Reconstruction of Chronic Injured Distal Tibiofibular Syndesmosis with Autogenous Tendon Graft: A Systematic Review

Background. Chronic injuries of the distal tibiofibular syndesmosis are common in patients who fail to receive adequate diagnosis and timely treatment. Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon graft in these patients is effective, although relatively rarely reported. Purpose. To investigate clinical outcomes of syndesmosis reconstruction with an autogenous tendon graft for chronic injuries of the distal tibiofibular syndesmosis by reviewing the current literature. Methods. An English literature search was conducted in the MEDLINE, CENTRAL, and Cochrane databases to identify published studies up to October 2017. Preset inclusion and exclusion criteria were applied to identify all eligible articles. Results. Five studies (all with level IV evidence) that included a total of 51 patients who underwent reconstruction with an autogenous tendon graft were identified. It was reported that the symptoms were relieved postoperatively, including obviously improved functional outcomes and restoration of motions and exercise capacity. The mean American Orthopedic Foot and Ankle Society scale score of 16 patients was 53 preoperatively and 89 postoperatively. The visual analogue scale score of 14 patients decreased from 82.4 preoperatively to 12.6 postoperatively. A total of 5 (9.8%) complication cases were reported. Conclusion. Reconstruction of the distal tibiofibular syndesmosis with an autogenous tendon for chronic syndesmosis injury showed a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The interosseous ligament could be an appropriate reconstruction target in the treatment of chronic syndesmosis injury.

Biomechanics of the Distal Tibiofibular Syndesmosis: A Systematic Review of Cadaveric Studies

Background: This investigation’s purpose was to perform a systematic review of the literature examining the biomechanics of the ligaments comprising the distal tibiofibular syndesmosis with specific attention to their resistance to translational and rotational forces. Although current syndesmosis repair techniques can achieve an anatomic reduction, they may not reapproximate native ankle biomechanics, resulting in loss of reduction, joint overconstraint, or lack of external rotation resistance. Armed with a contemporary understanding of individual ligament biomechanics, future operative strategies can target key stabilizing structure(s), translating to a repair better equipped to resist anatomic displacing forces. Study design: Systematic review. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist. Biomechanical studies testing cadaveric lower limb specimens in the intact and injured state measuring the distal tibiofibular syndesmosis resistance to translational and rotational forces were included in this review. Only studies that included numerical data were included in this review; studies that only reported figures and graphs were excluded. Results: Twelve studies met the inclusion and exclusion criteria. Two studies determined the mechanical properties of syndesmotic ligaments, finding superior strength and stiffness of the interosseous ligament (IOL), as compared to the anterior (AITFL) or posteroinferior tibiofibular ligament (PITFL). Four studies examined native ankle biomechanics establishing physiologic range of motion of the fibula relative to the tibia. Fibular range of motion was found to be up to 2.53 mm of posterior translation (Markolf et al), 1.00 mm lateral translation (Xenos et al), 3.6 degrees of external rotation (Burssens et al), and 1.4 degrees of internal rotation (Clanton et al). Four studies evaluated syndesmotic biomechanics under physiological loading and found that the AITFL, IOL, and PITFL provide the majority of resistance to external rotation, diastasis, and internal rotation, respectively. Two studies investigated the biomechanics of clinically and intraoperatively used tests for syndesmotic injuries and found increased sensitivity of sagittal plane posterior fibular translation, as opposed to coronal plane lateral fibular translation for unstable injuries. Conclusions: Study findings suggest that although the IOL is the strongest syndesmotic ligament, the AITFL has a dominant role stabilizing the distal tibiofibular syndesmosis to external rotation force. Because of these characteristics, operative repair of the AITFL along its native vector may provide a more biomechanically advantageous construct and should be investigated clinically. Additionally, evaluation of clinical stress tests revealed that the external rotation stress test is the most sensitive test to recognize an AITFL tear, and that a 3-ligament disruption is needed to cause diastasis greater than 2 mm.

Self-made wire-rope button plate: A novel option for the treatment of distal tibiofibular syndesmosis separation

Objective: To compare the clinical effect of the self-made wire-rope button plate and cortical screw in the treatment of the distal tibiofibular syndesmosis separation. Methods: Total 26 patients with distal tibiofibular syndesmosis separation were treated with internal fixation with a self-made wire-rope button plate and cortical screw. They were divided into a self-made wire-rope button plate group and cortical screw group. self-made wire-rope button plate group: 12 cases of inferior tibiofibular syndesmosis were reconstructed by self-made wire-rope button plate. Cortical screw group: 14 cases of inferior tibiofibular syndesmosis were reconstructed by cortical screw. The follow-up data of 2, 6, 12 weeks and 6 and 12 months after operation were collected. Results: There was no significant difference in operative time, the amount of intraoperative bleeding and postoperative complications between the two groups (P > 0.05). Comparison of postoperative complications: There was no loosening and rupturing of internal fixation in the self-made wire-rope button plate group. In the cortical screw group, the rupture of screws was found in 1 case, which occurred in the 10th weeks after the operation, and the broken screws were removed after 1 year with other internal fixations. Within 12 weeks of reoperation to remove the internal fixation rate: There was a significant difference in the rate of reoperation to remove the internal fixation within 12 weeks (p < 0.05). At the last follow-up, the AOFAS score of the ankle joint were 94 ± 4.79 in the self-made wire-rope button plate group and 92.8 ± 6.73 in the cortical screw group. There was no significant difference (P > 0. 05). Conclusion: The self-made wire-rope button plate and cortical screw can effectively treat the separation of the tibiofibular syndesmosis. It provides a new choice for the treatment of inferior tibiofibular syndesmosis.