Syndesmotic Fixation Research Articles

A Review of Syndesmosis Injuries and Preferred Treatment in Football Players.

Syndesmotic injuries are common football injuries. The unique demands of football athletes create large magnitude rotational moments about the ankle, even during low impact maneuvers. This review explores the structure and function of the syndesmosis, assesses recent data in football athletes at the professional and collegiate levels regarding epidemiology, describes available treatment options, and provides example cases from the authors' institution. The review concludes with clinical and surgical pearls for the evaluation and treatment of syndesmotic injury. In general, flexible syndesmotic fixation has demonstrated similar clinical outcome scores as rigid fixation. Flexible fixation has demonstrated benefit over rigid fixation in terms of implant failure, hardware removal, and local irritation. Both flexible and rigid fixation remain viable options for treatment of syndesmotic injuries yet the indications for selecting a construct are often subjective. Certain cases of high-risk football players such as linemen may warrant careful consideration of rigid fixation options despite the clinical advantages of flexible fixation. During fixation, direct visualization techniques with open or arthroscopic assistance for reduction of the syndesmosis remain superior and enable diagnosis of chondral defects. Flexible and rigid syndesmotic fixation techniques are viable for treatment of unstable syndesmotic injuries in athletes. Recent literature favors flexible fixation. However, at-risk football athletes or those with length unstable fibula fractures may benefit from rigid or supplemental flexible fixation as opposed to traditional flexible fixation. We recommend direct visualization of reduction at the syndesmosis during surgical treatment of unstable ankle injuries.

Comparison of tibiofibular syndesmosis stability following treatment of proximal, middle, and distal third fibula fractures

PurposeWhile treatment modalities for Maisonneuve fractures involving the proximal third of the fibula are established, no studies to date have reported outcomes associated with syndesmotic-only fixation of middle third fibular shaft fractures. The purpose of this study was to evaluate outcomes associated with syndesmotic-only fixation in the treatment of Maisonneuve fractures involving the middle third of the fibula.MethodsA retrospective review was conducted on 257 cases of syndesmotic ankle instability with associated fibular fractures at a level 1 trauma center between 2013 and 2023. Patients were divided into cohorts based on fibular fracture location in the proximal, middle, or distal third of the fibula. The Chi-square test of independence, two-sample t-test, and analysis of variance were used to compare outcome measures between cohorts.ResultsSixty-six patients were identified including 48% (n = 32) with proximal third fibular fractures, 20% (n = 13) with middle third fibular fractures, and 32% (n = 21) with distal third fibular fractures. Rates of infection, loss of reduction, wound healing complications, and reoperation did not vary significantly between cohorts. Functional outcome measures including range of motion, time to weight-bearing, and tibiofibular/medial clear space measurements at final follow-up were similar across cohorts.ConclusionPatients with Maisonneuve fractures involving the middle third of the fibula demonstrated positive outcomes with syndesmotic fixation alone, with no documented cases of infection, loss of reduction, or wound healing issues. By demonstrating maintenance of anatomic reduction and low rates of complications, our results support the use of syndesmotic-only fixation in the treatment of middle third Maisonneuve fractures.

Does Syndesmotic Fixation Technique Impact Complication Rates and Functional Outcomes Measured by PROMIS Scores Following Operative Repair of Ankle Fractures?

