Achim Biewener

Publications of Achim Biewener

• Long-bone critical-size defects treated with tissue-engineered polycaprolactone-co-lactide scaffolds: a pilot study on rats.

  Authors: Claudia Rentsch, Barbe Rentsch, Annette Breier, Kathrin Spekl, Roland Jung, Suzanne Manthey, Dieter Scharnweber, Hans Zwipp, Achim Biewener

  Journal of biomedical materials research. Part A. 12/2010; 95(3):964-72.

  The aim of this study was to evaluate the osteogenic potential of embroidered, tissue-engineered polycaprolactone-co-lactide (trade name: PCL) scaffolds for the reconstruction of large bone defects.The aim of this study was to evaluate the osteogenic potential of embroidered, tissue-engineered polycaprolactone-co-lactide (trade name: PCL) scaffolds for the reconstruction of large bone defects. Ten piled-up PCL scaffolds were implanted in femura with a critical size defect of immunodeficient nude rats for 12 weeks [n = 4, group 1: noncoated, group 2: collagen I (coll I), group 3: collagen I/chondroitin sulfate (coll I/CS), and group 4: collagen I/chondroitin sulfate/human mesenchymal stem cells (coll I/CS/hMSC)]. X-ray examination, computer tomography, and histological analyses of the explanted scaffold pads were performed. The quantification of the bone volume ratio showed a significantly higher rate of new bone formation at coll I/CS-coated scaffolds compared with the other groups. Histological investigations revealed that the defect reconstruction started from the peripheral bone ends and incorporated into the scaffold material. Additionally seeded hMSC on coll I/CS-coated scaffolds showed a higher matrix deposition inside the implant but no higher bone formation was observed. These data imply that the coll I/CS-coated PCL scaffolds have the highest potential for treating critical size defects. The scaffolds, being variable in size and structure, can be adapted to any bone defect.

• Evaluation of the osteogenic potential and vascularization of 3D poly(3)hydroxybutyrate scaffolds subcutaneously implanted in nude rats.

  Authors: Claudia Rentsch, Barbe Rentsch, Annette Breier, Andre Hofmann, Suzanne Manthey, Dieter Scharnweber, Achim Biewener, Hans Zwipp

  Journal of biomedical materials research. Part A. 02/2009;

  The aim of this study was to evaluate the osteogenic potential and the vascularization of embroidered, tissue engineered, and cell-seeded 3D poly(3)hydroxybutyrate (PHB) scaffolds in nude rats.The aim of this study was to evaluate the osteogenic potential and the vascularization of embroidered, tissue engineered, and cell-seeded 3D poly(3)hydroxybutyrate (PHB) scaffolds in nude rats. Collagen I (coll I)- and collagen I/chondroitin sulfate (coll I/CS)-coated PHB scaffolds were seeded with human mesenchymal stem cells (hMSCs). Proliferation and differentiation were characterized by different biochemical assays in vitro. For animal experiments, the cells were cultivated on coll I- or coll I/CS-coated scaffolds and either expanded or osteogenically differentiated. Scaffolds were piled up to create a 3D scaffold pad and implanted subcutaneously into nude rats. In vitro hMSC showed proliferation and differentiation on PHB scaffolds. Alkaline phosphatase (ALP) and calcium increased in the differentiation medium and in the presence of coll I/CS. In vivo blood vessels were found in the scaffold-stack. Histological/immunohistological analyses of explanted scaffolds showed osteogenic markers such as osteopontin, osteonectin, and coll I around the PHB fibers. Coll I/CS-coated scaffolds with expanded hMSC showed higher values of ALP and calcium than the other combinations. Embroidered PHB scaffolds, coated with extracellular matrix components, provided an adequate environment and, therefore, a template for hMSC which could be differentiated in osteogenic direction. (c) 2009 Wiley Periodicals, Inc. J Biomed Mater Res 2009.

• In vivo effects of modification of hydroxyapatite/collagen composites with and without chondroitin sulphate on bone remodeling in the sheep tibia

  Authors: Wolfgang Schneiders, Antje Reinstorf, Achim Biewener, Alexandr� Serra, Ren� Grass, Michael Kinscher, Jan Heineck, Sebastian Rehberg, Hans Zwipp, Stefan Rammelt

  Journal of Orthopaedic Research. 01/2009; 27:15--21.

