefoot Varus

Adult flatfoot is a common pathology characterized by multiplanar deformity involving hindfoot, midfoot, and forefoot. Various surgical techniques have been described for the treatment but may not adequately correct the fixed forefoot varus component. Residual forefoot supination can be addressed by a plantar flexing opening wedge osteotomy of the medial cuneiform, also known as a Cotton osteotomy. Thus, the aims of this study were to compare clinical, radiological, and functional outcome after Cotton osteotomy, in patients treated with bone allograft or metallic implant. Consequently, 36 patients treated with opening wedge osteotomy of the medial cuneiform for forefoot varus were studied retrospectively. Patients were divided into two groups: the bone allograft group (HBG) (n=18) and the metallic implant group with BIOFOAM® Cotton Wedges (TTW) (n=18). Radiographic assessment and clinical scores including American Orthopaedic Foot and Ankle Society score, Foot Function Index, and visual analogue scale for pain were collected before operation and the last follow-up. The difference between baseline and follow-up for both groups was statistically significant for all the clinical scores and radiographic angles (p < 0.05). Most participants (92%) were very satisfied after surgery. Our results showed that Cotton osteotomy with a metallic implant provided both good clinical and radiographic outcomes comparable with bone allograft.

scholarly journals Double column osteotomy for correction of residual adduction deformity in idiopathic clubfoot

2010 ◽  
Vol 92 (8) ◽  
pp. 673-679 ◽  
Author(s):  
Michel Eshak Loza ◽  
Sherif NG Bishay ◽  
Hassan Magdy El-Barbary ◽  
Atef Abdel-Aziz Zaki Hanna ◽  
Yehia Nour El-Din Tarraf ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Major Complication ◽  
Idiopathic Clubfoot ◽  
Grading System ◽  
Residual Deformity ◽  
Abductor Hallucis ◽  
Opening Wedge ◽  
Medial Cuneiform ◽  
Plantar Fasciotomy

INTRODUCTION Adduction of the forefoot is the most common residual deformity in idiopathic clubfoot. The ‘bean-shaped foot’, which is a term used to describe a clinical deformity of forefoot adduction and midfoot supination, is not uncommonly seen in resistant clubfoot. SUBJECTS AND METHODS Fifteen children (20 feet) with residual forefoot adduction in idiopathic clubfeet aged 3–7 years were analyzed clinically and radiographically. All of the cases were treated by double column osteotomy (closing wedge cuboid osteotomy and opening wedge medial cuneiform osteotomy) with soft tissue releases (plantar fasciotomy and abductor hallucis release), to correct adduction, supination and cavus deformities. Pre-operative measurements of certain foot angles were compared with their corresponding postoperative values. RESULTS A grading system for evaluation of the results using a point scoring system was suggested to evaluate accurately both clinical and radiographic results after a follow-up period of an average of 2.3 years. Eight feet (40%) had excellent, eight (40%) good, three (15%) fair, and one (5%) poor outcome. There was no major complication. There was significant improvement in the result (P > 0.04). CONCLUSIONS Double column osteotomy can be considered superior to other types of bone surgeries in correction of residual adduction, cavus and rotational deformities in idiopathic clubfoot.

scholarly journals Clinical and Radiographic Outcomes of 3D Printed Total Talus Arthroplasty

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0037
Author(s):  
Daniel Scott ◽  
John Steele ◽  
Amanda Fletcher ◽  
Selene Parekh
Keyword(s):  
Avascular Necrosis ◽  
Weight Bearing ◽  
Treatment Options ◽  
Ankle Motion ◽  
Motion Data ◽  
Radiographic Outcomes ◽  
Significant Difference ◽  
3D Printed ◽  
Vas Scores

