Suture Button Research Articles

A biomechanical in-vitro study on an alternative fixation technique of the pubic symphysis for open book injuries of the pelvis

PurposeImplant failure rates remain high after plate fixation in pelvic ring injuries. The aim of this study was to compare an alternative fixation technique with suture-button devices and anterior plate fixation in partially stable open-book injuries. Material and MethodsWe acquired 16 human fresh frozen anatomic pelvic specimens. The sacrospinous, sacrotuberous, and anterior sacroiliac ligaments were bilaterally released, and the pubic symphysis transected to simulate a partially stable open-book (AO/OTA 61-B3.1) injury. The specimens were randomly assigned to the two fixation groups. In the first group two suture-button devices were placed in a criss-crossed position through the symphysis. In second group a six-hole plate with standard 3.5 unlocked bicortical screws was used for fixation. Biomechanical testing was performed on a servo-hydraulic apparatus simulating bilateral stance, as described by Hearn and Varga. Cyclic compression loading with a progressively increasing peak load (0.5 N/cycle) was applied until failure. The failure mode, the load and the number of cycles at failure and the proximal and distal distance of the symphysis during testing were compared. ResultsThere was no implant failure in either of the two groups. Failures occurred in nine pelvises (56.2%) at the fixation between the sacrum and the mounting jig and in seven pelvises (43.8%) in the sacroiliac joint. Neither the ultimate load nor the number of cycles at failure differed between the surgical techniques (p = 0.772; p = 0.788, respectively). In the suture button group the mean ultimate load was 874.5 N and the number of cycles at failure was 1907.9. In the plate group values were 826.1 N and 1805.6 cycles, respectively. No significant differences at proximal and distal diastasis of the symphysis were monitored during the whole loading process. ConclusionThe fixation with suture button implants showed comparable results to anterior plate fixation in open-book injuries of the pelvis.

In-line Pullout Strength of 2 Acetabular Fixation Methods for Ligamentum Teres Reconstruction of the Hip: A Cadaveric Study.

Background:Ligamentum teres (LT) reconstruction is an appropriate alternative in select cases of LT full-thickness tears, resulting in hip micro- or macroinstability. Graft fixation at the acetabular fossa is critical to achieving the best functional results.Purpose:The purpose of this study is to compare the pullout strength of 2 graft fixation methods used for LT reconstruction of the hip.Study Design:Controlled laboratory study.Methods:In 7 cadaveric specimens, the acetabular socket was prepared after the native LT was transected and the femoral head was removed. Seven separate tibialis anterior grafts were then prepared by suturing a running-locking No. 2 suture on each tail of the graft. Three specimens had fixation of the graft to the acetabulum using an adjustable cortical suspension suture button; the remaining 4 were fixed to the acetabulum using a knotless suture anchor. Specimens were then mounted onto a custom jig within a mechanical test frame to allow for the in-line pull of the graft fixation construct. After a preload of 5 N, each specimen was loaded to failure at 0.5 mm/s. Stiffness and load to failure were measured for each specimen construct.Results:Suture button fixation had a higher mean load to failure when compared with the knotless anchor fixation method (mean ± SD, 438.1 ± 114.3 vs 195.9 ± 50.0 N; P = .01). There was no significant difference in mean stiffness between the methods of fixation (24.5 ± 1.4 vs 26.5 ± 5.8 N/mm; P = .6).Conclusion:In this cadaveric study, the suture button fixation demonstrated greater load to failure than the knotless anchor fixation.Clinical Relevance:Results of this study can guide surgical decision making when selecting an acetabular fixation method for LT reconstruction.