Submission Type: Ankle Fractures Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Various techniques are used to repair the distal tibiofibular syndesmosis. While traditionally performed with syndesmotic screws, recent techniques including the Syndesmosis TightRope® XP (TightRope, Arthrex) and InternalBrace™ (IB, Arthrex) have been developed to optimize natural flexibility and movement of the syndesmosis. It remains unclear whether syndesmotic fixation technique impacts complication rates and outcomes. This study aims to determine which repair technique results in the fewest complications and best functional outcomes as measured by Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests (CATs) of physical function (PF) and pain interference (PI). To our knowledge, this is the largest retrospective study comparing PROMIS scores between these syndesmotic fixation techniques. We hypothesized that Tightrope and IB would reduce complications and improve PROMIS scores compared to screws. Methods: 782 patients who underwent ankle fracture surgery at a single institution between January 2016-December 2021 were reviewed retrospectively. Two foot and ankle fellowship-trained orthopaedic surgeons independently reviewed all radiographs, determined fixation technique, and assessed complications at final follow-up. Multiple extremity injuries, open fractures, and pilon variants were excluded. 328 patients with syndesmotic ruptures were sent post-operative questionnaires. 159 patients with minimum one-year follow-up were analyzed for complications. 70 patients who completed PROMIS CATs were analyzed for functional outcomes. Due to rarity of complications and perfect separation in the data, we were unable to use statistical tests to compare complication incidence across techniques. The Kruskal-Wallis test compared PROMIS scores across repair types. Analysis of PROMIS scores had 80% power to detect large effect sizes (Cohen’s f = 0.40) with a 0.05 significance level but was underpowered for small and medium effects. PROMIS scores were modeled by repair technique using linear regression. Results: 62/159 patients underwent syndesmotic fixation with screw placement, 59/159 with Tightrope, and 38/159 with IB. Overall complication rates with syndesmotic screw fixation were 12.9% (8/62): 8.1% (5/62) degenerative joint disease (DJD), 0% end-stage arthritis, 1.6% (1/62) syndesmotic malreduction, 4.8% (3/62) syndesmotic malunion. Overall complication rate in Tightrope was 1.7% (1/59): 1.7% (1/59) DJD. IB had no radiographic complications. Mean PF was 50.38±9.39 screw, 53.87±9.70 Tightrope, and 52.18±13.08 IB (p=0.71). Mean PI was 49.28±8.22 screw, 47.91±8.80 Tightrope, and 49.15±10.46 IB (p=0.79). Compared to screws, adjusted models demonstrated mean PF 4.00 points greater for Tightrope (p=0.17) and 2.94 points greater for IB (p=0.34). Adjusted models for PI revealed mean scores of 2.05 points less for Tightrope (p=0.42) and 1.23 points less for IB (p=0.65) compared to screws. Conclusion: Our findings indicate that syndesmotic fixation with the Tightrope and IB reduce radiographic complications compared to screws. While this study was underpowered to detect small or medium effect sizes and thus was unable to demonstrate statistically significant differences in PROMIS scores, the higher PF and lower PI for Tightrope and IB compared to screws may reach statistical significance in larger sample sizes. Nevertheless, differences in PF scores in the adjusted model suggest that Tightrope and IB improve PF compared to screw, reaching the lower end range of the minimal clinically important difference for this outcome measure reported in the literature.

Outcomes of Early Weightbearing Following Open Reduction and Internal Fixation of Unstable Ankle Fractures in a Geriatric Population