  The addition of chondroitin sulphate (CS) to bone cements with calcium phosphate has lead to an enhancement of bone remodeling and an increase in new bone formation in small animals. The goal of thisThe addition of chondroitin sulphate (CS) to bone cements with calcium phosphate has lead to an enhancement of bone remodeling and an increase in new bone formation in small animals. The goal of this study was to verify the effect of CS in bone cements in a large animal model simulating a clinically relevant situation of a segmental cortical defect of a critical size on bone-implant interaction and bone remodeling. The influence of adding CS to hydroxyapatite/collagen (HA/Col) composites on host response was assessed in a standard sheep tibia model. A midshaft defect of 3 cm was created in the tibiae of 14 adult female sheep. The defect was filled with a HA/Col cement cylinder in seven animals and with a CS-modified hydroxyapatite/collagen (HA/Col/CS) cement cylinder in seven animals. In all cases the tibia was stabilized with an interlocked universal tibial nail. The animals in each group were analyzed with X-rays, CT scans, histology, immunohistochemistry, and enzymehistochemistry, as well as histomorphometric measurements. The X-ray investigation showed a significantly earlier callus reaction around the HA/Col/CS implants compared to HA/Col alone. The amount of newly formed bone at the end point of the experiment was significantly larger around HA/Col/CS cylinders both in the CT scan and in the histomorphometric analysis. There were still TRAP-positive osteoclasts around the HA/Col implants after 3 months. The number of osteopontin-positive osteoblasts and the direct bone contact were significantly higher around HA/Col/CS implants. We conclude that addition of CS enhances bone remodeling and new bone formation around HA/Col composites. � 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:15-21, 2009

• In vivo effects of modification of hydroxyapatite/collagen composites with and without chondroitin sulphate on bone remodeling in the sheep tibia.

  Authors: Wolfgang Schneiders, Antje Reinstorf, Achim Biewener, Alexandrè Serra, Renè Grass, Michael Kinscher, Jan Heineck, Sebastian Rehberg, Hans Zwipp, Stefan Rammelt

  Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 01/2009; 27(1):15-21.

  The addition of chondroitin sulphate (CS) to bone cements with calcium phosphate has lead to an enhancement of bone remodeling and an increase in new bone formation in small animals. The goal of thisThe addition of chondroitin sulphate (CS) to bone cements with calcium phosphate has lead to an enhancement of bone remodeling and an increase in new bone formation in small animals. The goal of this study was to verify the effect of CS in bone cements in a large animal model simulating a clinically relevant situation of a segmental cortical defect of a critical size on bone-implant interaction and bone remodeling. The influence of adding CS to hydroxyapatite/collagen (HA/Col) composites on host response was assessed in a standard sheep tibia model. A midshaft defect of 3 cm was created in the tibiae of 14 adult female sheep. The defect was filled with a HA/Col cement cylinder in seven animals and with a CS-modified hydroxyapatite/collagen (HA/Col/CS) cement cylinder in seven animals. In all cases the tibia was stabilized with an interlocked universal tibial nail. The animals in each group were analyzed with X-rays, CT scans, histology, immunohistochemistry, and enzymehistochemistry, as well as histomorphometric measurements. The X-ray investigation showed a significantly earlier callus reaction around the HA/Col/CS implants compared to HA/Col alone. The amount of newly formed bone at the end point of the experiment was significantly larger around HA/Col/CS cylinders both in the CT scan and in the histomorphometric analysis. There were still TRAP-positive osteoclasts around the HA/Col implants after 3 months. The number of osteopontin-positive osteoblasts and the direct bone contact were significantly higher around HA/Col/CS implants. We conclude that addition of CS enhances bone remodeling and new bone formation around HA/Col composites.

• Effect of chondroitin sulphate on material properties and bone remodelling around hydroxyapatite/collagen composites.

  Authors: Wolfgang Schneiders, Antje Reinstorf, Michael Ruhnow, Sebastian Rehberg, Jan Heineck, Irene Hinterseher, Achim Biewener, Hans Zwipp, Stefan Rammelt

  Journal of biomedical materials research. Part A. 06/2008; 85(3):638-45.