Treatment of chronic isolated distal tibiofibular syndesmosis injury. Literature update and case report using autologous semitendinous graft reconstruction

Isolated distal tibiofibular syndesmosis lesions are rare and can be easily missed. Diagnosis and treatment of chronic disruption is not easy, with limited published data. Surgical treatment of chronic syndesmosis injury is challenging as there is no international consensus on the optimal management. Diagnosis and treatment are still controversial and poorly discussed in literature. PubMed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1990 to December 2020 to identify studies relating to treatment of isolated chronic syndesmosis injury and 17 articles were identified. We found 5 studies reporting on the results of autologous semitendinosus tendon graft in chronic syndesmosis reconstruction. We describe the case of a 47-year-old man who sustained an isolated distal tibiofibular syndesmotic injury of his right ankle that was initially missed. The patient was diagnosed at 6 months after a motocross accident and underwent reconstruction of syndesmosis with semitendinous autologous tendon associated with debridement of the fibrosous scar tissue in the anterior tibial fibular area (with preservation of the anterior sleeve) and subsequent reinsertion with transosseous stitches in the fibular bone. We used a quadricortical screw to stabilize syndesmosis definitively. After 1 month, the reduction failed because of transyndesmosic screw breakage and the patient underwent another surgery. We removed the broken screw and then used a suture button to stabilize syndesmosis permanently. The literature review and clinical case seem to suggest that reconstruction of the distal tibiofibular syndesmosis with autogenous tendon for chronic syndesmosis injury determines a good therapeutic effect in terms of both subjective symptoms and objective evaluation scores. The autologous semitendinosus tendon graft may be an appropriate and promising reconstruction target in the treatment of chronic syndesmosis injury.

Effect of Modified Arthroscopic Latarjet on Acromiohumeral Distance at 5-Year Follow-up.

Background:It is unclear whether coracoacromial ligament release during the Latarjet procedure will increase superior translation of the shoulder joint.Purpose:To evaluate whether a modified suture button Latarjet procedure can decrease the acromiohumeral distance (AHD).Study Design:Case series; Level of evidence, 4.Methods:A retrospective analysis was conducted among 155 patients who underwent a modified suture button Latarjet procedure between 2013 and 2015. AHD was measured on bilateral computed tomography scans taken preoperatively and on scans of the affected shoulder taken on postoperative day 1 and postoperative month (POM) 6, POM 36, and POM 60. At each time point, we recorded pain on a visual analog scale (VAS) and objective shoulder function using the American Shoulder and Elbow Surgeons, Rowe, and Walch-Duplay scores. Preoperative and final follow-up VAS and functional scores were compared using the paired t test. Pairwise comparison of AHD values at each follow-up time point were compared with the preoperative intact side using the paired t test. Intra- and interobserver reproducibility of the AHD measurements was evaluated using the intraclass correlation coefficient.Results:A total of 104 patients who met the criteria completed the final follow-up, which occurred at 62.6 ± 2.4 months (mean ± SD). When compared with presurgery, the VAS and all functional scores improved significantly at the last follow-up (P < .001 for all). Intra- and interobserver intraclass correlation coefficients indicated good reliability for the ADH measurements. Preoperatively, there were no differences in AHD values between the intact and affected shoulders (7.8 ± 0.8 mm for both; P = .851). The AHD values at postoperative day 1 and POM 6, POM 36, and POM 60 were 9.6 ± 0.7 mm, 8.6 ± 0.9 mm, 8.0 ± 0.8 mm, and 7.9 ± 0.8 mm, respectively, all of which were larger than those of the preoperative intact side (P < .001 for all).Conclusion:The modified suture button Latarjet procedure not only offered satisfactory therapeutic effects but also did not decrease the AHD at 5-year follow-up.

Fixation Type Does not Affect the Learning Curve and Short-Term Radiographic Outcomes for Arthroscopic Anatomic Glenoid Reconstruction with Distal Tibia Allograft