Submission Type: Ankle Fractures Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Ankle fractures are among the most common extremity fractures, and their incidence is increasing in the elderly. While the operative indications in ankle fractures have been established, there is no consensus regarding timing of weightbearing. There has been a growing trend towards early weightbearing due to its advantages in rehabilitation and return to function. Even so, a survey study revealed that physicians tend to increase the non-weightbearing period for their geriatric population. Expanding on our prior data which advocated for early weightbearing in ankle ORIF patients with syndesmotic injuries, we investigated the effects of early weightbearing after ankle ORIF in the geriatric population. We hypothesized that there would not be an increased complication rate in this study cohort. Methods: A retrospective review was performed of patients over the age of 60 that underwent ankle ORIF at a level 1 trauma center and three neighboring community hospitals from 2015 to 2024. One of three senior surgeons were involved in all cases. Patient demographics, medical comorbidities, concomitant injuries, fixation method and complications were recorded. Maisonneuve injuries, fractures with articular surface involvement greater than 25%, open fractures, revision cases and patients with neuropathy were excluded. All patients underwent an ORIF with possible syndesmotic fixation depending on intraoperative findings. Postoperatively, patients were 50% partial weightbearing for 2 to 3 weeks for a period of soft tissue and wound healing. After that, all patients were permitted to bear as much weight as tolerable. Results: 137 patients were identified that met our criteria. The average age was 72.5 years old. 31 were male and 106 were female. The average BMI was 26.2%. 62% of patients reported one or more medical comorbidities. The average follow-up time was 191 days. We had zero major postoperative complications to report. We considered major complications to include: hardware failure, gross loss of reduction, need for revision ORIF, and accelerated post traumatic arthritis. Four patients were noted to have delayed wound healing. An additional five patients had minor surgical site infections that resolved with oral antibiotics. Eleven patients underwent hardware removal for various reasons. 72/137 (53%) patients received syndesmotic fixation of some form. Conclusion: This is the largest study to date reporting on effects of early weightbearing in the geriatric ankle ORIF population. In our study of 137 patients, all patients were allowed to weight bear as tolerated after short period of soft tissue rest, indiscriminate of syndesmotic injury or osteoporosis. We report no major complications and a limited number of soft tissues related complications. In a patient population with a known morbidity from prolonged immobility, as evidenced from the hip fracture literature, we hope our data helps to build confidence in early postoperative weightbearing.

Mini Fragment and Small Fragment Screws are Comparable in Acute Syndesmotic Injury.

Mini Fragment and Small Fragment Screws are Comparable in Acute Syndesmotic Injury.

A Single-Center Retrospective Study on the Clinical Outcomes of TightRope Fixation Versus Syndesmotic Screw Fixation in the Management of Acute Traumatic Ankle Syndesmotic Injuries.

Background Ankle fractures are one of the most commonpresentations in orthopaedic surgery and represent the third most frequent musculoskeletal injury in the elderly population. Syndesmotic injuries can be associated with ankle fractures, and surgical intervention is critical in these injuries to restore stability and prevent long-term disability. Traditionally, syndesmotic screw fixation has been the standard treatment for acute traumatic syndesmotic injuries, but controversies regarding this fixation method remain. Over recent years, the TightRope system (Arthrex,Florida, US)has gained popularity as a dynamic alternative, offering the advantage of restoring anatomical function while maintaining reduction. The optimal surgical fixation method for managing syndesmotic injuries remains a topic of ongoing debate withinorthopaedic practice. Therefore, this study aims to compare the clinical outcomes of these two fixation methods to provide further guidance on their use in managing acute traumatic syndesmotic injuries. Methods A retrospective cohort study was performed for all patients with ankle syndesmotic injuries who underwent surgical fixation using either TightRope devices or syndesmotic screws at Buckinghamshire Healthcare NHS Trust between June 2020 and June 2023, identified through the BlueSpier electronic record system (Bluespier, Droitwich, United Kingdom). Data on demographics and surgical details were extracted from electronic medical recordswhile radiographic images were systematically reviewed to confirm eligibility for inclusion. Clinic letters were also reviewed for complications and reasons for metalwork removal. Results A total of 217 patients met the eligibility criteria for this study, with 132 (61%) females and 85 (39%) males, aged between 13 and 93 years (mean age: 49 years). Of the cohort, 28 (13%) underwent syndesmotic fixation with TightRope deviceswhile 189 (87%) were treated with syndesmotic screws. Metalwork removal was required in 11% of TightRope cases (3 patients) and 28% of syndesmotic screw cases (52 patients). The most commonreason for metalwork removal in our study cohort was for broken or loosened screw(s), followed by discomfortand patient preferences. The metalwork removal rates in our study cohort are consistent with those reported in the current literature. Conclusion In conclusion, our study found that the use of TightRope devices is associated with lower removal rates in comparison to syndesmotic screws. This finding is consistent with those reported in the current literature. The most commondocumented reason for metalwork removal in our study cohort was due to screw breakage or loosening. Although emerging evidence suggests that routine removal of syndesmotic screws may not be necessary, given the lack of consensus regarding the routine removal of syndesmotic screws, decisions for metalwork removal should be tailored by clinical judgement and individual patient needs. Despite its limitations, this study contributes valuable insights into the outcomes and metalwork removal rates associated with syndesmotic fixation methods in the management of acute ankle fractures with syndesmotic injuries.