  Chondroitin sulphate (CS) has an anti-inflammatory effect and increases the regeneration ability of injured bone. The goal of this study was to characterize the material properties andChondroitin sulphate (CS) has an anti-inflammatory effect and increases the regeneration ability of injured bone. The goal of this study was to characterize the material properties and osteoconductive potency of calcium phosphate bone cements modified with CS. The early interface reaction of cancellous bone to a nanokristalline hydroxyapatite cement containing type I collagen (HA/Coll) without and with CS (HA/Coll/CS) in a rat tibia model was evaluated. Cylindrical implants were inserted press-fit into defect of the tibial head. Six specimens per group were analyzed at 2, 4, 7, 14, and 28 days. HA/Coll/CS composite cylinders showed a 15% increase in compressive strength and by investigations with powder X-ray diffraction more nontransformed cement precursor was found. The microstructures of both types of implants were similar. A significantly higher average number of TRAP positive osteoclasts and ED1 positive mononuclear cells were observed in the interface around HA/Coll/CS implants on day 4 and 7 (p < 0.05). At 28 days the direct bone contact and the percentage of newly formed bone were significantly higher around HA/Coll/CS implants (p < 0.05). The addition of CS appears to enhance bone remodelling and new bone formation around HA/Coll composites in the early stages of bone healing. Possible mechanisms are discussed.

• In vivo effects of coating loaded and unloaded Ti implants with collagen, chondroitin sulfate, and hydroxyapatite in the sheep tibia.

  Authors: Stefan Rammelt, Christian Heck, Ricardo Bernhardt, Susanne Bierbaum, Dieter Scharnweber, Jürgen Goebbels, Jörg Ziegler, Achim Biewener, Hans Zwipp

  Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 08/2007; 25(8):1052-61.

  The in vivo effects of coating titanium implants with organic extracellular matrix molecules were examined in the sheep tibia. Titanium screws (5.0 mm) were coated with type I collagen (Ti/Coll) orThe in vivo effects of coating titanium implants with organic extracellular matrix molecules were examined in the sheep tibia. Titanium screws (5.0 mm) were coated with type I collagen (Ti/Coll) or type I collagen and chondroitin sulfate (Ti/Coll/CS) by biomimetic fibrillogenesis. Uncoated screws (Ti) and screws coated with hydroxyapatite (Ti/HA) served as control. Six adult female sheep received one screw of each type to stabilize a midshaft tibial fracture with external fixation. Four cylindrical implants of 4-mm outer diameter and 3.3-mm inner diameter with the same coatings were inserted into the tibial head. No pin track infections were seen at the time of implant retrieval 6 weeks after implantation. Extraction torque was greater for Ti/HA (1181 Nmm) and Ti/Coll/CS (1088 Nmm) compared to Ti/Coll (900 Nmm) and Ti (904 Nmm) [N.S.]. Newly formed bone was noted around all coated screws within the medullary cavity. Macrophage and osteoclast activity was significantly reduced around Ti/Coll/CS in both types of implants compared to uncoated controls (p < 0.05). Osteoblast activity was significantly increased around loaded Ti/Coll and Ti/Coll/CS screws compared to uncoated Ti screws (p < 0.05). Microtomographic evaluation (SRmicroCT) revealed no significant differences in new bone formation around the unloaded tibial head implants.Coating of external fixation devices with of type I collagen and chondroitin sulfate appears to have similar effects with respect to stability and bone healing as HA but with less osteoclast activity. These findings were more pronounced under loaded than unloaded conditions in the sheeptibia.

• Effect of modification of hydroxyapatite/collagen composites with sodium citrate, phosphoserine, phosphoserine/RGD-peptide and calcium carbonate on bone remodelling.

  Authors: Wolfgang Schneiders, Antje Reinstorf, Wolfgang Pompe, Rene Grass, Achim Biewener, Michael Holch, Hans Zwipp, Stefan Rammelt

  Bone. 05/2007; 40(4):1048-59.

