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Tightrope fixation of syndesmotic injuries in Weber C ankle fractures: a multicentre case series

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Abstract

Background: No general consensus has yet been established for the gold standard treatment of ankle syndesmotic complex injuries. Recent literature has documented the success of ankle tightrope fixation for heterogeneous ankle fracture patterns, resulting in syndesmotic complex injuries. We present a multicentre case series assessing the clinical, radiological and functional outcomes of patients with Weber C ankle fractures treated with the Arthrex TightRope(®) fixation system. Method: We performed a retrospective analysis of all adult patients with Weber C ankle fractures who were treated with the Arthrex TightRope(®) fixation system at four centres over a 3-year period. All patients were followed up for a mean of 14 months (range 12-26). Outcomes measures were assessed subjectively using functional scores (AOFAS and Olerud and Molander) and objectively using radiological measurements, complication rates and revision surgery rates. Results: Thirty-six patients met our eligibility criteria. The mean age at operation was 31 years (range 18-65). There were 20 males and 16 females. No patients were lost to follow-up. The ankle tightrope maintained satisfactory reduction in the ankle mortise in 97% of cases. Of these 35 successfully treated cases, no evidence of re-displacement on follow-up radiographs of the syndesmotic complex was observed at an average of 10.8 months (range 6-12). Post-operative mean medial clear space was 3.1 mm, and mean tibio-fibular overlap was 10.1 mm. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.8 (range 67-98) at a mean follow-up of 14 months (range 12-26). The overall complication rate was 6% (one failure requiring revision surgery and one medial sided skin irritation requiring removal of suture button). No infections or wound complications occurred. Conclusion: Tightrope fixation is a safe alternative to screw fixation for syndesmotic complex injuries in Weber C ankle fractures. We have shown that it has low complication rates and a high patient satisfaction.
ORIGINAL ARTICLE ANKLE - FRACTURES
Tightrope fixation of syndesmotic injuries in Weber C ankle
fractures: a multicentre case series
Amarjit Anand
1
Ran Wei
2
Akash Patel
1
Vikas Vedi
3
Garth Allardice
4
Bobby Singh Anand
2,5
Received: 20 June 2016 / Accepted: 3 November 2016 / Published online: 10 January 2017
Springer-Verlag France 2017
Abstract
Background No general consensus has yet been estab-
lished for the gold standard treatment of ankle syndesmotic
complex injuries. Recent literature has documented the
success of ankle tightrope fixation for heterogeneous ankle
fracture patterns, resulting in syndesmotic complex inju-
ries. We present a multicentre case series assessing the
clinical, radiological and functional outcomes of patients
with Weber C ankle fractures treated with the Arthrex
TightRope
fixation system.
Method We performed a retrospective analysis of all adult
patients with Weber C ankle fractures who were treated
with the Arthrex TightRope
fixation system at four cen-
tres over a 3-year period. All patients were followed up for
a mean of 14 months (range 12–26). Outcomes measures
were assessed subjectively using functional scores
(AOFAS and Olerud and Molander) and objectively using
radiological measurements, complication rates and revision
surgery rates.
Results Thirty-six patients met our eligibility criteria.
The mean age at operation was 31 years (range 18–65).
There were 20 males and 16 females. No patients were
lost to follow-up. The ankle tightrope maintained satis-
factory reduction in the ankle mortise in 97% of cases.
Of these 35 successfully treated cases, no evidence of re-
displacement on follow-up radiographs of the syn-
desmotic complex was observed at an average of
10.8 months (range 6–12). Post-operative mean medial
clear space was 3.1 mm, and mean tibio-fibular overlap
was 10.1 mm. The mean American Orthopaedic Foot
and Ankle Society (AOFAS) score was 88.8 (range
67–98) at a mean follow-up of 14 months (range 12–26).
The overall complication rate was 6% (one failure
requiring revision surgery and one medial sided skin
irritation requiring removal of suture button). No infec-
tions or wound complications occurred.
Conclusion Tightrope fixation is a safe alternative to screw
fixation for syndesmotic complex injuries in Weber C
ankle fractures. We have shown that it has low complica-
tion rates and a high patient satisfaction.