Out With the Old and in With the New: "Flexible" Syndesmotic Fixation.

Out With the Old and in With the New: "Flexible" Syndesmotic Fixation.

Radiographic outcomes of flexible and rigid fixation techniques of syndesmotic injuries across various body mass indices: A retrospective analysis

Radiographic outcomes of flexible and rigid fixation techniques of syndesmotic injuries across various body mass indices: A retrospective analysis

Research on Determining Bony Landmarks for Accurate Tibiofibular Syndesmotic Fixation: Cadaveric Validity and Safety Analysis of Angle Bisector Method

Category: Trauma; Ankle Introduction/Purpose: Syndesmosis fixation, a common procedure, is vital for restoring ankle biomechanics, but malreduction occurs in up to 52% of cases, necessitating precise anatomic reduction. While AO guidelines recommend a 20-30 degree trajectory in the coronal plane, the proposed ideal syndesmotic alignment is the line connecting fibula and tibia centroids. Intraoperatively determining the ideal fixation angle is challenging due to non-patient-specific and surgeon-dependent angular direction decisions. This study explores the angle bisector method's potential in establishing a patient- and level-specific syndesmotic fixation angle in cadavers, aiming for reproducibility independent of the surgeon. Additionally, the research assesses the safety of this method concerning major neurovascular structures for potential surgical application. By addressing these aspects, the study contributes to enhancing the precision and reliability of syndesmotic fixation procedures. Methods: Fixations on cadaveric leg specimens were conducted utilizing the angle bisector method at two levels (2 cm and 3.5 cm proximal) parallel to the tibial plafond. Two surgeons employed an open lateral approach for the procedure. The angle bisector method involved using a drill (2.8 mm) and screw (3.5 mm) directed along the bisector of the angle formed between two percutaneously placed K-wires (1.8 mm) at the fixation level, tangent to the anterior and posterior aspects of the fibula and tibia (Figure 1a). Subsequently, CT images of the cadavers were obtained (Figure 1b). The angle between the true centroidal axis (determined by software) and the axis of the screw placed with the angle bisector method was measured. Furthermore, distances between entry points of the centroidal axis and the screw were measured. Distances in millimeters between the positioned K-wires and major neurovascular structures were measured on cadaver dissections. (Sponsored by AOFAS-grant) Results: The mean angle between the centroidal axis and the trajectory of the screw was 2.7 degrees (±2.2, range 0-9.2 degrees) at the 2 cm level and 1.8 degrees (±2.1, 0-7.8 degrees) at the 3.5 cm level. At the 2 cm level, the average distance between the fibular entry points of the centroidal axis and the screw was 1.7 mm (±1.2, range 0-3.2 mm), while at the 3.5 cm level, it was 1.2 mm (±1.3, range 0-2.5 mm). The results exhibited low inter-surgeon variability (ICC > 0.80). The distance between the placed K-wires and major neurovascular structures consistently exceeded 5 mm, ensuring the safety of the technique, as none of these structures incurred damage. Conclusion: Our findings demonstrate that the angle bisector method offers a precise trajectory for syndesmotic fixation, proving its safety and efficacy in surgical applications. It can provide a more precise and patient-specific anatomical trajectory for syndesmotic implant compared to the conventional freehand technique, without increasing fluoroscopy exposure.

