Radiographic Outcomes of Lisfranc Injuries Treated with a Suture Button Device

Category: Midfoot/Forefoot Introduction/Purpose: Controversy exists regarding the optimal treatment of Lisfranc injuries of the midfoot. There has been increasing interest in using a suture button device in lieu of traditional screw fixation. Biomechanical studies comparing screw fixation with suture button devices have demonstrated conflicting results. This study evaluates the radiographic outcomes of patients with Lisfranc injuries treated with a suture button device or a hybrid technique with supplemental fixation. Methods: Forty-three patients with a Lisfranc injury were treated operatively with either a suture button device (Tightrope, Arthrex, Naples, FL) or a hybrid technique with supplemental hardware fixation. The distances between the first and second metatarsal (M1-M2) and the medial cuneiform and second metatarsal (C1-M2) were measured on weightbearing radiographs. These measurements were used to assess the accuracy of reduction, maintenance of reduction, and magnitude of reduction. The accuracy of reduction was determined by comparing weightbearing AP radiographs of the uninjured foot with weightbearing radiographs of the operatively treated foot at 6 weeks postoperatively. The magnitude of reduction was assessed via a comparison of weightbearing AP radiographs of the injured foot preoperatively to the operatively treated foot at 6 weeks postoperatively. The maintenance of reduction was determined by comparing radiographic measurements at 6 weeks postoperatively to measurements taken at 12 weeks postoperatively. Results: An accurate reduction was obtained in both treatment groups with no significant difference in the M1-M2 and C1-M2 measurements at 6 weeks postoperatively compared to the uninjured foot. The magnitude of reduction was greater and statistically significant for the hybrid fixation group but was not maintained (Hybrid fixation M1-M2 magnitude of reduction: -1.39, p < .001; C1-M2 magnitude of reduction: -1.77, p < .001). The suture button treatment group attained a satisfactory reduction that was maintained with no statistically significant difference in the M1-M2 and C1-M2 distances at 6 weeks and 12 weeks postoperatively (Tightrope M1-M2 maintenance of reduction: 0.04, p=0.88; C1-M2 maintenance of reduction: 0.39, p=0.21). Conclusion: After open reduction of Lisfranc injuries, the suture button device appears to adequately maintain the reduction when patients have returned to full activity. Based on radiographic parameters, the suture button construct provides an effective alternative to traditional screw fixation for the treatment of Lisfranc injuries.

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Transcuneiform Screw Fixation in Ligamentous Lisfranc Injuries

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00434 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0043

Author(s):

Philip J. Shaheen ◽

Benjamin Crawford ◽

Nathan J. Kopydlowski ◽

Shwetang Patel ◽

John G. Bledsoe ◽

...

Keyword(s):

Statistical Analysis ◽

Pain Control ◽

Screw Fixation ◽

Weight Bearing ◽

Potential Reduction ◽

Second Metatarsal ◽

Significant Difference ◽

Fresh Frozen ◽

Bearing Stress ◽

Lisfranc Injuries

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Ligamentous Lisfranc injuries represent a devastating injury complex to the midfoot. Treatment with screw fixation across the first tarsometatarsal (TMT) joint and across the first cuneiform-second metatarsal joint (C1-M2) joint has been described, however there are no studies examining the utility of adding a transcuneiform screw across the first cuneiform-second cuneiform (C1-C2) joint. The purpose of this study was to evaluate the effectiveness of transcuneiform screws at minimizing interosseous displacement in ligamentous Lisfranc injuries when added to traditional Lisfranc screw fixation. Methods: Unstable ligamentous Lisfranc injuries were created on ten fresh-frozen cadaveric specimens by sectioning the interosseous ligaments in a manner that has been described previously. Simulated weight bearing stress (222.4 N) as well as manual abduction and adduction stresses were applied to each specimen and interosseous displacement at the C1-C2 and C1-M2 joints was measured on gross images using calibration with 2mm radiographic marker balls. These measurements were performed initially with no screws, followed by with two-screw fixation across the C1-M2 joint and the first TMT joint, and finally with a third transcuneiform screw across the C1-C2 joint. The images were analyzed and statistical analysis was performed to determine the effect of transcuneiform fixation on interosseous displacement at the C1-C2 and C1-M2 joints. Results: The addition of transcuneiform screw fixation to traditional two-screw fixation decreased the amount of interosseous widening at C1-M2 by an average of 0.03mm at rest, 0.39mm during abduction stress, 0.21mm during adduction stress, and 0.19mm during weight bearing. The interosseous widening at C1-C2 decreased with the addition of transcuneiform fixation by an average of 0.30mm at rest, 0.11mm during abduction stress, 0.18mm during adduction stress, and 0.05mm during weight bearing. Of these findings, only the change in interosseous widening at C1-M2 during abduction stress demonstrated a statistically significant difference (p=0.031) with the addition of the transcuneiform screw compared to traditional two-screw fixation. Conclusion: The addition of transcuneiform screw fixation in ligamentous lisfranc injuries allows less interosseous widening at the C1-M2 joint during abduction stress when compared to traditional two-screw Lisfranc fixation. Further research is required to determine the clinical significance of fixing the transcuneiform joint in Lisfranc injuries and whether or not this potential reduction in motion affects outcomes such as pain control, healing, or function.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00080 ◽

