ANKLE SYNDESMOSIS TIGHTROPE

Brian Thornes, MCh, FRCSI, MBADublin, Ireland

BROKEN SYNDESMOSIS SCREWS

LOSS OF SCREW FIXATION

COMPLICATIONS REMOVING 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

COMPLICATIONS REMOVING SCREWS

2007: S. Hakkalamani, et al Syndesmotic screw removal in Weber ‘C’ ankle fractures

42 patients

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

TOTAL: 26% complication rate

LATE DIASTASIS FOLLOWING REMOVAL

2007: Wahlquist M. Late Diastasis of the Syndesmosis following Syndesmotic Screw Removal (podium presentation)

21 patients

Average 2mm widening of tibio-fibular clear space

38% of patients symptomatic

SYNDESMOSIS SCREWS

SYNDESMOSIS SCREWS

BROKEN SCREWS BEST ??!!

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

SYNDESMOSIS SCREWS

Old Debate / Controversies

1. What size/number of screws to use (3.5mm / 4.5mm)?

2. How many cortices to engage (3 or 4 cortices)?

3. If/when to remove before screw breakage?

SYNDESMOSIS INJURIES

Better Questions:

1. What is the healing time for syndesmosis ligaments?

SYNDESMOSIS INJURIES

Better Questions:

1. What is the healing time for syndesmosis ligaments?

2. Is rigid fixation the correct environment to promote healing?

SYNDESMOSIS INJURIES

Better Questions:

1. What is the healing time for syndesmosis ligaments?

2. Is rigid fixation the correct environment to promote healing?

3. How to hold & maintain reduction, with physiological movement?

GENESIS OF THE TIGHTROPE

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

ORIGINAL SUTURE-ENDOBUTTON

COMPARATIVE CT SCAN

TIGHTROPE

TIGHTROPE

18YR OLD, 120KG WEIGHT...?NWB

CLINICAL SERIES

2009: Cottom JMTransosseous fixation of the syndesmosis: Comparison 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

CLINICAL SERIES

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

12 TightRope vs 12 Screw cases

12 month AOFAS score: 85 (TightRope) vs 76 (screw)

Significantly better range of motion in TightRope group

CLINICAL SERIES

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 button/suture knot... elective removal without difficulty

CLINICAL SERIES

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

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

The disrupted syndesmotic relationships were normalised by the application of the suture button and remained within normal limits through the study period in all cases.

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

CLINICAL SERIES

2012 (in press): Naqvi GA, Shafqat A, Awan NTightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications and 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

CURRENT CONTOVERSIES

1. Mal-Reduction

2. Mid-diaphyseal Fibular Fractures

3. Osteoporotic bone

MAL-REDUCTION

25 screw patients

52% incongruity of fibula within incisura on postop CT scan

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

REDUCTION IN INCISURA

MID-SHAFT FIBULA FRACTURE

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

All better with additional fibular plating versus syndesmosis (screw) fixation alone

Therefore: if you can, FIX THE FIBULA

OSTEOPOROTIC ANKLE #’S INCREASING

OSTEOPOROTIC ANKLE #’S INCREASING

OSTEOPOROTIC ANKLE #’S INCREASING

81YR OLD, OSTEOPOROTIC LADY...?NWB

NEXT TIME...

THANK YOU

www.ankletightrope.com