Keywords Ankle Fractures Tightrope Weber C
Syndesmosis Syndesmotic complex Syndesmosis
repair Syndesmosis reconstruction Syndesmosis
reduction Diastasis Suture button
&Bobby Singh Anand
bobby.anand2@nhs.net
Amarjit Anand
amarjitanand@gmail.com
Ran Wei
ranwei@nhs.net
Akash Patel
mrakashpatel@doctors.org.uk
Vikas Vedi
Vikas.Vedi@thh.nhs.uk
Garth Allardice
garthvon@btinternet.com
1
Imperial College London Hospitals, London, UK
2
Croydon University Hospital, 530 London Road,
Surrey CR7 7YE, UK
3
Hillingdon and Mount Vernon Hospital, London, UK
4
Northwick Park Hospital, Watford Road,
Harrow, Middlesex HA1 3UJ, UK
5
The Elective Orthopaedic Centre, Dorking Road,
Epsom KT18 7EG, UK
123
Eur J Orthop Surg Traumatol (2017) 27:461–467
DOI 10.1007/s00590-016-1882-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The AOFAS score also improved significantly in a study from 32.4 (range 21.3-37.2) preoperatively to 94.5 (range 84-98) at 2 years post-surgery (P=0.004).1 Another study showed that postoperative mean AOFAS score was 88.8(range 67-98) at a mean follow up of 14 months. 16,17 The higher scores showed in their studies were related to the longer follow up period compared to that of our study. [16] Limitations of the study This study had some limitations. ...
... 16,17 The higher scores showed in their studies were related to the longer follow up period compared to that of our study. [16] Limitations of the study This study had some limitations. It did not compare suture-endobutton fixation with syndesmotic screw, another method for fixation of ankle syndesmotic injury. ...
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Background: The distal tibiofibular syndesmosis connects the lower leg bones and supports the ankle joint. When this structure is injured, often due to ankle fractures, it can cause long-term problems that require surgical repair. Two common methods of surgery are screw and suture-button fixation, with the latter showing better results in recent studies. The aim of this study was to evaluate the outcome of suture-endobutton fixation for acute ankle syndesmotic injury. Material & Methods: This study followed 24 patients with acute ankle syndesmotic injury who underwent suture endobutton fixation at NITOR, Dhaka, from May 2019 to August 2021. The patients were observed for 24 weeks and their outcomes were evaluated by the AOFAS score and radiological analysis together with reported complications.Results: The study involved 24 patients with acute ankle syndesmotic injury who underwent surgery. The patients were mostly male 19 (79.17%), had PER type of injury 23 (95.83%), and injured by RTA 12 (50.00%) or twisting force 10 (41.67%). According to the AOFAS score, at the final follow up 12 (50%) patients had an excellent outcome, 08 (33.33%) patients had a good outcome, 3 (12.5%) patients had a fair outcome, and 1 (4.2%) patient had a poor outcome.Conclusions: The aim of this study was to evaluate the outcome of suture-endobutton fixation for acute ankle syndesmotic injury. From this study it can be concluded that suture endobutton fixation is an effective treatment option for acute syndesmotic injuries of ankle.
... The Tightrope system is an innovative minimally invasive method for treating syndesmosis injuries. Research reports an overall repair satisfaction rate exceeding 95%, with no need for secondary implant removal [36]. Furthermore, the Bolt Tightrope system, which combines bolt compression with a suture-loop titanium plate, has demonstrated favorable clinical outcomes. ...
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The deltoid ligament (medial collateral ligament) and the syndesmosis (a composite ligamentous structure at the distal tibiofibular junction) are critical for maintaining ankle stability. In cases of high-energy ankle fractures, these structures are often injured simultaneously, leading to instability and potential long-term complications such as post-traumatic arthritis. This review aims to explore advancements in minimally invasive techniques for the treatment of combined deltoid ligament and syndesmosis injuries, with a focus on optimizing surgical outcomes and reducing patient morbidity. Current treatment strategies primarily involve cortical screws for syndesmosis stabilization and anchor fixation for deltoid ligament repair. Recent innovations, such as bioabsorbable screws, suture-button devices with elastic micromotion, and syndesmotic plates, have demonstrated potential in improving biomechanical stability while minimizing complications. Furthermore, minimally invasive techniques, including arthroscopic repairs with suture anchors, as well as ligament reconstruction using autografts, allografts, or synthetic ligaments, are becoming increasingly popular. By incorporating these advancements, the field is moving toward more effective and patient-centered approaches to achieve anatomical and functional restoration under minimally invasive principles. Future research should focus on further validating these techniques and identifying the most effective strategies for complex injuries.