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.

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

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00001 ◽

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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Evaluation of Reduction Accuracy of Suture-Button and Screw Fixation Techniques for Syndesmotic Injuries

Foot & Ankle International ◽

10.1177/1071100716661221 ◽

2016 ◽

Vol 37 (12) ◽

pp. 1317-1325 ◽

Cited By ~ 32

Author(s):

Onur Kocadal ◽

Mehmet Yucel ◽

Murad Pepe ◽

Ertugrul Aksahin ◽

Cem Nuri Aktekin

Keyword(s):

Screw Fixation ◽

Ct Scans ◽

Functional Evaluation ◽

Level Of Evidence ◽

Cross Sectional ◽

Suture Button ◽

Fixation Group ◽

Significant Difference ◽

The Mean

Background: Among the most important predictors of functional results of treatment of syndesmotic injuries is the accurate restoration of the syndesmotic space. The purpose of this study was to investigate the reduction performance of screw fixation and suture-button techniques using images obtained from computed tomography (CT) scans. Methods: Patients at or below 65 years who were treated with screw or suture-button fixation for syndesmotic injuries accompanying ankle fractures between January 2012 and March 2015 were retrospectively reviewed in our regional trauma unit. A total of 52 patients were included in the present study. Fixation was performed with syndesmotic screws in 26 patients and suture-button fixation in 26 patients. The patients were divided into 2 groups according to the fixation methods. Postoperative CT scans were used for radiologic evaluation. Four parameters (anteroposterior reduction, rotational reduction, the cross-sectional syndesmotic area, and the distal tibiofibular volumes) were taken into consideration for the radiologic assessment. Functional evaluation of patients was done using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale at the final follow-up. The mean follow-up period was 16.7 ± 11.0 months, and the mean age was 44.1 ± 13.2. Results: There was a statistically significant decrease in the degree of fibular rotation ( P = .03) and an increase in the upper syndesmotic area ( P = .006) compared with the contralateral limb in the screw fixation group. In the suture-button fixation group, there was a statistically significant increase in the lower syndesmotic area ( P = .02) and distal tibiofibular volumes ( P = .04) compared with the contralateral limbs. The mean AOFAS scores were 88.4 ± 9.2 and 86.1 ± 14.0 in the suture-button fixation and screw fixation group, respectively. There was no statistically significant difference in the functional ankle joint scores between the groups. Conclusion: Although the functional outcomes were similar, the restoration of the fibular rotation in the treatment of syndesmotic injuries by screw fixation was troublesome and the volume of the distal tibiofibular space increased with the suture-button fixation technique. Level of Evidence: Level III, retrospective comparative study.

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Restoration of Tibiofibular Kinematics with a Tricortical Screw or Suture Button Fixation After Syndesmotic Ankle Injuries

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000063 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0000

Author(s):

Conor Murphy ◽

Thomas Pfeiffer ◽

Jason Zlotnicki ◽

Volker Musahl ◽

Richard Debski ◽

...

Keyword(s):

