Suture Button versus Screw Fixation for Distal Tibiofibular Injury and Expected Value Decision Analysis

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.

Download Full-text

Comparison of Time-dependent Changes in Syndesmotic Reduction Between Suture-button and Screw Fixation for Ankle Malleolar Fractures with Tibiofibular Diastasis

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00293 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0029

Author(s):

Seiji Kimura ◽

Satoshi Yamaguchi

Keyword(s):

Fracture Fixation ◽

Screw Fixation ◽

Time Dependent ◽

Fixation Method ◽

Suture Button ◽

Malleolar Fractures ◽

Fixation Group ◽

Postoperative Changes ◽

Group B ◽

Over Time

Category: Trauma Introduction/Purpose: Reduction of the tibiofibular syndesmosis is one of the most important factors that affect the clinical outcome after ankle malleolar fractures with syndesmotic diastasis. Recent studies have shown that suture-button fixation can yield better syndesmotic reduction than screw fixation immediately after surgery. However, the time-dependent change in the reduction for each fixation method has not been well studied. The purpose of this study was to compare the postoperative changes in the syndesmotic reduction after surgical treatment of ankle malleolar fractures between suture-button fixation and screw fixation using bilateral computed tomography. Methods: Patients who sustained ankle malleolar fractures with tibiofibular diastasis and underwent tibiofibular fixation were included. Suture-button fixation (Group B; n=14; age, 39 years) was used between 2015 and 2016, and syndesmotic screw fixation (Group S; n=20; age, 35 years) was used between 2012 and 2014. The syndesmotic screws were routinely removed. Patients underwent CT scanning of the bilateral ankles at 2 time points: at 2 weeks and 1 year after fracture fixation. Side-to-side differences in the anterior and posterior tibiofibular distances, and anteroposterior fibular translation were measured. Syndesmotic melreduction was defined as a side-to-side difference?2 mm in either of the measurements. The changes in each measurement and incidence of malreduction for each group were assessed using the Wilcoxon signed-ranks test and McNemar’s test. Differences between the two groups at each time point were also compared. Results: At 2 weeks after fracture fixation, the side-to-side difference in anterior tibiofibular distance was significantly wider in Group B (1.9 mm) than in Group S (0.7 mm) (p=0.03). Additionally, the fibulas were more translated posteriorly in Group B (1.5 mm) than in Group S (0.2 mm). At 1 year, the anterior tibiofibular distance decreased to 0.8 mm in Group B (p=0.09). On the contrary, it significantly increased to 1.9 mm in Group S (p=0.002). In Group B, the incidences of malreduction were 4/14 and 2/14 at 2 weeks and 1 year, respectively (p=0.74). Two ankles, which were malreduced at 2 weeks, changed to a reduced syndesmosis at 1 year. In Group S, the incidences were 8/20 and 9/20 at 2 weeks and 1 year, respectively (p=0.35). Conclusion: Syndesmotic alignment changed over time in both fixation methods, however, the patterns of change were different. Using suture-button fixation, the anterior tibiofibular distance decreased over time. As a result, the widened syndesmoses at 2 weeks changed to reduced syndesmoses at 1 year. On the contrary, using tibiofibular screw fixation, the anterior tibiofibular distance widened after screw removal. Our result suggests that the flexible suture-button fixation allows the fibula to move to the optimal location over time.

Download Full-text

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.

Download Full-text

A 3-D CT Analysis of Screw and Suture-Button Fixation of the Syndesmosis

Foot & Ankle International ◽

10.1177/1071100716673590 ◽

2016 ◽

Vol 38 (2) ◽

pp. 208-214 ◽

Cited By ~ 18

Author(s):

Jason M. Schon ◽

Brady T. Williams ◽

Melanie B. Venderley ◽

Grant J. Dornan ◽

Jonathon D. Backus ◽

...

Keyword(s):

Screw Fixation ◽

Joint Space ◽

Intact State ◽

Suture Button ◽

Repair Technique ◽

Cortical Screw ◽

Tibiofibular Joint ◽

Ct Analysis ◽

Mean Differences ◽

Repair Techniques

Background: Historically, syndesmosis injuries have been repaired with screw fixation; however, some suggest that suture-button constructs may provide a more accurate anatomic and physiologic reduction. The purpose of this study was to compare changes in the volume of the syndesmotic space following screw or suture-button fixation using a preinjury and postoperative 3-D computed tomography (CT) model. The null hypothesis was that no difference would be observed among repair techniques. Methods: Twelve pairs of cadaveric specimens were dissected to identify the syndesmotic ligaments. Specimens were imaged with CT prior to the creation of a complete syndesmosis injury and were subsequently repaired using 1 of 3 randomly assigned techniques: (a) one 3.5-mm cortical screw, (b) 1 suture-button, and (c) 2 suture-buttons. Specimens were imaged postoperatively with CT. 3-D models of all scans and tibiofibular joint space volumes were calculated to assess restoration of the native syndesmosis. Analysis of variance and Tukey’s method were used to compare least squares mean differences from the intact syndesmosis among repair techniques. Results: For each of the 3 fixation methods, the total postoperative syndesmosis volume was significantly decreased relative to the intact state. The total mean decreases in volume compared with the intact state for the 1-suture-button construct, 2-suture-button construct, and syndesmotic screw were −561 mm3 (95% CI, −878 to −244), −964 mm3 (95% CI, −1281 to −647) and −377 mm3 (95% CI, −694 to −60), respectively. Conclusion: All repairs notably reduced the volume of the syndesmosis beyond the intact state. Fixation with 1 suture-button was not significantly different from screw or 2-suture-button fixation; however, fixation with 2 suture-buttons resulted in significantly decreased volume compared with screw fixation. Clinical Relevance: The results of this study suggest that the 1-suture-button repair technique and the screw fixation repair technique were comparable for reduction of syndesmosis injuries, although both may overcompress the syndesmosis.

Download Full-text

Allograft Versus Autograft Decision for Anterior Cruciate Ligament Reconstruction: An Expected-Value Decision Analysis Evaluating Hypothetical Patients

Arthroscopy The Journal of Arthroscopic and Related Surgery ◽

10.1016/j.arthro.2011.09.007 ◽

2012 ◽

Vol 28 (4) ◽

pp. 539-547 ◽

Cited By ~ 21

Author(s):

Robert S. Rice ◽

Brian R. Waterman ◽

James H. Lubowitz

Keyword(s):

Anterior Cruciate Ligament ◽

Anterior Cruciate Ligament Reconstruction ◽

Decision Analysis ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Expected Value ◽

Cruciate Ligament Reconstruction ◽

Anterior Cruciate

Download Full-text

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.

Download Full-text

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.

Download Full-text