... [6]. Another study Anand et al. [19] showed that postoperative mean AOFAS score was 88.8(range 67-98) at a mean follow up of 14 months. The higher scores showed in their studies were related to the longer follow up period compared to that of our study. ...
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Background: Ankle syndesmosis injuries, comprising disruptions to the distal tibiofibular joint, present challenges in orthopedic management, necessitating effective interventions to restore optimal function. Suture-endobutton fixation has emerged as a promising surgical technique for stabilizing the syndesmotic complex. The aim of this study was to determine the improvement of AOFAS score after suture endobutton fixation for ankle syndesmosis injury. Material & Methods: This prospective interventional study was conducted in National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh from May 2019 to August 2021. Due to COVID-19 pandemic only 24 samples could be collected who completed the final follow-up. Results: In our study we found the mean AOFAS sub score of pain was 18.33±5.64 in pre-operative follow up and 29.58±2.04 in 24 weeks follow up. P-value was <0.001 which is statistically significant. The mean AOFAS score improved significantly from a preoperative value of 22.71±7.07 to 85.29±9.41 at final follow up. Conclusions: In conclusion, this prospective interventional study underscores the effectiveness of suture-endobutton fixation in improving AOFAS scores and overall outcomes for patients with ankle syndesmosis injuries.
... This is similar in principle to screw breakage in ankle syndesmosis injuries, which in some centers, are routinely removed to avoid this problem. More recently, the development of synthetic suture button systems has allowed the avoidance of this issue without compromising biomechanical stability [14]. Feng et al. have attempted to use suture button devices in symphysis fixation [15], however, we believe the biomechanical demands placed on the implant are far greater in the symphysis than in the ankle syndesmosis. ...
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Purpose Pubic symphysis disruption is common in pelvic trauma. Open reduction and internal fixation with a plate is the gold standard technique. Despite increasing interest in an endoscopic approach, the challenges of specific endoscopic instrumentation, reduction and fixation remains. In this feasibility cadaveric study, we aimed to describe a novel endoscopic technique of fixation of pubic symphysis disruption with a spinal vertebral tethering system. Methods Endoscopic pubic symphysis fixation with the tethering method was performed on a female cadaver specimen as well as an artificial pelvic model. Results We describe a step-by-step technique where three abdominal portals were utilized in order to insert screws in the pubic body and superior pubic ramus under endoscopic visualization. The synthetic tether ligament was introduced through a lateral portal and fixed and tensioned to reduce and compress the pubic symphysis. Conclusions While open plate fixation is the current gold standard of pubic symphysis disruption there is increasing interest in the minimally invasive endoscopic approach. In this feasibility cadaveric study, we present a new minimally invasive endoscopic fixation method to treat pubic symphysis disruption with a synthetic ligament.
... A 2021 prospective study by Kurtoglu et al. demonstrated no difference between single and double interosseous suture endobutton systems among 43 patients (35). Similarly, Anand et al. reported no difference in patient outcomes regarding the number of suture endobuttons used with Arthrex Tightrope (Naples, Florida) fixation for Weber C ankle injuries (36). The findings of these studies highlight the importance of translating biomechanical findings to practice, but also raise the question if a less costly, single button system would be an overall better choice. ...
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... Evaluation of alignment with SB fixation has also been performed. Weber C ankle fractures repaired with SB systems have been shown to achieve a return of the syndesmosis to a normal radiographic pre-injury alignment without evidence of re-displacement in followup imaging [11]. The rate of malreduction may increase over time with the use of screw fixation, but the use of SB fixation has been shown to maintain reduction when evaluated with computerized tomography (CT) at least two years after surgery [12]. ...
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Background In the ankle, suture bridge fixation for syndesmotic injuries is commonly employed. Initial recommendations for suture bridge constructs advised against using the device in patients with insufficient quantity or quality of bone. Therefore, many surgeons limit its use to younger, more athletic patients and use traditional screw fixation in older, less active patients. The purpose of this study is to compare the outcomes of suture bridge fixation for syndesmotic repair in patients ≥ 60 years old vs patients < 60 years old. Methods A retrospective review of 140 ankle fracture patients from a single institution who received suture bridge fixation between July 13, 2010, and February 2, 2022, was performed. Patient data was obtained from patient records in the electronic health record. Univariate analysis, including chi-square and independent t-tests, was used. Complications included delayed wound healing, infection, hardware loosening, and non-union. Results There were no significant differences in demographics, comorbidities, primary or other procedures, loss of fixation, and neuropathy between groups. There was also no difference within the distribution of the mechanism of injury, affected side, or Weber classification. Finally, the rate of complication and complication type showed no significant differences between patients 60 years and older versus 60 years and younger. Complication rates and types in patients > 60 years versus < 60 years were not significantly different. Conclusion The use of the suture bridge fixation in patients > 60 years may not lead to an increased risk of complications and appears to be safe for use.