Category: Ankle, Ankle Arthritis, Hindfoot, Trauma Introduction/Purpose: Patients with talar avascular necrosis have limited treatment options to manage their symptoms. Historically, surgical options have been limited and can leave patients with little ankle motion and have high failure rates. The use of custom 3D printed total talar replacements (TTR) has arisen as a treatment option for these patients, possibly allowing for better preservation of hind-foot motion. Patients undergoing TTR will demonstrate a statistically significant improvement in FAOS scores at one year after surgery. Methods: We retrospectively reviewed 15 patients who underwent a TTR over 2 years. Patient outcomes were reviewed including age, sex, comorbidities, etiology of talar pathology, number and type of prior surgeries, pre-operative and post-operative weight bearing radiographs, as well as FAOS and VAS scores, and range of motion. Data analysis performed with student T-test and multivariate regression. Results: Results: FAOS scores showed statistically significant improvements post-operatively as compared to pre-operative scores. There was a statistically significant decrease in VAS pain scores from 7.0 pre-operatively to 3.4 post operatively. There was no significant difference in pre-operative and post-operative coronal and sagittal alignment on weight bearing radiographs. All FAOS sub-score shows statistically significant improvements, with the exception of the sports/recreation sub-scale, did show a trend towards improved outcomes (p =0.19). Average follow-up was 12.8 months. Conclusion: Our hypothesis was confirmed that these patients show statistically significant improvements in AOFS and VAS scores at 1 year. Sagittal and coronal alignment was well maintained at an average of 1 year following surgery. TTR represents an exciting treatment options for patients with talar avascular necrosis, though longer-term follow-up is needed.

scholarly journals Surgical Outcomes after Simple Coalition Bar Excision in Naviculo-Medial Cuneiform Coalition in Adults

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0029
Author(s):  
Jaeyoung Kim ◽  
Jonathan Day ◽  
Woo-Chun Lee
Keyword(s):  
Demographic Data ◽  
Weight Bearing ◽  
Rare Condition ◽  
Considerable Proportion ◽  
X Rays ◽  
Morphological Pattern ◽  
Abnormal Finding ◽  
Medial Cuneiform ◽  
Patient Reported

Category: Midfoot/Forefoot; Other Introduction/Purpose: Coalition of the naviculo-medial cuneiform joint (NCJ) is a relatively rare condition among the tarsal bone coalitions. Thus, optimal treatment is still largely unknown. There is a paucity of literature, with few cases documenting arthrodesis of the NCJ in adults with varied outcomes. As the NCJ contributes to the majority of motion along the medial column of the foot, arthrodesis of the joint may cause excessive stress on adjacent joints. Furthermore, the nonunion rate of NCJ is reportedly high, ranging from 3 to 15%. The purpose of this study was to report the outcomes of simple coalition bar excision in patients with NCJ coalition. Additionally, we investigated preoperative abnormal conditions around the NCJ using weight bearing computed tomography (WBCT). Methods: We retrospectively identified 21 feet in 18 prospectively followed patients from 2010 to 2018 who underwent simple coalition bar excision of NCJ in our institution. Chart review was performed to retrieve demographic data of the patients, clinical presentation findings, and concomitant procedures with coalition bar excision. Radiographically, the location and morphological pattern of the coalition were analyzed. Several angular parameters including medial arch sag angle (MASA) were measured on weightbearing x-rays to see if there are any angular collapse at NCJ after coalition bar excision (Figure 1). The existence of abnormal conditions adjacent to the NCJ such as arthritis of the first and second tarsometatarsal joint (TMTJ) and talonavicular joint (TNJ) were assessed using WBCT (n=17). Clinically, pre- and postoperative visual analogue scale (VAS) and foot function index (FFI) were compared to assess for improvement in patient-reported outcomes. Results: The mean age of the patients was 30.9 years (range, 16-62) and the follow-up was 15.9 months (range, 12-24). Majority of the patient had fibrous coalition at the plantar-medial aspect and only one patient had bony coalition. The morphology of fibrous coalition was classified as irregular (n=8), cystic (n=1), and combined (n=11) based on CT findings. Intraoperatively, the motion of the NCJ was identified in every patient after coalition bar excision. WBCT revealed 15 feet (71.4%) having at least one abnormal finding around the NCJ (First TMTJ plantar gap; n=10, second TMTJ narrowing; n=9, first TMTJ spur & irregularity; n=2, TNJ spur; n=1). Pre- and postoperative MASA did not change significantly (p=0.932). There was significant improvement in VAS and FFI at final follow-up (p<0.001) Conclusion: A considerable proportion of patients with NCJ coalition had at least one radiographically arthritic feature at adjacent joints preoperatively, which may be caused by the restriction in motion associated with NJC coalition. Simple coalition bar excision in adults resulted in satisfactory outcomes without NC joint angular deterioration, while restoring motion at the joint.