PurposeThe purpose of this study was to compare the learning curves and radiographic variables between screw and suture button fixation of the allograft for surgeons learning the all-arthroscopic anatomic glenoid reconstruction (AAGR) technique for anterior shoulder instability. We compared the surgical times of these two fixation techniques, as well as the graft placement in the vertical and medial-lateral directions.MethodsThis was a retrospective review of patients who underwent AAGR for recurrent anterior shoulder instability. Start and end times were recorded for each procedure, and learning was assessed through the change in operative time over successive surgeries and by variability of operative time. Graft placement, in terms of vertical positioning, medial-lateral step formation, and obliquity of fixation (alpha angle), was evaluated using 3-dimensional CT scans at approximately 6 months postoperation.ResultsA total of 43 patients were included in our study. Twenty-seven had screw fixation, and 16 had suture button fixation. The surgical duration of the button fixation technique was comparable to that of screw fixation (P = .72), with no significant difference in the variability of surgical time in either cohort (P > .05). Both groups showed similarly optimal vertical positioning of the graft onto the lower third of the glenoid (P = .89). Desired obliquity of graft fixation was identified more frequently with button fixation (P < .001). Both fixation methods provided clinically acceptable medial-lateral step formations, with suture-button fixation being significantly larger (P = .03).ConclusionsSuture button fixation of the allograft is a potential alternative to screw fixation for the management of glenoid bone loss in recurrent anterior shoulder instability. The results of this study show that this method has a comparable learning curve, with a similar surgical duration, while not compromising the optimal accuracy of vertical and medial-lateral placement of the graft and achieves a superior alpha angle of fixation.Level of EvidenceLevel III, retrospective cohort study.

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

Patient preference for fixation technique of syndesmotic injury in the presence of an ankle fracture is not known. This study followed a five-step process for expected value decision analysis: decision tree, outcome probabilities, expected patient values, foldback analysis, and sensitivity analysis. Outcome variables were “well” (cases that did not require further procedures or suffer any complications related to surgery), surgical site infection (SSI), loss of reduction (LOR), hardware removal (HWR), and malreduction. The systematic review included 22 studies including 358 patients who underwent suture button fixation and 739 who underwent screw fixation. Outcome probabilities for suture button fixation were 76.4% well, 6.2% SSI, 5.4% LOR, 10.4% HWR, and 1.6% malreduction. Outcome probabilities for screw fixation were 47.1% well, 4.3% SSI, 8.1% LOR, 30.7% HWR, and 9.8% malreduction. After the survey and foldback analysis, overall utility values for suture button and screw fixation were 7.46 and 4.78, respectively. One-way sensitivity analysis revealed that the overall utility value for suture button fixation was greater than the utility value of screw fixation under all circumstances except when the rate of malreduction for suture button fixation was theoretically elevated to 85%. Level of evidence: therapeutic, level IV.

Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective

ObjectivesAlthough the body of literature on syndesmosis injuries is growing with regard to both the biomechanics and clinical outcomes for various fixation constructs, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavoured to assess the current approaches to managing syndesmotic injuries through a Research Electronic Data Capture survey. MethodsThe survey consisted of 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment and technique, and postoperative management. Responses were generated through six different athlete scenarios: moderate impact, high impact, and very high impact athletes with/without complete deltoid injury. Frequencies and percentages were calculated for all categorical responses. ResultsA total of 742 providers responded to the survey, including 457 American surgeons and 285 members of various international societies. Flexible devices were the preferred fixation construct (47.1%), followed by screws (29.6%), hybrid fixation (e.g. combination of flexible device and screw, 18%), and other (5.3%). Sixty-four percent of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated return to full participation, largely dependent on the presence or absence of a deltoid ligament injury. ConclusionThe most common elements used as surgical indications were syndesmosis widening > 2 mm on x-ray, an anterior inferior talofibular ligament injury in combination with a posterior inferior talofinular ligament or deltoid ligament involvement on magnetic resonance imaging, and widening of the distal tibiofibular joint during arthroscopic evaluation. Overall, flexible fixation (e.g. suture button) was the preferred device choice for the repair of an injured syndesmosis. Most respondents did not alter their rehab protocol or anticipated return to play timeline based on the injury severity. However, there was considerable variability between respondents on the time to weight-bearing, running, and full participation. Further pragmatic outcomes data are necessary to guide safe return to play protocols for syndesmotic injuries. Level of evidenceLevel IV.