Outcomes Following Early Weight Bearing in Syndesmotic Injuries: A Randomized Controlled Trial

Category: Trauma; Ankle Introduction/Purpose: Syndesmotic injuries occur in 10% of ankle fractures. Restoration and maintenance of the distal tibiofibular stability is crucial. The literature regarding time to weight bearing is scarce, with the majority recommending greater than 6 weeks of non-weight bearing. No studies examine whether early weight bearing as tolerated is safe in syndesmotic injuries, and current early weight bearing studies after ankle fractures typically exclude syndesmotic injuries. Purpose: The purpose of this randomized controlled trial is to measure differences between early weight bearing at 2 weeks and delayed weight bearing at 6 weeks in terms of outcomes, hardware failure, and loss of reduction at 1 year. Methods: All rotational ankle fractures in patients over 18 were enrolled preoperatively. Only those who received syndesmotic fixation were randomized post-operatively to early vs delayed weight bearing. No fracture types were excluded. All syndesmotic fixation utilized suture buttons. A total of 39 patients were enrolled. Primary outcome was maintenance of reduction at 1 year comparing post-operative and 1 year CT scan of both ankles. Secondary outcomes included pain scores, surgical experience (SSQ-8), AAOS Foot and Ankle, range of motion, and complications. Data was analyzed using unpaired t-test and Fishers exact. Statistical significance was set at p < 0.05. Results: 16 patients were randomized to early weight bearing and 23 patients to delayed. The early weight bearing group had a significantly higher pain score (4.69 ± 2.84 vs 2.87 ± 2.31, p = 0.039) at the baseline 2 week visit. At 1 year, dorsiflexion in the early weight bearing group was significantly higher (14.2° ± 3.97° vs 7.71° ± 4.46°) than the delayed group (p = 0.017). There was no significant difference in syndesmotic malreduction, loss of reduction, pain scores, PROs, development of arthritis or complication rates at any other timepoint. Conclusion: Early weight bearing is safe following syndesmotic fixation in ankle fractures, at least in those receiving suture button fixation.

Isolated Syndesmotic Fixation is Associated with Increased Risk of Arthrodesis and Arthroplasty Operations Compared to Nonoperatively Managed Syndesmotic Injury: A Propensity-Scored Analysis

Category: Trauma; Sports Introduction/Purpose: Disruption of the distal tibiofibular syndesmosis can occur concomitantly with ankle fracture or as an isolated soft tissue injury. Although syndesmotic fixation is effective in providing stability to the distal tibiofibular joint, biomechanical studies suggest that over-reduction of the syndesmosis may increase ankle contact pressures and potentially accelerate tibiotalar joint degeneration in the longer term. The purpose of this investigation was to evaluate reoperation rates in patients with isolated syndesmotic disruption who underwent fixation versus those who were managed nonoperatively. Methods: A large, nationwide insurance database was retrospectively reviewed to identify all patients who were diagnosed with an isolated distal tibiofibular syndesmotic injury (without concomitant fracture) between 2010 and 2019. Patients who underwent surgical stabilization were matched using a propensity scoring algorithm to patients who were managed nonoperatively. The rates of reoperation including subsequent ankle arthroscopy, ankle arthrodesis, and total ankle arthroplasty (TAA) were compared between groups. Results: 24,758 patients who underwent operative stabilization were matched to 24,758 patients who underwent nonoperative management for syndesmotic injury. Patients who underwent surgical stabilization had an increased risk of ankle arthrodesis (4.04; p< 0.001) and TAA (OR 3.11; p< 0.001) within ten years compared to patients managed nonoperatively. There was no difference between groups with regard to the comparative risk of subsequent ankle arthroscopy within five years. Conclusion: Patients with isolated syndesmotic injury who underwent operative stabilization were more likely to require an ankle arthrodesis or total ankle arthroplasty within 10 years compared to those who were managed nonoperatively. These findings in a large, propensity-matched cohort suggest that surgeons should consider the implications of syndesmotic over-reduction when managing these injuries intraoperatively. Moreover, surgeons may incorporate these data into the decision making process when counseling patients regarding the expected outcomes of operative and nonoperative management for syndesmotic injury.

A Cadaveric Study: Does Ankle Positioning Impact the Quality of Anatomic Syndesmosis Reduction?