... Anand et al. published a multicenter case series consisting of 36 patients. They demonstrated that the ankle suture button device maintained satisfactory reduction in the ankle mortise in 97% of cases, with a mean follow-up of 14 months [50]. Sagi and colleagues [42] used CT and clinical follow-up at a minimum of two years from fracture fixation. ...
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The accuracy and maintenance of syndesmosis reduction are essential when treating ankle fractures with accompanying syndesmosis injuries. The primary aim of this study was to compare syndesmosis screw and TightRope fixation in terms of accuracy and maintenance of syndesmosis reduction using bilateral computed tomography (CT). Single centre, prospective randomised controlled clinical trial; Level of evidence 1. This study (ClinicalTrials.gov, NCT01742650) compared fixation with TightRope(®) (Arthrex, Naples, FL, USA) or with one 3.5-mm tricortical trans-syndesmotic screw in terms of accuracy and maintenance of syndesmosis reduction in Lauge-Hansen pronation external rotation, Weber C-type ankle fractures with associated syndesmosis injury. Twenty-one patients were randomised to TightRope fixation and 22 to syndesmotic screw fixation. Syndesmosis reduction was assessed using bilateral CT intraoperatively or postoperatively, and also at least 2 years after surgery. Functional outcomes and quality of life were assessed using the Olerud-Molander score, a 100-mm Visual Analogue Scale, the Foot and Ankle Outcome Score, and the RAND 36-Item Health Survey. Grade of osteoarthritis was qualified with follow-up cone-beam CT. According to surgeons' assessment from intraoperative CT, screw fixation resulted in syndesmosis malreduction in one case whereas seven syndesmosis were considered malreduced when TightRope was used. However, open exploration and postoperative CT of these seven cases revealed that syndesmosis was well reduced if the ankle was supported at 90˚. Retrospective analysis of the intra- and post-operative CT by a radiologist showed that one patient in each group had incongruent syndesmosis. Follow-up CT identified three patients with malreduced syndesmosis in the syndesmotic screw fixation group, whereas malreduction was seen in one patient in the TightRope group (P=0.33). Functional scores and the incidence of osteoarthritis showed no significant difference between groups. Syndesmotic screw and TightRope had similar postoperative malreduction rates. However, intraoperative CT scanning of ankles with TightRope fixation was misleading due to dynamic nature of the fixation. After at least 2 years of follow-up, malreduction rates may slightly increase when using trans-syndesmotic screw fixation, but reduction was well maintained when fixed with TightRope. Neither the incidence of ankle joint osteoarthritis nor functional outcome significantly differed between the fixation methods. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
OBJECTIVES:: To compare the clinical and radiographic outcome after stabilization of an acute syndesmosis rupture with either a static implant (a 3.5mm metallic screw through four cortices) or a dynamic device (Tightrope, Arthrex, Naples, FL). DESIGN:: Multicenter randomized double-blind controlled trial. SETTINGS:: Study realised in five trauma centers (two Level 1 and 3 Level 2) in 2 countries. PATIENTS/PARTICIPANTS:: 70 subjects admitted for an acute ankle syndesmosis rupture entered the study and were randomized in two groups (dynamic fixation = 34, static fixation = 36). The two groups were similar regarding demographic, social and surgical data. 65 patients (dynamic = 33, static = 32) completed the study and were available for analysis. INTERVENTION:: Syndesmosis fixation in the static group was realised with a four cortices 3,5 mm cortical screw (Synthes, West Chester, PA), and in the dynamic group with one Tightrope (Arthrex, Naples, FL). Standardised rehabilitation process for the two groups: no weight-bearing in a cast for 6 weeks, then rehabilitation without protection. MAIN OUTCOME MEASUREMENT:: Olerud-Molander score. RESULTS:: Subjects with dynamic fixation achieved better clinical performances as described with the Olerud-Molander scores at three (68.8 vs 60.2, p=0,067), six (84.2 vs 76.8, p=0,082), and twelve months (93.3 vs 87.6, p=0,046). We also observed higher AOFAS scores at three months (78.6 vs 70.6, p=0,016), but THESE WERE not significant at six (87.1 vs 83.8, p=0,26) OR twelve months (93.1 vs 89.9, p=0,26). Implant failure was higher in the screw group (36.1% vs 0%, p<0,05). Loss of reduction was observed in 4 cases in the static screw group (11.1% vs 0%, p=0,06). CONCLUSION:: Dynamic fixation of acute ankle syndesmosis rupture with a dynamic device appears to result in better clinical and radiographic outcomes. The implant offers adequate SYNDESMOTIC stabilization without failure or loss of reduction, and THE reoperation rate is significantly lower than with conventional screw fixation. LEVEL OF EVIDENCE:: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Article
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. Clinical relevance: Although the clinical relevance is unknown, dynamic syndesmotic fixation may mitigate clamp-induced malreduction.