Suture button versus syndesmotic screw in ankle fractures - evaluation with 3D imaging-based measurements

BackgroundInadequate reduction of syndesmotic injuries can result in disabling clinical outcomes. The aim of the study was to compare syndesmosis congruity after fixation by syndesmotic screws (SYS) or a suture button system (SBS) using three-dimensional (3D) computed imaging techniques.MethodsIn a retrospective single-center study, patients with unilateral stabilization of an ankle fracture with a syndesmotic injury and post-operative bilateral CT scans were analyzed using a recently established 3D method. The side-to-side differences were compared for tibio-fibular clear space (∆CS), translation angle (∆α), and vertical offset (∆z) among patients stabilized with syndesmotic screws or suture button system. Syndesmotic malreduction was defined for ∆CS > 2 mm and for |∆α| > 5°. ∆CS and ∆α were correlated with two-dimensional (2D) measurements.ResultsEighteen patients stabilized with a syndesmosis screw and 29 stabilized with a suture button system were analyzed. After stabilization, both groups revealed mild diastasis (SYS: mean ∆CS 0.3 mm, SD 1.1 mm vs SBS: mean ∆CS 0.2 mm, SD 1.2 mm, p = 0.710). In addition, both stabilization methods showed slight dorsalization of the fibula (SYS: mean ∆α 0.5°, SD 4.6° vs SBS: mean ∆α 2.1°, SD 3.7°, p = 0.192). Also, restoration of the fibula-to-tibia length ratio also did not differ between the two groups (SYS: mean Δz of 0.5 mm, SD 2.4 mm vs SBS: mean Δz of 0 mm, SD 1.2 mm; p = 0.477). Malreduction according to high ∆α was most common (26% of cases), with equal distribution between the groups (p = 0.234). ∆CS and ∆α showed good correlation with 2D measurements (ρ = 0.567; ρ = 0.671).ConclusionThis in vivo analysis of post-operative 3D models showed no differences in immediate post-operative alignment after syndesmotic screws or suture button system. Special attention should be paid to syndesmotic malreduction in the sagittal orientation of the fibula in relation to the tibia in radiological control of the syndesmotic congruity as well as intra-operatively.

Outcomes of "Cross-Coupling Suture Button Suspensionplasty" for Thumb Carpometacarpal Joint Osteoarthritis: A Preliminary Report.

Thumb carpometacarpal joint osteoarthritis is a common condition that is treated nonsurgically. When conservative treatments fail, surgery is considered. Recently, suture button suspensionplasty has attracted attention and yielded good clinical results. We have developed a novel suture button suspensionplasty procedure called "cross-coupling suture button suspensionplasty" (CC-SBS) using a pair of suture button devices after a complete trapeziectomy. This retrospective study aimed to report the short-term clinical results of patients who underwent CC-SBS at our institution. We evaluated 10 hands of 10 patients (9 women and 1 man; average age, 67 years) who were refractory to conservative treatment and underwent CC-SBS at our institution between 2015 and 2017. We evaluated the preoperative Eaton stage and postoperative trapezial space height immediately after surgery and at the final visit; measured the trapezial space height, range of motion of the palmar and radial abduction of the carpometacarpal joint at the final visit; measured the preoperative and postoperative pinch strength; and recorded postoperative complications. The mean trapezial space height was 6.5 mm, and the mean radial and palmar abductions were 47° and 45°, respectively, at the final visit. The average pinch strength improved to 3.8 kg at the final visit compared to that pre-operation. In one case, a second metacarpal fracture occurred 2 weeks post-surgery, but no other complications were reported. Conclusion: CC-SBS showed short-term clinical outcomes similar to those of ligament reconstruction and tendon interposition and demonstrated faster overall recovery. Our procedure does not need a donor tendon for suspension and is technically simple and less invasive than ligament reconstruction tendon interposition. Thus, stronger initial fixation is obtained by using two suture button devices, and rehabilitation can be started from an early stage. We believe that this procedure is a good surgical option for carpometacarpal joint osteoarthritis.