Category: Trauma; Ankle Introduction/Purpose: To compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). Methods: Two fellowship-trained orthopaedic surgeons disrupted syndesmoses of 10 cadaveric ankle specimens from 5 donors. All ankles were initially placed in neutral plantarflexion and were subsequently reduced and stabilized with one 0.062-inch K-wire in a quadricortical fashion. Post-reduction computed tomography (CT) scans were then obtained. This process was repeated with the ankles placed in maximal dorsiflexion. Post-reduction CT scans were compared to baseline CT imaging obtained prior to syndesmotic disruption. Mixed-effects linear regression was used to assess differences between baseline scans and reduction in neutral plantarflexion and maximal dorsiflexion with significance set at P< 0.05. Results: Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared to baseline scans [13.0 degrees ± 5.4 degrees (mean ± SD) vs. 7.5 degrees ± 2.4 degrees, P=0.002]. There was a tendency towards lateral translation of the fibula with the ankle placed in maximal dorsiflexion (3.3 mm ± 1.0 mm vs. 2.7 mm ± 0.7 mm, P=0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion and baseline were present (P>0.05). Conclusion: Reducing the syndesmosis with the ankle in maximal dorsiflexion leads to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

A Cadaveric Study: Does Ankle Positioning Affect the Quality of Anatomic Syndesmosis Reduction?

The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05. Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05). Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

Clinical and Radiographic Results After Treatment of Traumatic Syndesmotic Instability Using a Novel Screw-Suture Syndesmotic Fixation Device.

The objective of this study was to report early outcomes of a novel screw-suture syndesmotic device compared with suture button fixation devices when treating traumatic syndesmotic instability. Retrospective chart review. Single academic Level 1 Trauma Center. All adult patients who had syndesmotic fixation with the novel device [novel syndesmotic repair implant (NSRI) group] compared with a suture button device (SB group) between January 2018 and December 2022. Medial clear space and tibiofibular overlap measurements were compared immediately postoperatively and at the final follow-up. Patients were followed for a minimum of 1 year or skeletal healing. Fifty-nine patients (25 female) with an average age of 47 years (range 19-78 years) were in the NSRI group compared with 52 patients (20 female) with an average age of 41 years (range 18-73 years) in the SB group. There were no significant differences when comparing body mass index, diabetes, or smoking status between groups (P > 0.05). There was no difference when comparing the postoperative and final medial clear space measurements in the NSRI group compared with the SB group (P = 0.86; 95% confidence interval, -0.32 to 0.27). There was no difference when comparing the postoperative and final tibiofibular overlap measurements in the NSRI group compared with the SB group (P = 0.79; 95% confidence interval, -0.072 to 0.09). There were 3 cases of implant removal in the NSRI group compared with 2 in the SB group (P = 0.77). There was 1 failure in the NSRI group and none in the SB group. The remaining patients were all fully ambulatory at the final follow-up (P = 0.35). A novel screw-suture syndesmotic implant provides the fixation of a screw, and the flexibility of a suture had similar radiographic outcomes compared with suture button fixation devices in treating ankle syndesmotic instability. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Prospective Study on Fixation of Syndesmotic Ankle Injury: Tight Rope Versus Screw Fixation.

Background Syndesmotic injury can result in significant instability and long-term complications if not treated correctly. Traditional management has involved transyndesmotic screw fixation, but a newer technique, the tight rope system, has been developed to mitigate some of the issues related to screw fixation, such as hardware discomfort and the necessity for hardware removal. Methods In this randomized, prospective study, 32 patients with ankle injuries requiring syndesmotic fixation were equally divided into two groups: one receiving the tight rope system (n=16) and the other undergoing screw fixation (n=16). The patients were monitored for six months following surgery. The study measured outcomes such as time to weight-bearing, range of motion, pain levels, functional outcomes using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Scale, and complication rates. Results Both groups had comparable demographic and injury profiles. The tight rope group achieved weight-bearing significantly earlier (6.19 ± 0.9 weeks vs. 7.13 ± 0.95 weeks, p=0.008) and had better functional outcomes at six months (87.5% excellent AOFAS scores vs. 37.5%, p=0.003) compared to the screw fixation group. The range of motion and pain scores were similar between the groups. Different complications were observed: screw breakage was more common in the screw fixation group, while the tight rope group experienced more laxity. Overall complication rates were similar. Conclusion Both techniques were effective in reducing pain and maintaining range of motion. However, the tight rope system allowed for earlier weight-bearing and better functional outcomes at six months. These results indicate that the tight rope system may provide certain advantages in treating syndesmotic injuries, although the choice of technique should be tailored to the specific injury and patient factors.