Article
17 patients with ankle syndesmosic injury were treated with a 4.5mm single cortical screw fixation (passage of screw 4 cortices) and 15 patients were treated with single-level elastic fixation material. All patients were evaluated according to the AOFAS ankle and posterior foot scale at the third, sixth and twelfth months after the fixation. The ankle range of movement was recorded together with the healthy side. The Student's t test was used for statistical comparisons. No statistical significant difference was observed between the AOFAS scores (p>0.05). The range of dorsiflexion and plantar flexion motion of the elastic fixation group at the 6th and 12th months were significantly better compared to the screw fixation group (p<0.01). Elastic fixation is as functional as screw fixation in the treatment of ankle syndesmosis injuries. The unnecessary need of a second surgical intervention for removal of the fixation material is another advantageous aspect of this method of fixation. Copyright © 2015. Published by Elsevier Ltd.
Article
No consensus had been reached about the optimal method for syndesmotic fixation. The present study analysed syndesmotic fixation based on the highest level of clinical evidence in order to obtain more reliable results. Medline, Embase and Cochrane database were searched through the OVID retrieval engine. Manual searching was undertaken afterward to identify additional studies. Only randomized controlled trials (RCT) and prospective comparative studies were selected for final inclusion. Study screening and data extraction were completed independently by two reviewers. All study characteristics were summarized into a table. The extracted data were used for data analysis. Twelve studies were finally included: six of them were RCTs, two were quasi-randomized studies and four were prospective comparative studies. Four comparisons with traditional metallic screw were identified in terms of bioabsorbable screws, tricortical fixation method, suture-button device as well as non-fixation choice in low syndesmotic injuries. Both absorbable screws and the tricortical fixation method showed almost no better results than traditional quadricortical metallic screw (p > 0.05). Additionally, existing studies could not illustrate their efficiency of reducing hardware removal rate. The suture button technique had significantly better functional score (p = 0.003), ankle motion (p = 0.02), time to full weightbearing (p < 0.0001) and much less complications (p = 0.0008) based on short and intermediate term follow-up data. Transfixation in low syndesmotic injuries showed poorer results than the non fixed group in all outcome measurements, but didn't reach a significant level (p > 0.05). The present evidence still couldn't find superior performance of the bioabsorbable screw and tricortical fixation method. Their true effects in decreasing second operation rate need further specific studies. Better results of the suture-button made it a promising technique, but it still needs long-term testing and cost-efficiency studies. The patients with low syndemotic injuries should be well assessed before fixation determination and the indication of screw placement in such conditions needs to be further defined.
Article
Background: Open reduction and screw fixation is the current standard treatment for displaced injuries of the ankle syndesmosis. Despite reduction and stable internal fixation, however, these injuries do not uniformly have excellent outcomes. In addition, screw fixation has potential disadvantages. Materials and methods: An ongoing prospective, randomized clinical trial comparing conventional screw fixation with TightRope ® fiber wire fixation for syndesmosis injuries. The objective of this paper is also to provide an overview of the important anatom- ical and biomechanical issues relating to syndesmosis injuries. Results: At medium term follow-up the TightRope ® fiber wire fixation group had a statistically significant better range of motion compared to conventional screw fixation. The AOFAS ankle and hindfoot score did not show a significant difference between the two groups.