Failed Latarjet Treated With Full Arthroscopic Eden–Hybinette Procedure Using Two Cortical Suture Buttons Leads to Satisfactory Clinical Outcomes and Low Recurrence Rate

To report clinical and radiologic outcomes of arthroscopic Eden-Hybinette using 2 cortical suture buttons in a series of patients with previous failed Latarjet and persistent glenoid bone loss. Between 2015 and 2019, patients with recurrent anterior instability after failed Latarjet underwent arthroscopic Eden-Hybinette procedure using 2 cortical buttons for graft fixation. Exclusion criteria were open and primary Eden-Hybinette and less than one year follow-up. Functional assessment was performed using Rowe and Walch-Duplay scores, subjective shoulder value, visual analog scale, and degree of satisfaction. Iliac crest bone graft placement and healing were assessed postoperatively with computed tomography imaging. A total of 17 patients with a mean age of 28 years (range, 21-43 years) at time of revision were included. The mean glenoid bone loss was 23% (range, 18%-42%). Medium or deep Hill-Sachs lesion (Calandra 2 and 3) was present in 65% of cases. At a mean follow-up of 3 ± 1.6 years, all but 1 patient (94%) considered their shoulder stable, and 15 patients (88%) were satisfied or very satisfied. The subjective shoulder value increased from 51% to 87% (P < .05), the Walch-Duplay increased from 23 to 86 points (P < .05), and Rowe scores improved from 30 to 92 points (P < .05). Apprehension was still positive in 3 patients (17.6%), with this percentage being greater in the presence of Hill-Sachs Calandra 3 (P= .02). Postoperative computed tomography scans showed optimal bone autograft position in all patients (below the glenoid equator and flush to the glenoid rim). Iliac crest bone graft healed to the anterior glenoid neck in 16 shoulders (94%). The rate of recurrent instability was 11.7% but only 1 patient required revision surgery (5.8%). Arthroscopic Eden-Hybinette using 2 cortical buttons leads to satisfactory clinical outcomes and a low recurrence rate after failed Latarjet, allowing successful reconstruction of the anterior glenoid rim and simultaneous treatment of capsular deficiency and humeral bone loss. Therapeutic, level IV, retrospective case series.

Arthroscopic “Double-Inlay” Eden-Hybinette Procedure with Modified Suture Button Fixation for the Revision of Failed Bristow-Latarjet

Bristow-Latarjet procedure has been widely regarded as a reliable and satisfactory operation for recurrent anterior glenohumeral instability, especially for patients with significant glenoid bone loss or high sports demand. Once failed, however, the subsequent revision surgery could be challenging. Eden-Hybinette procedure is the most common operation for revision of failed Bristow-Latarjet. It can perfectly restore the bone defect of the failed Bristow-Latarjet by harvesting a proper size of iliac bone block. Furthermore, several studies have shown the advantages of using suture button fixation in the revision surgery for failed Bristow-Latarjet procedure. However, the potential inferior biomechanical strength of suture button fixation is still a concern. This Technical Note introduced an arthroscopic “double-inlay” Eden-Hybinette procedure with modified suture button fixation for the revision of failed Bristow-Latarjet. With its “quadruple” reinforcement effect, this procedure can achieve an excellent biomechanical strength of fixation.

Meniscal Root Repair

Background: Meniscal root tears typically result from a hyperflexion/squatting injury or are in conjunction with ligamentous knee injury. Once a complete tear occurs, the meniscus is unable to convert axial loads to transverse hoop stresses which result in increased tibiofemoral contact pressure and osteoarthritis. The goal of a meniscal root repair is to anatomically reattach the meniscal root to the tibia plateau. Complete and partial healing occurs in over 93% of cases with retear rates ranging from 0% to 7%. Indications: We present a case of a highly active 21-year-old male collegiate soccer play that sustained a medial meniscal root tear after slipping on ice. Technique: An anatomic medial meniscal root repair was performed using a transtibial guide and 2 loop sutures tied over a button. Results: Full anatomic footprint coverage was able to be achieved intraoperatively and gentle range of motion from 0 to 90° of flexion did not result in gap formation. Discussion/Conclusion: Successful outcomes with full anatomic footprint coverage of the medial meniscal root can be achieved with 2-loop suture button configuration.