scholarly journals Preliminary Experience Using Bioactive Glass Wedges for Cotton Osteotomy

2018 ◽  
Vol 3 (4) ◽  
pp. 247301141879686
Author(s):  
Tood Borenstein ◽  
Tyler Gonzalez ◽  
Janet Krevolin ◽  
Bryan Den Hartog ◽  
David Thordarson
Keyword(s):  
Bioactive Glass ◽  
Case Series ◽  
Clinical Results ◽  
Delayed Union ◽  
Complication Rates ◽  
Level Of Evidence ◽  
Opening Wedge ◽  
Radiographic Outcomes ◽  
Initial Correction

Background: Medial cuneiform dorsal opening wedge (Cotton) osteotomy is often used for treating forefoot varus in patients undergoing surgery for stage II posterior tibialis tendon dysfunction. The goal of this study was to examine the radiographic outcomes of Cotton osteotomy with bioactive glass wedge to assess for both maintenance of correction and clinical results and complications. We hypothesized that bioactive glass wedges would maintain correction of the osteotomy with low complication rates. Methods: Between December 2015 and June 2016, the charts of 17 patients (10 female and 7 male) who underwent Cotton osteotomy using bioactive glass wedges were retrospectively reviewed. Patient age averaged 56.8 years (range, 16-84). The average follow-up was 6.5 months. Radiographs were reviewed to assess for initial correction and maintenance of correction of medial column sag as well as for union. Charts were reviewed for complications. Results: The medial column sag correction averaged 15.6% on the final postoperative lateral radiograph. Meary angle averaged 19 degrees (3.14-42.8 degrees) preoperatively and 5.5 degrees (0.4-20.7 degrees) at final follow-up. All patients achieved clinical and radiographic union. One patient developed neuropathic midfoot pain and was managed with sympathetic blocks. One patient had a delayed union that healed at 6 months without surgical intervention. No patients required the use of custom orthotics or subsequent surgical procedures. Conclusion: Cotton osteotomy with bioactive glass wedges produced consistent correction of the medial column with low risk. Level of Evidence: Level IV, case series.

scholarly journals Screw Versus Suture Button in Treatment of Syndesmosis Instability: Clinical and Radiographic Outcomes Using PROMIS and Weight Bearing CT Scan

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0008
Author(s):  
Mohamed E. Abdelaziz ◽  
Noortje Hagemeijer ◽  
Daniel Guss ◽  
Ahmed El-Hawary ◽  
A. Holly Johnson ◽  
...  
Keyword(s):  
Ct Scan ◽  
Screw Fixation ◽  
Weight Bearing ◽  
Pilon Fracture ◽  
P Values ◽  
Normal Side ◽  
Suture Button ◽  
Radiographic Outcomes ◽  
Injured Side