Screw Fixation ◽

External Rotation ◽

Tracking System ◽

Optical Tracking ◽

Ankle Injuries ◽

Suture Button ◽

Tibiofibular Ligament ◽

Cortical Screw ◽

Significant Difference ◽

Posterior Translation

Category: Ankle, Sports, Trauma Introduction/Purpose: Anterior inferior tibiofibular ligament (AITFL), Posterior inferior tibiofibular ligament (PITFL) and Interosseous membrane (IOM) disruption is a predictive measure of residual symptoms after ankle injury. In unstable injuries, the syndesmosis is treated operatively with cortical screw fixation or a suture button apparatus. Biomechanical analyses of suture button versus cortical screw fixation methods show contradicting results regarding suture button integrity and maintenance of fixation. The objective of this study is to quantify tibiofibular joint motion in syndesmotic screw and suture button fixation models compared to the intact ankle. Methods: Five fresh-frozen human cadaveric specimens (mean age 58 yrs.; range 38-73 yrs.) were tested using a 6-degree-of- freedom robotic testing system. The tibia and calcaneus were rigidly fixed to the robotic manipulator and the subtalar joint was fused. The full fibular length was maintained and fibular motion was unconstrained. Fibular motion with respect to the tibia was tracked by a 3D optical tracking system. A 5 Nm external rotation moment and 5 Nm inversion moment were applied to the ankle at 0°, 15°, and 30° plantarflexion and 10° dorsiflexion. Outcome variables included fibular medial-lateral (ML) translation, anterior-posterior (AP) translation, and external rotation (ER) in the following states: 1) intact ankle, 2) AITFL transected, 3) PITFL and IOM transected, 4) 3.5 mm cannulated tricortical screw fixation, 5) suture button fixation. An ANOVA with a post-hoc Tukey analysis was performed for statistical analysis (*p<0.05). Results: Significant differences in fibular motion were only during the inversion moment. Fibular posterior translation was significantly higher with complete syndesmosis injury compared to the intact ankle at 0°, 15°, and 30° plantarflexion and the tricortical screw at 15° and 30°. Significantly higher fibular posterior translation was observed with the suture button compared to the intact ankle at 15° and 30 plantarflexion and to the tricortical screw at 15°. ER was significantly increased with complete injury compared to the tricortical screw at 0° and 30° plantarflexion. The suture button demonstrated significantly greater ER at 0° plantarflexion and 10° dorsiflexion compared to the intact ankle. The only significant difference in ML translation exists between the tricortical screw and complete injury at 30° plantarflexion. Conclusion: The suture button did not restore physiologic motion of the syndesmosis. It only restored fibular ML translation. Significant differences in AP translation and ER persisted compared to the intact ankle. The tricortical screw restored fibular motion in all planes. No significant differences were observed compared to the intact ankle. These findings are consistent with previous studies. This study utilized a novel setup to measure unconstrained motion in a full length, intact fibula. Physicians should evaluate AP translation and ER as critical fibular motions when reconstructing the syndesmosis with suture button fixation.

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A Prospective, Randomized Investigation of Syndesmosis Injury Fixation

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00006 ◽

2020 ◽

Vol 5 (2) ◽

pp. 2473011420S0000

Author(s):

Eric Giza ◽

Todd Oliver ◽

Patrick S. Barousse ◽

Tyler Allen ◽

Trevor Shelton ◽

...

Keyword(s):

Adverse Events ◽

Clinical Outcomes ◽

Screw Fixation ◽

Syndesmotic Injury ◽

Short Term ◽

Suture Button ◽

Syndesmotic Screw ◽

Fixation Group ◽

Significant Difference ◽

Vas Scores

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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InternalBrace Has Biomechanical Properties Comparable to Suture Button but Less Rigid than Screw in Ligamentous Lisfranc Model

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00221 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0022

Author(s):

Justin Hopkins ◽

Kevin Nguyen ◽

Nasser Heyrani ◽

Trevor Shelton ◽

Christopher Kreulen ◽

...

Keyword(s):

Soft Tissue ◽

Ultimate Strength ◽

Cartilage Damage ◽

Biomechanical Properties ◽

Early Weight Bearing ◽

Suture Button ◽

Axial Tension ◽

Significant Difference ◽

Potential Benefits ◽

Lisfranc Injuries

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Lisfranc injuries occurring between the medial cuneiform and base of the 2nd metatarsal require anatomic fixation. Suture button and screws are standard techniques for fixation, but the screw may decrease physiologic motion, whereas suture buttons may cause increased soft tissue irritation and iatrogenic cartilage damage. Potential benefits of the InternalBrace include physiologic motion, decreased iatrogenic damage, collagen ingrowth, limited bony erosion and decreased soft tissue irritation. In light of these potential benefits, no studies have investigated the biomechanical properties of the InternalBrace in a Lisfranc injury model. However, it is unknown whether there is significant difference in the biomechanical properties of the IB compared to the screw, or SB during load to failure, and cyclical loading. Methods: Three groups of sawbones were fixed together with either a 3.5 mm screw, SB, or IB, composed of a curved button, fibertape, and 4.75 mm biotenodesis screw. Sawbone constructs were held in a mechanical testing system (Model 809, MTS Systems Corp, Minneapolis MN). The first three groups of 10 were loaded in axial tension at 0.5mm/sec until failure to determine load-displacement data. Yield, stiffness, ultimate strength (US), yield energy, post-yield energy and ultimate strength energy were calculated. Three more groups of 8 constructs were loaded in-vitro at cyclical physiologic loads until displacement of 1.5 mm occurred. Constructs were first loaded for 10,000 cycles at 69 N (estimate for 50% body weight or assisted walking). Surviving specimens were loaded at 138 N (normal walk) for an additional 10,000 cycles and then 207 N (jog) for an additional 10,000 cycles. Displacement was recorded. The biomechanical properties were then compared between groups. Results: When loaded in axial tension at 0.5mm/sec until failure, the screw was found to be the stiffest construct (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Qualitatively, the InternalBrace was also found to hold load more consistently and for larger displacement prior to failure when compared to the suture button. Cyclic loading was performed with 10,000 cycles of 69 N, 138 N, and 207 N. The screw had the greatest resistance to fatigue. The InternalBrace maintained stiffness as well or better than the suture button, but the fatigue life was shorter than that of the suture button. Conclusion: To our knowledge, the biomechanical properties of the IB have not been compared to screw and SB for ligamentous lisfranc injuries. This study gives valuable information about the mechanical integrity of InternalBrace and supports continued use. However, further studies are warranted before making conclusions regarding early weight bearing.