Surgical Outcomes of Syndesmotic Fixation of Ankle Fractures Using Syndesmotic Screws Versus Suture Button Devices.

Ankle fractures associated with disruption of the syndesmotic complex could potentially have poorer outcomes if missed or malreduced at the time of surgery.Favourable results have been reported for the suture button (SB) technique and may provide advantages over standard screw fixation of the syndesmosis, although this remains the gold standard method in many units. To compare the outcomes of syndesmotic screws (SS) with SB fixation of the syndesmosis during ankle fracture fixation at a high-volume orthopaedic department of a Scotland trauma unit. A cross-sectional, retrospective study looking at ankle fracture fixations was undertaken at the Clyde Trauma Unit, Paisley. Relevant information was obtained from electronic patient records for 457 ankle fracture patients between August 2019 and February 2022 and followed up for six months. The digital patient archive system (PACS) was used for evaluating radiographs. Patients were divided into two groups depending on whether they had an SS or SB fixation of their syndesmosis. We focused on the surgical and radiological outcomes following syndesmotic fixation as no functional scores following surgery were conducted on the patients. Out of the entire study group, 26.3% (120/457 patients) required syndesmotic fixation. Within the syndesmotic fixation group, 70.8% (85/120 patients) underwent SS fixation, and 29.2% (35/120 patients) had an SB fixation. Both groups were statistically well-matched. Additionally, 21.1% (18/85) of SS fixation went on to have a second surgical procedure (four fixation failures, five planned removals, five for pain/stiffness, two infections, and two metalwork breakage/migration), whereas 8.6% (3/35) of the SB fixation group had a secondary procedure - two for fixation failures and one for infection. We reported a higher incidence of associated syndesmotic injury in our series of 457 ankle fractures than previously described. There were significantly fewer sequelae in the SB group compared to the SS fixation group (P = 0.0464). Although we did not observe a statistically significant difference in the rate of reoperation (P = 0.1184), this is likely due to the small numbers in the SB group.Our study suggests that SB fixation may be associated with a lower rate of reoperation for post-op complications such as metalwork failure, pain, and stiffness (21.1% SS vs 8.6% SB). Regardless of the fixation method used, accurate reduction of the ankle mortice and syndesmosis is a key step to a successful surgical outcome.

Syndesmotic fixation in Weber B ankle fractures: A systematic review.

Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.