Category: Ankle, Sports, Trauma, Syndesmosis Introduction/Purpose: Traumatic injuries to the distal tibiofibular syndesmosis are relatively common and can be associated with ankle fractures or occur as purely ligamentous injuries. Unstable syndesmotic injuries require surgical repair, generally performed using either screw or suture button fixation. The superiority of either fixation method remains a subject of ongoing debate. The aim of this study is to compare both clinical and radiographic outcomes of screw and suture button fixation of syndesmosis instability using Patient-Reported Outcomes Measurement Information System (ROMIS) and weight bearing CT scan (WBCT). Methods: Medical records were reviewed to identify patients who had a unilateral syndesmotic injury requiring surgical stabilization and who were at least one year out from injury. Exclusion criteria included patients less than 18 years old, ipsilateral pilon fracture, history of contralateral ankle or pilon fracture or syndesmosis injury, BMI >40, and any neurological impairment. Twenty eligible patients were recruited to complete PROMIS questionnaires and undergo bilateral WBCT scan of both ankles, divided into two groups. In the first group (n=10) the patients had undergone screw fixation of the syndesmosis, while in the second group (n=10) the syndesmosis was fixed using a suture button construct. All patients completed PROMIS questionnaires for pain intensity, pain interference, physical function and depression. Radiographic assessment was performed using axial images of WBCT scan of both the injured ankle and the contralateral normal side at a level one cm proximal to the tibial plafond (Figure 1). Results: At an average follow up of three years, none of the recruited patients required a revision surgery. There was no significant difference between the two groups in terms of the four PROMIS questionnaires (P values ranged from 0.17 to 0.43). In the suture button group, the measurements of the injured side were significantly different from the normal side for the syndesmotic area (P=0.003), fibular rotation (P=0.004), anterior difference (P=0.025) and direct anterior difference (P=0.035). Other measurements of posterior difference, middle difference, direct posterior difference and fibular translation were not significantly different (P values ranged from 0.36 to 0.99). In the screw fixation group, the syndesmotic area was the only significantly different measurement in the injured side as compared to the normal side (P=0.006). Conclusion: Screw and suture button fixation for syndesmotic instability have similar clinical outcomes at average three years follow up as measured by PROMIS scores. Both screw and suture button did not entirely restore the syndesmotic area as compared to the contralateral normal ankle, suggesting some residual diastasis on weight bearing CT. In addition, as compared to screw fixation, the suture button did not seem to restore the normal fibular rotation, with residual external rotation of the fibula noted. Longer clinical follow up is necessary to understand the clinical implication of such malreduction.

scholarly journals Joint-Preserving Surgery for Hyperextension Deformity of the Hallux Interphalangeal Joint in a Patient with Rheumatoid Arthritis

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Takumi Matsumoto ◽  
Yuki Shimizu ◽  
Song Ho Chang ◽  
Taro Kasai ◽  
Jun Hirose ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
Plantar Flexion ◽  
Weight Bearing ◽  
Proximal Phalanx ◽  
Metatarsophalangeal Joint ◽  
Metatarsal Head ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
Joint Preserving Surgery ◽  
Medial Cuneiform

Interphalangeal hyperextension is one of the major hallux deformities in patients with rheumatoid arthritis; however, there is yet no established surgical method for this deformity. We here present the case of a 69-year-old female patient with rheumatoid arthritis who developed hallux interphalangeal hyperextension and painful callosity on the plantar hallux accompanied by limited dorsiflexion at the metatarsophalangeal joint. Lateral weight-bearing radiograph of the foot revealed misalignment of the medial column and hallux, including a collapsed medial arch, elevated first metatarsal, plantar flexion and deviation of the proximal phalanx, and hyperextension of the distal phalanx. The foot was successfully treated and became symptom-free with opening wedge osteotomy of the medial cuneiform, plantar and proximal translation of the metatarsal head, and tenotomy of the extensor hallucis longus. This case suggests that reconstruction of the sagittal alignment of the medial column and hallux through a combination of osteotomy and soft tissue intervention could be an optional treatment for interphalangeal hyperextension.

Syndesmotic Fixation Utilizing a Novel Screw: A Retrospective Case Series Reporting Early Clinical and Radiographic Outcomes

2019 ◽  
Vol 13 (5) ◽  
pp. 397-403 ◽  
Author(s):  
Derek Stenquist ◽  
Brian T. Velasco ◽  
Patrick K. Cronin ◽  
Jorge Briceño ◽  
Christopher P. Miller ◽  
...  
Keyword(s):  
Weight Bearing ◽  
Case Series ◽  
Break Point ◽  
Retrospective Case ◽  
Level Of Evidence ◽  
Radiographic Outcomes ◽  
Retrospective Case Series ◽  
Screw Breakage ◽  
Tissue Stabilization