  This study describes the early interface reaction of cancellous bone to a nanocrystalline hydroxyapatite cement containing type I collagen (HA/Coll) and its modifications with sodium citrate (CI),This study describes the early interface reaction of cancellous bone to a nanocrystalline hydroxyapatite cement containing type I collagen (HA/Coll) and its modifications with sodium citrate (CI), calcium carbonate (CA), phosphoserine (P) and phosphoserine plus RGD-peptide (RGD). Cylindrical implants of HA/Coll and its modifications were inserted into the tibia of Wistar rats. We analysed 6 specimens per group at days 2, 4, 7, 14 and 28. CI, P and RGD modifications showed improved material properties (finer microstructure and higher compressive strength) compared to CA and HA/Coll implants. The powder X-ray diffraction (XRD) showed that the addition of P and CI led to an increase of alpha-TCP peaks while the diffraction patterns of the non-modified cement (HA/Coll) were quite similar with that of natural bone. All of the implants healed without adverse reactions. A significantly higher number of TRAP-positive osteoclasts were observed around CI, RGD and P on day 7 compared to CA and HA/Coll. Around CI, P and RGD a significantly delayed increase of ED1-positive mononuclear cells was detected. The amount of direct bone contact after 28 days was significantly higher around CI, P and RGD compared to CA and HA/Coll implants. The addition of CI, P and RGD appears to enhance bone remodelling at the early stages of bone healing, leading to increased bone formation around HA/Coll composite cements.

• Osteocalcin enhances bone remodeling around hydroxyapatite/collagen composites.

  Authors: Stefan Rammelt, Mirjam Neumann, Uwe Hanisch, Antje Reinstorf, Wolfgang Pompe, Hans Zwipp, Achim Biewener

  Journal of biomedical materials research. Part A. 07/2005; 73(3):284-94.

  The effect of osteocalcin (OC), an extracellular bone matrix protein, on bone healing around hydroxyapatite/collagen composites was investigated. Cylindrical nanocrystalline hydroxyapatite implantsThe effect of osteocalcin (OC), an extracellular bone matrix protein, on bone healing around hydroxyapatite/collagen composites was investigated. Cylindrical nanocrystalline hydroxyapatite implants of 2.5-mm diameter containing 2.5% biomimetically mineralized collagen type I were inserted press-fit into the tibial head of adult Wistar rats. To one implant group, 10 mug/g OC was added. Six specimens per group were analyzed at 2, 7, 14, 28, and 56 days. After 14 days, newly formed woven bone had reached the implant surface of the OC implants whereas a broad fibrous interface could still be observed around controls. Woven bone was formed directly around both implant groups after 28 days and had been replaced partially by lamellar bone around the OC implants only. No significant differences in total bone contact were seen between both groups after 56 days. The higher number of phagocytosing cells and osteoclasts characterized immunohistochemically with ED1, cathepsin D, and tartate-resistant alkaline phosphatase around the OC implants at the early stages of bone healing suggests an earlier onset of bone remodeling. The earlier and increased expression of bone-specific matrix proteins and multifunctional adhesion proteins (osteopontin, bone sialoprotein, CD44) at the interface around the OC implants indicates that OC may accelerate bone formation and regeneration. This study supports the observations from in vitro studies that OC activates both osteoclasts and osteoblasts during early bone formation.

• Precise positioning of unreamed solid nails in short distal libial fragments with percutaneous K-wires.

  Authors: Achim Biewener, Rene Grass, Hans Zwipp, Stefan Rammelt

  Orthopedics. 04/2005; 28(3):263-5.

• Coating of titanium implants with type-I collagen.

  Authors: Stefan Rammelt, Eva Schulze, Ricardo Bernhardt, Uwe Hanisch, Dieter Scharnweber, Hartmut Worch, Hans Zwipp, Achim Biewener

  Journal of orthopaedic research : official publication of the Orthopaedic Research Society. 09/2004; 22(5):1025-34.

