Syndesmotic Suture Button Fixation Research Articles

Functional outcome by using American Orthopaedic Foot and Ankle Society: Ankle and hind foot scale scoring system of distal fibula fractures with syndesmotic injury managed by distal fibula anatomical locking compression plate and syndesmotic suture-button fixation

Abstract Background: The study aimed to study the functional outcome by using American Orthopaedic Foot and Ankle Society (AOFAS)—ankle and hind foot scale scoring system of distal fibula fractures with syndesmotic injury managed by distal fibula anatomical locking compression plate and syndesmotic suture-button fixation. Objective: Solated fibula fractures are very common injuries. Diagnostic exams must rule out ankle instability. Surgical treatment must be considered in the case of associated ankle instability. Risk factors for wound related complications must be considered when choosing the surgical technique. Materials and Methods: The study was performed at the Ravindra Nath Tagore Medical College and Maharana Bhupal Government Hospital, Udaipur, in the Department of Orthopaedics and Traumatology. The type of the study is prospective. Inclusion criteria are as follows: Age above 18 years/skeletally matured; distal fibula fractures with Weber B and Weber C type of Danis–Weber classification; X-ray (stress view) suggestive of associated syndesmotic injury; and patients willing to give consent and willing for follow-up. Exclusion criteria are as follows: Weber A type fractures; distal fibula fracture without syndesmotic injury; pediatric and skeletally immature patients; compound injuries; and patients unfit for surgery. The sample size was 25. Results: Twenty-five cases were operated and followed up. A total of 22 cases (85%) had an excellent outcome, and three cases (15%) had a good outcome. The average AOFAS score is 92.84. All the patients at the end of 6 months were comfortable to do their day-to-day activities without any pains. No case required routine implant removal. Conclusions: Injuries to the syndesmosis are a diagnostic and therapeutic challenge to the orthopedic surgeon. The lack of clear radiographic parameters on which to make surgical decisions places greater importance on the physical examination and advanced imaging. Lack of injury to the deltoid ligament and posterior tibiofibular ligament based on magnetic resonance imaging is a reliable determinant to consider nonoperative treatment. Injury to the deltoid ligament or disruption of the relationship of the tibia and fibula typically is treated with surgical reduction and fixation. Use of the contralateral lower extremity is the most reliable in determining the normal relationship of the tibia and fibula for the patient both preoperatively and intraoperatively. Sagittal instability is more critical than coronal instability and must be taken into account when considering reduction of fixation of the syndesmosis. Further studies will determine the need for primary repair of the deltoid ligament and fixation of the posterior malleolus in the setting of ankle fracture and syndesmotic injuries. As the understanding of the longer term outcomes following injury to the syndesmosis advances, a logical algorithm to the treatment of these injuries should emerge.

A Prospective Randomized Investigation Comparing Functional Outcomes of Syndesmotic Suture-Button Fixation to Screws

A Prospective Randomized Investigation Comparing Functional Outcomes of Syndesmotic Suture-Button Fixation to Screws

A prospective study of functional outcome of distal fibula fractures with syndesmotic injury managed by anatomical locking compression plate and syndesmotic suture button fixation

Syndesmotic injury can occur after trauma to the ankle, both with and without a fracture. In fractures of the ankle, syndesmotic injury occurs in about 50% of type Weber B and in all type Weber C fractures. Syndesmotic diastasis left unnoticed can lead to persisting pain, instability and progressive arthritis. This study focusses on the application of syndesmotic suture button anchor as a fixation method for the syndesmotic joint diastasis. The syndesmotic button fixation does not convert the joint into a rigid articulation and still allows micro motion to happen. In this study, Distal fibular fractures with syndesmotic injuries are selected and anatomically precontoured locking compression plate is applied for fracture fixation and syndesmotic suture button fixation is done for the syndesmotic injury and their functional outcomes studied by various modalities.

Syndesmotic Fixation With Suture Button: Neurovascular Structures at Risk: A Cadaver Study.

The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study.

Syndesmotic Fixation With Suture Button. Neurovascular Structures at Risk. A Cadaver Study

Category: Trauma Introduction/Purpose: Damage to distal tibiofibular syndesmosis occurs in 25% of operative ankle fractures. Syndesmotic stabilization is crucial to prevent significant pain, instability and degeneration of the joint. One operative method is insertion of suture buttons. Though effective, this method can result in entrapment and damage of the saphenous neurovasculature of the medial tibia. The purpose of this study was to describe the anatomic risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Methods: This study was performed on 10 below knee cadaveric leg specimens. Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1cm, 2cm, and 3cm above the tibial plafond at an anterior angle of 30 degrees to the coronal plane. Dissection was performed through medial tibial incision to record the distance and position of each button from the greater saphenous vein and saphenous nerve. Statistical measurement and analysis was performed with SPSS. Results: The mean age of cadavers was 78.2 ± 6.9 years and mean BMI was 21.6 ± 2.2. The mean distance of the saphenous nerve to the suture buttons at 1cm, 2cm, and 3cm were 7.1 ± 5.6mm, 6.5 ± 4.6mm, and 6.1 ± 4.2mm, respectively. The saphenous nerve was compressed in 2 cadavers (20%) at 1cm, 2 cadavers (20%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Mean distance of the greater saphenous vein from the suture buttons at 1cm, 2cm and 3cm were 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9mm respectively. The great saphenous vein was compressed in 2 cadavers (20%) at 1cm, 1 cadaver (10%) at 2cm and 1 cadaver (10%) at 3cm by suture buttons. Conclusion: There was at least one case of injury to both the saphenous vein and nerve at every level of button insertion at a rate of 10-20%. The close proximity of the suture button to neurovasculature combined with significant anatomic variation in saphenous nerve anatomy suggest that neurovascular injury may be best avoided by direct visualization prior to suture button placement. Great care should be taken to avoid injury to saphenous neurovascular structures during suture button insertion. Keeping an eye on close proximity of neurovasculatures, we recommend medial incision for during syndesmotic suture button fixation.