SYNDESMOSIS INJURIES

Brian Thornes, MCh, FRCSI, MBADublin, Ireland

PROBLEM: SYNDESMOSIS SCREWS

2011: Schepers T, et al Complications of Syndesmosis Screw Removal

76 patients

N=7 (9%) wound infectionN=5 (7%) recurrent diastasisN=5 (7%) occult broken screw

TOTAL: 22% complication rate

2007: S. Hakkalamani, et al Syndesmotic Screw Removal in Weber ‘C’ fractures

42 patients

N=6 wound infection (14%) N=4 instability pain (10%) N=1 DVTN=1 occult broken screw

TOTAL: 26% complication rate

2007: Wahlquist M. Late Diastasis following Syndesmotic Screw Removal

21 patients

Average 2mm widening of tibio-fibular clear space

38% of patients symptomatic

2009. Hamid N, et al Outcome after fixation of ankle fractures with an injury to the syndesmosis. The effect of a syndesmosis screw

52 patients

27 intact screws (AOFAS score 83)15 elective removal (AOFAS score 86)10 broken screws (AOFAS score 92)

Average 30 (12-56) month follow-up

2012. Mendelsohn ES, et al. The Effect of Obesity on Early Failure after Operative Syndesmosis Injuries

Re-operations for displacement:

15 in 102 (15%) obese patients vs.

2 in 111 (2%) non-obese patients

Obese: 12 times more likely to displace

2003: Thornes B, Walsh A, Hislop M, Murray P, O’Brien M Suture-Endobutton Fixation of Ankle Tibio-Fibular Diastasis: A Cadaver Study

2005: Thornes B, Shannon F, Guiney AM, Masterson ESuture-Button Syndesmosis Fixation. Accelerated Rehabilitation and Improved Outcomes

2006: Thornes B, McCartan DAnkle Syndesmosis Injuries Treated with the TightRope Suture-Button Kit

2009: Cottom JMComparison of suture-button to traditional screw fixation in 50 cases

25 Tightrope vs 25 Screw cohorts

Similar ankle outcome scores

68% removal rate with screws 0% removal rate with TightRope

2009: Coetzee JCSyndesmoses disruptions: A prospective, randomized study of screw fixation vs TightRope®

12 TightRope vs 12 Screw cases

12 month AOFAS score: 85 (TightRope) 76 (Screw)

Better range of motion in TightRope group

2011: DeGroot H, et alOutcomes of Suture Button Repair of the Distal Tibiofibular Syndesmosis

24 TightRope cases

AOFAS score: 94 (71-100) at 18 months

6 cases: local irritation from suture knot elective removal without difficulty

DISCUSSION“In summary, we believe the suture button device represents a viable alternative to screw fixation for syndesmosis injuries.

Because of the ease of use of the device and the ability to allow full weight-bearing without concerns about implant breakage, we feel that suture-button fixation is superior to conventional metallic screws.”

2011: DeGroot H, et alOutcomes of Suture Button Repair of the Distal Tibiofibular Syndesmosis

2012: Naqvi GA, Shafqat A, Awan NTightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications & technique modification

49 TightRope cases

AOFAS score 86 (78-93) at 6 months

3 cases of implant removal (irritation/infection)

Senior author recommends burying lateral suture tails sub-perisoteally

1. Mal-Reduction

2. Mid-Diaphysis Fibula Fractures

3. Osteoporosis & Diabetes

CURRENT DEBATE

52% incongruity of fibula within incisura on postop CT scan

2006: Gardner M, et alMalreduction of the Tibiofibular Syndesmosis in Ankle Fractures

2008. Ho JY et al. Mid-Diaphyseal Fibular Fractures with Syndesmotic Disruption: Should We Plate the Fibula?

Cadaver study, 8 paired samples

• Rotational stability• Load-to-failure • Stiffness

Better with additional fibular plating vs. syndesmosis (screw) fixation alone

Therefore: if you can, FIX THE FIBULA

2010. Craik JD, et al. The Financial Impact of disatasis screw versus TightRope fixation of unstable syndesmosis injuries of the ankle

2 year audit of 79 cases

Ave. 5.9 follow-up OPD appointments (Screw)

Ave. 4.0 follow-up OPD appointments (TightRope)

TightRope saves:

34 theatre slots per annum

68 OPD appointments

£12,138 annual saving (60% of staff nurse salary in UK)

THANK YOU

www.ankletightrope.com