Background. Syndesmotic disruption occurs in 20% of ankle fractures and requires anatomical reduction and stabilization to maximize outcomes. Although screw breakage is often asymptomatic, the breakage location can be unpredictable and result in painful bony erosion. The purpose of this investigation is to report early clinical and radiographic outcomes of patients who underwent syndesmotic fixation using a novel metal screw designed with a controlled break point. Methods. We performed a retrospective review of all patients who underwent syndesmotic fixation utilizing the R3lease Tissue Stabilization System (Paragon 28, Denver, CO) over a 12-month period. Demographic and screw-specific data were obtained. Postoperative radiographs were reviewed, and radiographic parameters were measured. Screw loosening or breakage was documented. Results. 18 patients (24 screws) met inclusion criteria. The mean follow-up was 11.7 months (range = 6.0-14.7 months). 5/24 screws (21%) fractured at the break point. No screw fractured at another location, nor did any fracture prior to resumption of weight bearing; 19 screws did not fracture, with 8/19 intact screws (42.1%) demonstrating loosening. There was no evidence of syndesmotic diastasis or mortise malalignment on final follow-up. No screws required removal during the study period. Conclusion. This study provides the first clinical data on a novel screw introduced specifically for syndesmotic fixation. At short-term follow up, there were no complications and the R3lease screw provided adequate fixation to allow healing and prevent diastasis. Although initial results are favorable, longer-term follow-up with data on cost comparisons and rates of hardware removal are needed to determine cost-effectiveness relative to similar implants. Level of Evidence: Level IV: Retrospective case series

scholarly journals Screw Versus Suture Button in Treatment of Syndesmosis Instability: Clinical and Radiographic Outcomes Using PROMIS and Weight Bearing CT Scan

2020 ◽  
Vol 5 (2) ◽  
pp. 2473011420S0000
Author(s):  
Mohamed Abdelaziz ◽  
Daniel Guss ◽  
Anne H. Johnson ◽  
Christopher DiGiovanni ◽  
Noortje Hagemeijer ◽  
...  
Keyword(s):  
Ct Scan ◽  
Screw Fixation ◽  
Weight Bearing ◽  
Pilon Fracture ◽  
P Values ◽  
Normal Side ◽  
Suture Button ◽  
Radiographic Outcomes ◽  
Injured Side

Category: Trauma; Ankle; Sports Introduction/Purpose: Traumatic injuries to the distal tibiofibular syndesmosis are relatively common and can be associated with ankle fractures or occur as purely ligamentous injuries. Unstable syndesmotic injuries require surgical repair, generally performed using either screw or suture button fixation. The superiority of either fixation method remains a subject of ongoing debate. The aim of this study is to compare both clinical and radiographic outcomes of screw and suture button fixation of syndesmosis instability using Patient-Reported Outcomes Measurement Information System (PROMIS) and weight bearing CT scan (WBCT). Methods: Medical records were reviewed to identify patients who had a unilateral syndesmotic injury requiring surgical stabilization and who were at least one year out from injury. Exclusion criteria included patients less than 18 years old, ipsilateral pilon fracture, history of contralateral ankle or pilon fracture or syndesmosis injury, BMI >40, and any neurological impairment. Twenty eligible patients were recruited to complete PROMIS questionnaires and undergo bilateral WBCT scan of both ankles, divided into two groups. In the first group (n=10) the patients had undergone screw fixation of the syndesmosis, while in the second group (n=10) the syndesmosis was fixed using a suture button construct. All patients completed PROMIS questionnaires for pain intensity, pain interference, physical function and depression. Radiographic assessment was performed using axial images of WBCT scan of both the injured ankle and the contralateral normal side at a level one cm proximal to the tibial plafond ( Figure 1 ). Results: At an average follow up of three years, none of the recruited patients required a revision surgery. There was no significant difference between the two groups in terms of the four PROMIS questionnaires (P values ranged from 0.17 to 0.43). In the suture button group, the measurements of the injured side were significantly different from the normal side for the syndesmotic area (P=0.003), fibular rotation (P=0.004), anterior difference (P=0.025) and direct anterior difference (P=0.035). Other measurements of posterior difference, middle difference, direct posterior difference and fibular translation were not significantly different (P values ranged from 0.36 to 0.99). In the screw fixation group, the syndesmotic area was the only significantly different measurement in the injured side as compared to the normal side (P=0.006). Conclusion: Screw and suture button fixation for syndesmotic instability have similar clinical outcomes at average three years follow up as measured by PROMIS scores. Both screw and suture button did not entirely restore the syndesmotic area as compared to the contralateral normal ankle, suggesting some residual diastasis on weight bearing CT. In addition, as compared to screw fixation, the suture button did not seem to restore the normal fibular rotation, with residual external rotation of the fibula noted. Longer clinical follow up is necessary to understand the clinical implication of such malreduction.

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