Trapeziectomy with suture-button suspensionplasty versus ligament reconstruction and tendon interposition: a randomized controlled trial

The purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months’ follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.

Comparison of Outcomes Between Suture Button Technique and Screw Fixation Technique in Patients With Acute Syndesmotic Diastasis: A Meta-analysis of Randomized Controlled Trials.

Background:Our aim was to compare the outcome between suture button (SB) stabilization and syndesmotic screw fixation (SF) in patients with acute syndesmotic diastasis.Methods:A systematic literature search up to June 30, 2021, was performed to identify randomized controlled trials (RCTs) comparing outcomes of SB with SF techniques in patients with acute syndesmotic diastasis. We calculated mean differences for continuous outcomes, using the Hartung-Knapp-Sidik-Jonkman method, and odds ratio for dichotomous outcomes, using the Mantel-Haenszel method.Results:Eight RCTs involving 569 patients met the inclusion criteria, 1 RCT with level I evidence, and 7 RCTs with level II evidence. The meta-analysis showed that the SB technique had a higher AOFAS score <6 months and 12 months postoperatively (MD = 4.74, 95% CI 1.68-7.80, P = .01; and MD = 5.42, 95% CI 1.50-9.33, P = .02) and reduced the risk of implant irritation (OR = 0.31, 95% CI 0.11-0.89, P = .03), implant failure (OR = 0.06, 95% CI 0.02-0.23, P < .01), and reoperation (OR = 0.43, 95% CI 0.22-0.83, P = .01). The 2 approaches did not differ in further functional outcomes or postoperative complications.Conclusion:Because functional outcomes showed no relevant difference between both SB and SF, the advantage of SB appears to be in the lower risk for postoperative complications. The SB technique led to fewer cases of implant irritation, implant failure, and reoperation compared with SF.Level of Evidence:Level I, meta-analysis of RCTs.

Fixation of distal clavicle fractures with coracoclavicular instability: acomparative biomechanical study in human cadavers.

BackgroundThe need for coracoclavicular (CC) stabilization in the fixation of fractures with CC instability (Neer type IIB and V) was biomechanically demonstrated by higher construct strength than isolated locking plate osteosynthesis. It was the purpose of this study to prove noninferiority of the new cow-hitch suture repair technique compared with the well-established suture tape double-button fixation with regard to overall fixation strength and cyclic loading properties.MethodsTwelve human cadaver shoulders (7 right and 5 left) were matched for sex and age (mean age: 75 ± 5 years). An oblique parasagittal fracture line 20 mm medial to the acromioclavicular joint line was created, and the CC ligaments were dissected. Six shoulders were reconstructed by a double FiberTape fixation with two suture buttons (group DB), and the remaining six shoulders by a cow-hitch suture repair using a double FiberWire with only coracoid button fixation (group CH). Both reconstruction techniques were tested in a servo-hydraulic material testing machine for cyclic displacement (mm), stiffness (N/mm), and maximum load-to-failure (N) after 500 cycles at 3 mm/s and inferosuperior load between 15 and 70 N. Superior fragment displacement in space was recorded using a MicroScribe digitizer.ResultsThere were no statistically significant differences regarding cyclic displacement (group DB: 0.7 mm; group CH: 1.3 mm; P = .36), stiffness (group DB: 177 N/mm; group CH: 116 N/mm; P = .17), maximum load-to-failure (group DB: 560 N; group CH: 492 N; P = .59), and superior displacement in space of the medial fragment (group DB: 3.2 mm; group CH: 1.6 mm; P = .48).ConclusionFixation of unstable distal clavicle fractures using a double FiberWire cow-hitch suture repair with isolated coracoid button fixation for stand-alone CC stabilization resulted in similar biomechanical properties to a double-suture button fixation with FiberTapes while avoiding prominent clavicular implants.