  PURPOSE: Type-I collagen, the major structural protein in bone, has beneficial properties regarding bone regeneration. Little is known about the potential effects of collagen coating on orthopedicPURPOSE: Type-I collagen, the major structural protein in bone, has beneficial properties regarding bone regeneration. Little is known about the potential effects of collagen coating on orthopedic implants. METHODS: 3 to 6 microg/cm2 of lyophilized type-I collagen was absorbed on titanium rods. Six coated and uncoated pins of 0.9 mm diameter were inserted into the tibia of adult male Wistar rats for 1, 2, 4, 7, 14, and 28 days. Specimens were embedded in methacrylate-based Technovit 9100N resin. From one portion cutting and grinding sections were obtained. The implant was removed from the other half that was depolymerized, sectioned, and mounted for immunohistochemistry. RESULTS: At day 4, the interface around the collagen-coated implants displayed a granulation tissue with higher numbers of cathepsin D-positive mononucleated cells compared to the uncoated implants (p<0.05). Active osteoblasts, reactive for osteopontin, were increased around the collagen-coated pins at day 4 and 7 (p<0.01). After 28 days of implantation, direct bone contact averaged 74.9% around the collagen-coated implants and 62.1% around uncoated implants (NS). The amount of newly formed bone averaged 76.3% around the collagen-coated pins and 67.8% around the uncoated pins (NS). The histomorphometric findings were confirmed by SRmicroCT in two specimens. CONCLUSIONS: The earlier observation of mononuclear phagocytozing cells and the earlier and higher expression of bone-specific matrix proteins suggest an increased early bone remodeling around titanium pins through collagen coating. A tendency towards increased bone formation was observed around the coated implants.

• Arthrodesis of the ankle joint.

  Authors: René Grass, Stefan Rammelt, Achim Biewener, Hans Zwipp

  Clinics in podiatric medicine and surgery. 05/2004; 21(2):161-78.

  Arthrodesis of the ankle that uses lag screws for internal fixation is a safe and biomechanically stable method to obtain a solid ankle fusion; it generates good to excellent results in mostArthrodesis of the ankle that uses lag screws for internal fixation is a safe and biomechanically stable method to obtain a solid ankle fusion; it generates good to excellent results in most patients. Prompt bone healing can be expected and allows a functional rehabilitation with full weight bearing. The surgical technique can be simplified further when using cannulated screws. Malalignment hazards while doing the ankle fusion are minimized by respecting the shape of the ankle mortise because no osteotomy of the lateral malleolus is performed. Generally, removal of the implanted material is not necessary. Major complications such as infection, stress fractures, or nonunion were not seen in our series. A meticulous resection of all cartilage and sclerotic bone and an atraumatic surgical technique are essential for preventing those major complications.The need for revision surgery is minimized by correction of talar malalignment, fusion with the ankle in a 90 degrees position, and preoperative evaluation of the subtalar joint. External fixation methods are used in cases of osteitis, osteonecrosis, osteoporosis, and poor soft tissue conditions. With severe loss of bone stock at the distal tibia, stability can be achieved by using an intramedullary nail for ankle fusion.

• Collagen type I increases bone remodelling around hydroxyapatite implants in the rat tibia.

  Authors: Stefan Rammelt, Eva Schulze, Martin Witt, Elisabeth Petsch, Achim Biewener, Wolfgang Pompe, Hans Zwipp

  Cells, tissues, organs. 02/2004; 178(3):146-57.

  The early interface reaction of cancellous bone to a nanocrystalline hydroxyapatite (HA) cement containing 3 wt% collagen type I (HA/Coll) with a setting under physiological temperature and pH wasThe early interface reaction of cancellous bone to a nanocrystalline hydroxyapatite (HA) cement containing 3 wt% collagen type I (HA/Coll) with a setting under physiological temperature and pH was observed using immunohistochemical techniques. Pure HA served as a control. Cylinders with a diameter of 2 mm were implanted into the proximal tibia of 72 adult Wistar rats. Histological sections of 6 animals were prepared after 1, 2, 4, 6, 14 and 28 days. First, osteoblast-like cells as well as a marked reaction for osteonectin, osteopontin and its ligand CD44 were observed as early as 2 days after implantation at the interface around HA/Coll implants. Further, reactivity for ED1 and cathepsin D, both markers for phagocytotic cells, appeared earlier and stronger around HA/Coll. In cell counts, a significantly higher average number of ED1- and cathepsin D-positive phagocytotic cells was observed around the HA/Coll implants on days 6 (p < 0.01), 14 and 28 (p < 0.05). The number of osteopontin-positive cells was significantly higher around HA/Coll implants at days 6 and 14 (p < 0.05). Two weeks after the implantation, first islands of newly formed woven bone were observed around the HA/Coll implant, but not around the control implant. The amount of direct bone contact after 28 days averaged 28% around pure HA and 51% around HA/Coll implants (p < 0.05). While both implants displayed a good osteoconductivity, a higher bone remodelling activity was observed around collagen-containing HA implants compared to pure HA implants. It appears that the addition of collagen to HA implants can enhance both phagocytotic and osteogenic processes. This may result in an earlier acceptance and better osseointegration of the HA/Coll implants into the surrounding tissue.