DARI Evaluation Syndesmosis

Introduction/Purpose: Return to play (RTP) assessment and decision-making protocols are among the most discussed topics in sports medicine. Given the lack of validated guidelines, physicians and rehabilitation practitioners often rely on subjective functional evaluation to guide decisions to RTP. Biomechanical assessment using motion capture may be a useful strategy to evaluate an athlete’s post-injury functional status, and to estimate their ability to RTP with reduced risk of re-injury. The purpose of this case-study was to determine the efficacy of using marker-less 3D motion capture to provide an objective functional evaluation to tailor rehabilitation and aid RTP status for a patient who underwent syndesmotic fixation. Methods: In this case-study, a National Collegiate Athletic Association Division I collegiate football offensive lineman (Height: 1.96 m, Weight: 141 kg) performed a movement screen 5 weeks after left ankle syndesmotic fixation for purely ligamentous syndesmotic injury. Testing was performed at the anticipated time of RTP. After a standardized warm-up, the patient performed a series of 14 movements consisting of upper and lower extremity actions in all three planes of motion, including bilateral and unilateral lower extremity actions. Kinematic data was captured using an 8-camera marker-less motion capture system (MLMCS). Left and right joint-specific ranges of motion were compared for symmetry and to normative data produced by the MLMCS manufacturer. Results: The participant successfully performed all 14 movements without limitation. Ankle flexion was symmetrical during bilateral and unilateral squatting actions. However, left ankle (i.e., involved side) flexion was consistently less than right ankle flexion during more dynamic actions (Table 1). Despite the asymmetries, ankle range of motion was within normal ranges for both sides in all movements. From a performance standpoint, left-side jump heights were consistently less than the right-side efforts during the unilateral countermovement jump (left: 34.5 cm versus right: 41.1 cm; -16.0%) and consecutive hops (left: 29.5 cm versus right: 33.0 cm; -10.8%). Results were shared with the athletic trainer to focus rehabilitation efforts. The patient was able to fully RTP at 6 weeks. Conclusion: In this case-study, the patient successfully performed a movement screen without limitation at the time of RTP after left ankle syndesmotic fixation. A MLMCS detected kinematic differences that would be difficult to qualitatively recognize. Specifically, the patient expressed reduced ankle flexion and jumping performance on the operative side. No baseline screening was performed, but the observed asymmetries were consistent with what would be expected from the specific injury. Further research is needed to compare baseline measures to kinematic changes. These findings suggest that a basic movement screen using MLMCS can detect kinematic asymmetries after syndesmotic fixation. Table 1. Kinematic Assessment of Ankle Range of Motion

A comparison of screw and suture button fixation in the management of adolescent ankle syndesmotic injuries.

Ankle injuries involving the tibiofibular syndesmosis often necessitate operative fixation to restore stability to the ankle. Recent literature in the adult population has suggested that suture button fixation may be superior to screw fixation. There is little evidence as to which construct is preferable in the pediatric and adolescent population. This study investigates outcomes of suture button and screw fixation in adolescent ankle syndesmotic injuries. A retrospective matched cohort study over 10 years of pediatric patients who underwent ankle syndesmotic fixation at a large Level 1 Trauma Center was conducted. Both isolated syndesmotic injuries and ankle fractures with syndesmotic disruption were included. Preoperative variables collected include basic patient demographics, body mass index, and fracture type. Suture button and screw cohorts were matched based on age, race, sex, and open fracture utilizing propensity scores. Outcomes assessed include reoperation and implant failure. A total of 44 cases of operative fixation of the ankle syndesmosis were identified with a mean age of 16 years. After matching cohorts based on age, sex, race, and open fracture status, there were 17 patients in the suture button and screw cohorts, respectively. Patients undergoing screw fixation had a six times greater risk of reoperation (p = 0.043) and 13 times greater risk of implant failure (p < 0.001). Out of six cases of reoperation in the screw cohort, five were unplanned. Our findings favor suture button fixation in operative management of adolescent tibiofibular syndesmotic injuries. Compared with screws, suture buttons are associated with lower risk of both reoperation and implant failure. level III therapeutic.

Postoperative Return to Play and the Role of Imaging.

Return to play (RTP) following surgery is a complex subject at the interface of social and internal pressures experienced by the athlete, psychological readiness, and intrinsic healing of the surgically repaired structures. Although functional testing, time from surgery, clinical examination, and scoring metrics can help clarify an athlete's readiness to return to sport, imaging can allow for a more direct assessment of the structures in question. Because imaging is often included in the diagnostic work-up of pain following surgery, the radiologist must be familiar with the expected postsurgical imaging appearance, as well as the associated complications. We briefly review such findings following anterior cruciate ligament reconstruction, Achilles tendon repair, syndesmotic fixation, and ulnar collateral ligament reconstruction in the context of the athlete, highlighting issues related to RTP.