Investigating the Radiological Outcomes of Syndesmosis Injuries in Ankle Fracture Patients After Suture Button Fixation

Concomitant syndesmotic injury occurs in 10% of ankle fractures. Anatomic reduction and maintenance of this reduction is critical in ensuring ankle stability and preventing long-term complications. This is a retrospective cohort study aimed at evaluating the mid-term radiological outcomes of syndesmotic injuries in ankle fracture patients after surgical fixation with suture button device. The study group included 33 patients. Plain radiographs including anteroposterior, lateral and mortise views of the affected ankle were performed preoperatively, postoperatively and at 3-month follow-up. Anteroposterior views were used to measure the amount of tibiofibular overlap and tibiofibular clear space. Paired Student's t test and linear model regression were performed. Between the immediate postoperative and 3-month follow-up period, there was a mean decrease in tibiofibular overlap of 0.841 (±2.07) mm (p = .0259). There was a mean increase in tibiofibular clear space of 0.621 (±1.46) mm (p = .0201). In addition, we found significant correlation between fracture type and change in tibiofibular clear space (p = .047). Our study showed that there is statistically significant widening of the syndesmosis after suture button fixation at 3-month follow-up as evidenced by reduced tibiofibular overlap and increase in tibiofibular clear space. However, they remain within the maximum threshold for acceptable syndesmotic widening of 1.5 mm. Further correlation between radiological outcomes and patient function is needed to determine clinical significance of these changes.

Latissimus Dorsi Tendon Reconstruction at the Myotendinous Junction With Acellular Dermal Allograft

Background: Limited available data have shown latissimus dorsi tendon reconstruction to be an effective treatment for tendon tears in specific subpopulations of elite overhead throwing athletes. Indications: Primary indication for latissimus dorsi tendon reconstruction is a symptomatic, full-thickness humeral avulsion with or without a concomitant teres major tendon tear. Surgical candidates are typically young, high-demand, elite or professional overhead throwing athletes. In this case, the patient is a 29-year-old male former minor league pitcher and current pitching coach with a full-thickness avulsion of the latissimus dorsi tendon. Technique Description: The patient was positioned left lateral decubitus with a dynamic limb positioner maintaining the arm in 90° abduction and maximal internal rotation. This technique used a single posterior axillary incision, which was performed and dissected down to the ruptured latissimus dorsi tendon. We circumferentially applied an acellular dermal allograft to augment the reconstruction at the myotendinous junction. Subsequently, the construct was prepared for transfer with a Krackow suture technique. Suture buttons were used to secure the reconstructed latissimus dorsi tendon to the anatomic footprint on the proximal humerus with a tension slide technique. Results: One case series showed return to the previous level of competition for all baseball pitchers who underwent a latissimus dorsi reconstruction with excellent improvement in visual analog scale pain, American Shoulder and Elbow Surgeons, and Kerlan-Jobe Orthopaedic Clinic scores. Another larger study demonstrated equal return to play rates for professional baseball pitchers with a latissimus dorsi tear treated either nonoperatively or operatively. However, those treated operatively had no decline in performance, whereas the nonoperative cohort saw decline in some statistics. Conclusion: Latissimus dorsi tendon reconstruction using an acellular dermal allograft at the myotendinous junction is a viable treatment option for elite overhead throwing athletes with full-thickness tendon avulsions. It allows for full return to play, particularly if the patient has failed nonoperative management.

