Abstract
Purpose: The recommendations for surgical fixation of tibiofibular syndesmosis injuries are increasingly challenging for many clinical orthopedists, as international consensus has not been published for the optimal treatment of the injury. Thus, we have created a 3D-printed navigation template for a precise bone tunnel and a novel adjustable EndoButton fixation (NAE) for the ideal treatment. The purpose of this research was to evaluate the accuracy of the 3D-printed navigation template and explore the biomechanical performance of the NAE technique by comparing it with the intact syndesmosis, screw technique, and TightRope (TR) technique. Methods: Twenty-four human cadaveric legs were randomly allocated to four groups: the NAE group (n = 6), TR group (n = 6), screw group (n = 6), and intact group (n = 6). A personalized navigation template based on computed tomography scans was designed, and 3D printing models were generated for the distal tibiofibular syndesmosis. The NAE, TR, and screw group were performed via 3D-printed navigation template, respectively. All groups were tested under increasing loading forces including axial loading (from 100 N to 700 N) and torsional loading (from 1 N to 5 N), which were performed in different ankle positions. The displacements of the tibiofibular syndesmosis were analyzed using the Bose Electroforce 3510-AT biomechanical testing equipment. Results: Surgical fixations were conducted successfully through a 3D-printed navigation template. Both in axial or torsional loading experiments, no statistically significant difference was observed in the displacements among the NAE, TR, and intact groups in most situations (p > 0.05), whereas the screw group demonstrated obviously smaller displacements than the abovementioned three groups (p < 0.05). Conclusion: The 3D printing technology application may become beneficial and favorable for locating and making the bone tunnel. Also, the NAE fixation provides the performance of complete ligaments; it also restores physiologic micromotion and avoids insufficient or excessive reduction when compared to the TR and screw technique. This may offer a new fixation for the treatment of tibiofibular syndesmosis injuries that is desirable for clinical promotion.
Highlights
The separation of the distal tibiofibular syndesmosis is a common orthopaedic injury that is usually associated with 1–20% of all ankle sprains and 13% of ankle fractures in patients (Egol et al, 2010; Liu et al, 2018; Shimozono et al, 2019; Corte-Real and Caetano, 2021)
Most surgical fixations for syndesmosis diastasis have been operated with the flexible fixation method involving the suture button (Chen et al, 2019; Alastuey-López et al, 2021)
We found a statistically non-significant difference in the displacements among the novel adjustable EndoButton (NAE), TR, and intact groups at most of these testing points
Summary
The separation of the distal tibiofibular syndesmosis is a common orthopaedic injury that is usually associated with 1–20% of all ankle sprains and 13% of ankle fractures in patients (Egol et al, 2010; Liu et al, 2018; Shimozono et al, 2019; Corte-Real and Caetano, 2021). For most unstable syndesmosis injuries, with ankle fractures, patients are advised to be treated operatively (van Dijk et al, 2016). Screw fixation is one of the most common methods, it does not respect the dynamic properties, and there still exist some inevitable complications, including screw loosening and breakage and a high risk of reoperation for screw removal (McBryde et al, 1997; Jurkowitsch et al, 2016; Azoulay et al, 2020). Most surgical fixations for syndesmosis diastasis have been operated with the flexible fixation method involving the suture button (Chen et al, 2019; Alastuey-López et al, 2021). Based on suture button design, TightRope (TR) has become a relatively new operation which provides accurate reduction and anatomical maintenance (Qu et al, 2017). The TR system fixation brings about several new potential complications, which include knot infection and looseness (Xie et al, 2018; Pang et al, 2019)
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