Treatment of syndesmotic disruptions with the Arthrex Tightrope (TM): A report of 25 cases
ABSTRACT The complexity of syndesmotic injuries, often with both bone and soft tissue injury mandates an expeditious diagnosis and treatment to avoid unfavorable long term outcomes. Various methods of fixation of the syndesmosis have been reported. We present the largest series evaluating the Arthrex Tightrope for management of syndesmotic injuries.
Twenty-five patients with disruption of the distal tibiofibular articulation underwent treatment with an Arthrex Tightrope. In 21 cases, a single tightrope was placed, and in four cases, two tightropes were utilized. Associated ankle fractures were treated using proper AO technique. Those patients with diabetes and/or neuroarthropathic changes foot or ankle were not included in this study. Postoperative evaluation parameters included radiographic measurements, a modified AOFAS scoring system and SF-12.
Average followup was 10.8 months. The mean time to full weightbearing was 5.5 (range, 2 to 8) weeks. Postoperative radiographic analysis of the mean distance from the tibial plafond to the placement of the tightrope(s), medial clear space, average postoperative tibiofibular overlap and the mean tibiofibular clear space demonstrated no evidence of re-displacement of the syndesmotic complex at an average of 10.8 (range, 6 to 12) months. The modified AOFAS hindfoot scoring scale and SF-12 both demonstrated significant improvements; preoperative values were assessed in the office with the first patient visit as they are incorporated into the patient intake form that each patient fills out at the initial visit.
Utilization of the tightrope in diastasis of the syndesmosis should be considered as a good option. The method of placement is quick, can be minimally invasive, and obviates the need for hardware removal. In this series, it maintained excellent reduction of the syndesmosis.
SourceAvailable from: Phinit Phisitkul[Show abstract] [Hide abstract]
ABSTRACT: Background: The accuracy of reduction of distal tibiofibular syndesmosis disruptions has been associated with the clinical outcome. Suture-button fixation of the syndesmosis is a dynamic alternative mode of fixation. We hypothesized that with deliberate clamp-induced malreduction, suture-button fixation of the syndesmosis would allow a more anatomic post-fixation position compared with screw fixation. Methods: Forty-eight syndesmotic fixations were performed on twelve through-knee cadaveric specimens. The syndesmosis was destabilized and off-axis clamping was used to produce both anterior and posterior malreduction patterns. In twelve scenarios (six anterior and six posterior malreductions), syndesmotic screw fixation was used, followed by computed tomography. With tenacula holding the malreduction, the syndesmosis screws were exchanged for a suture-button construct and the specimens underwent a subsequent computed tomography scan. In the other twelve scenarios, the suture-button fixation was achieved first, followed by screw fixation. Standardized measurements of anterior-posterior and medial-lateral fibular displacement were performed by two observers blinded to the method of fixation. Results: With anterior off-axis clamping, the mean sagittal malreduction was 2.7 +/- 2.0 mm with screw fixation and 1.0 +/- 1.0 mm with suture-button fixation (p = 0.02). With posterior off-axis clamping, the sagittal malreduction was 7.2 +/- 2.3 mm with screw fixation and 0.5 +/- 1.4 mm with suture-button fixation (p < 0.01). No differences were observed between fixation types in the coronal plane (p = 0.20 for anterior malreductions and p = 0.06 for posterior malreductions). Conclusions: With deliberate malreduction in a cadaver model, suture-button fixation of the syndesmosis results in less post-fixation displacement compared with screw fixation. The suture button's ability to allow for natural correction of deliberate malreduction was greatest with posterior off-axis clamping.The Journal of Bone and Joint Surgery 10/2014; 96(20):1732-8. DOI:10.2106/JBJS.N.00198 · 4.31 Impact Factor
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ABSTRACT: Hallux valgus has been reported as one of the most common foot problems and is associated with age, gender and footwear. The disease imposes heavy economic and social burden on hospital expenditure, pain-suffering and manpower lost. Additionally, Hallux valgus also imposes risk of falling on elderly patients and additional risk to patients with diabetic or neuropathic feet. Different surgical and conservative treatments have been suggested. These protocols have been modified or optimized. Some physicians and researchers suggested decision-making pathway to determine the treatment to be conveyed. However, these protocols were qualitative and empirical. Although identifying the pathogenesis of hallux valgus has long been conducted, the mechanism and initialization of the pathology have not come into clear conclusion and consensus. Pathoanatomy, pathomechanics and hypermobility studies were conducted to evaluate the features of hallux valgus. Some biomechanical studies also aimed to quantify