Traumatic Heel Pad Avulsion in a Pediatric Patient

Introduction: Heel pad injuries can have devastating and debilitating consequences. All efforts to primarily reapproximate the heel pad should be undertaken. Reconstruction of the heel pad can often require multiple complex surgeries including microvascular flaps and tissue transfers. There is a paucity of successful techniques for primary repair in the literature. Case Presentation: In this case report, we describe the successful use of polydioxanone suture with sterile buttons for the repair of the heel pad in a pediatric patient. An 8-year-old male was struck by a vehicle, sustaining a full-thickness heel pad avulsion injury measuring approximately 16-cm in length. The soft tissue was sharply debrided and repaired primarily to the calcaneal periosteum using #1 polydioxanone suture with external suture buttons, and an incisional wound VAC was applied. He was placed into a long-leg bent knee cast and kept non-weight bearing for a total of 6 weeks, at which time the suture and buttons were removed and he was progressed to weight bearing as tolerated in a walking boot. At the 6-month follow-up examination, the heel pad was viable and well-fixed; the patient reported no pain and was not limited in any chosen activities. Conclusion: This construct was shown to provide effective fixation while mitigating reported concerns of tissue necrosis caused by suture repair. At 1 year from injury, the patient’s mother noted a slight limp with running but not with walking. He reported no pain at any time, and his Oxford Ankle-Foot Questionnaire for Children score was 58, indicating excellent patient-reported outcome following his procedures.

The Impact of Suture Button Removal in Syndesmosis Fixation.

The suture button (SB) device was introduced to negate the need for routine hardware removal in the treatment of syndesmosis injuries. However, a considerable SB removal rate has been reported, and the impact of removal is unknown. This study aimed to evaluate the radiographic and clinical outcomes after removal of SB for syndesmosis fixation. A total of 36 patients who underwent removal surgery after syndesmosis fixation using SB were identified. The mean postoperative time to removal was 12.2 months. On a plain radiograph, tibiofibular clear space (TFCS) was measured and compared at three follow-up time points. In patients with computed tomography (CT) imaging (n = 18), the anterior-to-posterior (A/P) ratio was measured to evaluate changes in quality of reduction. Additionally, clinical outcomes were assessed. There were no significant differences in TFCS between the three follow-up periods. None of the patients exhibited recurrent diastasis after SB removal. Although CT analysis demonstrated malreduction in six patients (33.3%), five of six patients had a subsequent spontaneous reduction of the syndesmosis. Clinically, all patients described the resolution of symptoms related to painful hardware at the final follow-up. Our results demonstrate that SB removal at one year following syndesmosis fixation leads to improved clinical symptoms without negatively impacting the quality of syndesmosis reduction.

Does the orientation of syndesmosis fixative device affect the immediate reduction of the distal tibiofibular joint?

IntroductionIncongruent stabilization of the distal tibiofibular joint (syndesmosis) results in poorer long-term outcome in malleolar fractures. The aim was to analyze whether the orientation of the syndesmotic stabilization would affect the immediate reduction imaged in computed tomography (CT).Materials and methodsThe syndesmotic congruity in 114 ankle fractures with stabilization of the syndesmosis were retrospectively analyzed in the post-operative bilateral CT scans. The incisura device angle (IDA) was defined and correlated with the side-to-side difference of Leporjärvi clear-space (ΔLCS), anterior tibiofibular distance (ΔantTFD) and Nault talar dome angle (ΔNTDA) regardless of the stabilization technique and separately for suture button system and syndesmotic screw. Asymmetric reduction was defined as ΔLCS > 2 mm and |ΔantTFD|> 2 mm.ResultsRegardless of the stabilization technique, no correlation between the IDA and the ΔLCS (r = 0.069), the ΔantTFD (r = 0.019) nor the ΔNTDA (r = 0.177) could be observed. There were no differences between suture button system and syndesmotic screw. Asymmetrical reduction was detected in 46% of the cases, while sagittal asymmetry was most common. No association was found between the orientation of stabilization device and occurrence of asymmetrical reduction (p > 0.05). The results of suture button system and syndesmotic screw were comparable in this respect (p > 0.05).ConclusionPoor correlation between the orientation of the stabilization device and the immediate post-operative congruity of the syndesmosis could be shown. In contrast to current literature, this study did not show difference of suture button system over syndesmotic screw in this regard. Careful adjustment of the fibula in anteroposterior orientation should be given special attention.