• Impact of helicopter transport and hospital level on mortality of polytrauma patients.

  Authors: Achim Biewener, Ulf Aschenbrenner, Stefan Rammelt, René Grass, Hans Zwipp

  The Journal of trauma. 01/2004; 56(1):94-8.

  BACKGROUND: Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identifiedBACKGROUND: Despite numerous studies analyzing this topic, specific advantages of helicopter transport of blunt polytrauma patients as compared with ground ambulances have not yet been identified unequivocally. METHODS: Four possible pathways in 403 polytrauma patients (Injury Severity Score [ISS] > 16) who were in reach of the helicopter emergency medical service (HEMS) Dresden were analyzed as follows: HEMS-UNI group (n = 140), transfer by HEMS into a university hospital; AMB-REG group (n = 102), transfer by ground ambulance into a regional (Level II or III) hospital; AMB-UNI group (n = 70), transfer by ground ambulance into the university hospital; and INTER group (n = 91), transfer by ground ambulance into a regional hospital, followed by transfer to the university hospital. Scores used were the ISS and the TRISS. Tests used for statistical analysis included chi2 and Fisher's tests. Statistical significance was set at p > 0.05. RESULTS: Age, gender, and mean ISS (range, 33.3-35.6) revealed extensive homogeneity of the groups. Mortality of the AMB-REG group was almost doubled (41.2%) compared with HEMS-UNI (22.1%) patients (p = 0.002). The AMB-UNI group displayed the lowest mortality (15.7%, p = not significant). TRISS analysis (PRE-Chart) revealed identical outcome for AMB-UNI and HEMS-UNI patients. Rescue time averaged 90 +/- 29 minutes for HEMS-UNI patients, 68 +/- 25 minutes for AMB-UNI patients, and 69 +/- 26 minutes for the AMB-REG group. CONCLUSION: Primary transfer by HEMS into a Level I trauma center reduces mortality markedly. In principle, this benefit can be attributed to superior preclinical therapy, primary admission to a Level I trauma center, or both. However, the identical probability of survival of the AMB-UNI and HEMS-UNI groups in this and comparable studies does not confirm generally better survival rates on account of a more aggressive on-site approach.

• Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis.

  Authors: Rene Grass, Stefan Rammelt, Achim Biewener, Hans Zwipp

  Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 06/2003; 24(5):392-7.

  The distal tibiofibular syndesmosmotic ligament complex is important for dynamic stability and congruency of the ankle joint. Syndesmotic lesions in the ankle fracture-dislocations are wellThe distal tibiofibular syndesmosmotic ligament complex is important for dynamic stability and congruency of the ankle joint. Syndesmotic lesions in the ankle fracture-dislocations are well recognized and classified systematically. Chronic insufficiency of the syndesmosis leads to a lateral shift of the talus and under eversion stress permits a pathological rotation of the talus. There is also retroversion of the distal fibula representing a painful deformity. Little experience exists with surgical reconstruction of the syndesmosis. This article describes a new ligamentoplasty with a split peroneus longus tendon graft that mimics the normal anatomic conditions of the syndesmotic complex in 16 patients with symptomatic chronic syndesmotic insufficiency after pronation-external rotation and pronation abduction injuries to the ankle joint. Postoperatively, no infections or hematomas were seen. One patient had asymptomatic breakage of the syndesmosis screw; one patient had a 10 degree decrease of dorsiflexion at the ankle because of a partial anterior tibiofibular synostosis. Fifteen of 16 patients had pain relief at a mean follow-up period of 16.4 months (range, 13-29 months); all patients had relief of the chronic swelling of the ankle and the giving way. The mean Karlsson score at follow-up was 88 (range, 70-100) points. It may be concluded that peroneus longus ligamentoplasty in a preliminary series resulted in reliable ankle stability and considerable pain relief in patients with chronic syndesmotic instability.