the characteristics of hallux valgus. Hallux valgus is not well-understood and remains on the research bench. There were cases of failures, complications and recurrence of interventions. Physicians are heading for better protocols and methods to improve the interventions. The objective of this study was to construct a biomechanical platform to examine the pathomechanism of hallux valgus and evaluate its interventions. The research findings enhanced understandings of hallux valgus and thus would improve treatment outcome in the long run. This biomechanical study included 3 components involving computational simulation (finite element analysis), physical experiment (to provide input to simulation and validation), and clinical study. Finite element foot model was constructed. This simulation platform was validated with physical experiments, including motion analysis, pedobarographic and cadaveric study. The data collected by the motion analysis system were also input into the simulation platform for finite element analysis. The simulation of hallux valgus initialization was mimicked by ligament laxity. The influence of ligament laxity on joint loading was investigated. The hypermobile foot (represented by the influence of ligament laxity) showed increase of metatarsocuneiform and metatarsophalangeal joint forces in all directions comparing with the normal foot. During the push-off phase, the joint forces of the metatarsocuneiform joint and the metatarsophalangeal joint were 27% and 10% larger than that of the normal foot. The increase could be due to the impairment of shock absorption. It could be also due to the extended obligation of the first ray to maintain stability upon ligament laxity. The abrupt change of the metatarsocuneiform joint force in mediolateral direction provided additional evidence on the relationship between hypermobile foot and metatarsus primus varus. The higher joint loading also suggested that foot with hypermobility could predispose risk of arthritis and joint incongruence. The simulation was continued on the evaluation of metatarsocuneiform arthrodesis, one of the hallux valgus interventions, which was reported with high failure rate (Coughlin & Mann, 2012). The objective of this simulation was to study the stress distribution of the bone graft used in the arthrodesis procedure, and thus evaluate rather inter-fragmentary compression could be achieved. The result of the simulation showed that compressive stress was ensured at the superior portion of the bone graft and tensile stress happened on the inferior side during stance. The magnitude of the stress increased drastically with about 20% of the graft volume exceeded 4MPa upon the initial push-off. The graft used for arthrodesis might absorb the physiological motion by sustaining bending stress that attributed to difficulty in fusion. The traditional metatarsocuneiform arthrodesis might not guarantee inter-fragmentary compression. Parametric study on the resection angle and the graft stiffness can be conducted to study possible improvement on the procedure. A modified soft tissue procedure for hallux valgus (syndesmosis procedure) was evaluated. A retrospective study on the patients pre-operatively and 2-year follow-up was conducted. The evaluation included questionnaires, radiographic and plantar pressure evaluation. The objective of this study was to evaluate the clinical satisfactoriness as well as the biomechanical outcome of this surgical procedure. The retrospective study demonstrated good clinical, radiological outcome, and improved load-bearing under the hallux and the first ray in the plantar pressure study. This study presented a comprehensive biomechanical platform starting with the research on the biomechanics of hallux valgus using a validated computational model. The computational model was then used to study the interventions of hallux valgus. Evaluation of intervention was also carried out in the clinical sector, based on clinical, radiological and biomechanical measurements.10/2013, Degree: PhD, Supervisor: Aaron Kam-Lun Leung
Article: Syndesmotic Injuries in Athletes[Show abstract] [Hide abstract]
ABSTRACT: Ligamentous injuries around the ankle are one of the most common injuries in athletes, and syndesmotic (high ankle) sprains are being diagnosed at an increasing rate in recent years. Syndesmotic injuries can lead to significant pain, disability, and time away from sport with prolonged rehabilitation. Advanced imaging with ultrasound, CT, and MRI have improved the detection of syndesmosis injury, and arthroscopy can confirm the diagnosis and help identify any additional intra-articular pathology. Recently, there has been increased interest and research surrounding the treatment of high-grade syndesmotic injuries in athletes with a focus on early rehabilitation and surgical intervention in select patients. Athletes can potentially return to training and play earlier if the syndesmosis is surgically stabilized, but the literature is controversial regarding the overall management of these injuries.Operative Techniques in Sports Medicine 09/2014; 22(4). DOI:10.1053/j.otsm.2014.09.003 · 0.21 Impact Factor