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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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Hybrid Fixation Restores Tibiofibular Kinematics for Early Weightbearing After Syndesmotic Injury

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120946744 ◽

2020 ◽

Vol 8 (9) ◽

pp. 232596712094674

Author(s):

Neel K. Patel ◽

Calvin Chan ◽

Conor I. Murphy ◽

Richard E. Debski ◽

Volker Musahl ◽

...

Keyword(s):

Axial Compression ◽

Repeated Measures ◽

Screw Fixation ◽

External Rotation ◽

Optical Tracking ◽

Hybrid Fixation ◽

Suture Button ◽

Tibiofibular Ligament ◽

Lateral Translation ◽

Posterior Translation

Background: Disruption of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and interosseous membrane (IOM) is a predictive measure of residual symptoms after an ankle injury. Controversy remains regarding the ideal fixation technique for early return to sport, which requires restoration of tibiofibular kinematics with early weightbearing. Purpose: To quantify tibiofibular kinematics after syndesmotic fixation with different tricortical screw and suture button constructs during simulated weightbearing. Study Design: Controlled laboratory study. Methods: A 6 degrees of freedom robotic testing system was used to test 9 fresh-frozen human cadaveric specimens (mean age, 65.1 ± 17.3 years). A 200-N compressive load was applied to the ankle, while a 5-N·m external rotation and a 5-N·m inversion moment were applied independently to the ankle at 0° of flexion, 15° and 30° of plantarflexion, and 10° of dorsiflexion. Fibular medial-lateral translation, anterior-posterior translation, and internal-external rotation relative to the tibia were tracked by use of an optical tracking system in the following states: (1) intact ankle; (2) AITFL, PITFL, and IOM transected ankle; (3) single-screw fixation; (4) double-screw fixation; (5) hybrid fixation; (6) single suture button fixation; and (7) divergent suture button fixation. Repeated-measures analysis of variance with Bonferroni correction was performed for statistical analysis. Results: In response to the external rotation moment and axial compression, single tricortical screw fixation resulted in significantly higher lateral translation of the fibula compared with that of the intact ankle at 10° of dorsiflexion ( P < .05). Suture button fixation resulted in significantly higher posterior translation of the fibula at 0° of flexion and 10° of dorsiflexion, whereas divergent suture button fixation resulted in higher posterior translation at only 0° of flexion ( P < .05). In response to the inversion moment and axial compression, single tricortical screw and hybrid fixation significantly decreased lateral translation in plantarflexion, whereas double tricortical screw fixation and hybrid fixation significantly decreased external rotation of the fibula compared with that of the intact ankle at 15° of plantarflexion ( P < .05). Conclusion: Based on the data in this study, hybrid fixation with 1 suture button and 1 tricortical screw may most appropriately restore tibiofibular kinematics for early weightbearing. However, overconstraint of motion during inversion may occur, which has unknown clinical significance. Clinical Relevance: Surgeons may consider this data when deciding on the best algorithm for syndesmosis repair and postoperative rehabilitation.

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

BMC Surgery ◽

10.1186/s12893-021-01394-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Fan Yongfei ◽

Liu Chaoyu ◽

Xu Wenqiang ◽

Ma Xiulin ◽

Xu Jian ◽

...

Keyword(s):

Rigid Fixation ◽

Operative Techniques ◽

Biomechanical Stability ◽

X Ray ◽

Vas Score ◽

Second Metatarsal ◽

Significant Difference ◽

Elastic Fixation ◽

Lisfranc Injuries

Abstract 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.

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