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VOLUME 7 , ISSUE 3 ( November, 2012 ) > List of Articles

Review

Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature

Annick den Daas, Wouter J. van Zuuren, Stéphane Pelet, Arthur van Noort, Michel P. J. van den Bekerom

Keywords : Syndesmosis, Screw, Ankle fracture, Flexible implant, Instability, Biomechanical

Citation Information : den Daas A, van Zuuren WJ, Pelet S, van Noort A, van den Bekerom MP. Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature. 2012; 7 (3):123-129.

DOI: 10.1007/s11751-012-0147-2

License: CC BY-NC-SA 4.0

Published Online: 01-06-2013

Copyright Statement:  Copyright © 2012; The Author(s).


Abstract

Syndesmotic rupture is present in 10 % of ankle fractures and must be recognized and treated to prevent late complications. The method of fixation is classically rigid fixation with one or two screws. Knowledge of the biomechanics of the syndesmosis has led to the development of new dynamic implants to restore physiologic motion during walking. One of these implants is the suture-button system. The purpose of this paper is to review the orthopaedic trauma literature, both biomechanical and clinical, to present the current state of knowledge on the suture-button fixation and to put emphasis on the advantages and disadvantages of this technique. Two investigators searched the databases of Pubmed/Medline, Cochrane Clinical Trial Register and Embase independently. The search interval was from January 1980 to March 2011. The search keys comprised terms to identify articles on biomechanical and clinical issues of flexible fixation of syndesmotic ruptures. Ninety-nine publications met the search criteria. After filtering using the exclusion criteria, 11 articles (five biomechanical and six clinical) were available for review. The biomechanical studies involved 90 cadaveric ankles. The suture-button demonstrated good resistance to axial and rotational loads (equivalent to screws) and resistance to failure. Physiologic motion of the syndesmosis was restored in all directions. The clinical studies (149 ankles) demonstrated good functional results using the AOFAS score, indicating faster rehabilitation with flexible fixation than with screws. There were few complications. Preliminary results from the current literature support the use of suture-button fixation for syndesmotic ruptures. This method seems secure and safe. As there is no strong evidence for its use, prospective randomized controlled trials to compare the suture-button to the screw fixation for ankle syndesmotic ruptures are required.


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  1. Ahl T, Dalen N, Lundberg A et al (1987) Mobility of the ankle mortise. A roentgen stereophotogrammetric analysis. Acta Orthop Scand 58(4):401-402
  2. Bartonicek J (2003) Anatomy of the tibio-fibular syndesmosis and its clinical relevance. Surg Radiol Anat 25(5-6):379-386
  3. Beumer A, Valstar ER, Garling EH et al (2003) Kinematics of the distal tibio-fibularsyndesmosis: radiostereometry in 11 normal ankles. Acta Orthop Scand 74(3):337-343
  4. Bostman OM, Pihlajamaki HK (2000) Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop 371:216-227
  5. Brown OL, Dirschl DR, Obremskey WT (2001) Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 15(4):271-274
  6. Cottom JM, Hyer CF, Philbin TM et al (2008) Treatment of syndesmotic disruptions with the Arthrex Tightrope: a report of 25 cases. Foot Ankle Int 29(8):773-780
  7. Cottom JM, Hyer CF, Philbin TM et al (2009) Transosseous fixation of the distal tibio-fibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases. J Foot Ankle Surg 48(6):620-630
  8. De Groot H, Al-Omari AA, El Ghazaly SA (2011) Outcomes of suture button repair of the distal tibio-fibular syndesmosis. Foot Ankle Int 32(3):250-256
  9. De Souza LJ, Gustillo RB, Meijer TJ (1985) Results of operative treatment of displaced external rotation-abduction fractures of the ankle. JBJS Am 67(7):1066-1074
  10. Forsythe K, Freedman KB, Stover MD et al (2008) Comparison of a novel fiberwire-button construct versus metallic screw fixation in a syndesmotic injury model. Foot Ankle Int 29(1):49-54
  11. Fritschy D (1989) An unusual ankle injury in top skiers. Am J Sports Med 17:282-285
  12. Hahn DM, Colton CL (2000) Fractures of the malleoli. In: Ruedi TP, Murphy WM, Colton CL et al. (eds) AO principles of fracture management. AO publishing, Davos, p 581
  13. Hamid N, Loeffler BJ, Braddy W, Kellam JF, Cohen BE, Bosse MJ (2009) Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg Br 91(8):1069-1073
  14. Hansen L (1950) N: fractures of the ankle. II. Combined experimental- surgical and experimental-roentgenologic investigations. Arch Surg 60:957-985
  15. Kennedy JG, Soffe KE, Dalla Vedova P et al (2000) Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma 14(5):359-366
  16. Kerkhoffs GM, Rowe BH, Kelly K et al. (2002) Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 3(3):CD003762
  17. Klitzman R, Zhao H, Zhang LQ et al (2010) Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis. Foot Ankle Int 31(1):69-75
  18. Lundberg A (1989) Kinematics of the ankle and foot- in vivo roentgen stereophotogrammetry. Acta Orthop Scand Suppl 223:1-24
  19. Marqueen T, Owen J, Nicandri G et al (2006) Comparison of the syndesmosis staple to the transsyndesmotic screw; a biomechanical study. Foot Ankle Int 26:224-230
  20. Michelson J, Solocoff D, Waldmann B et al (1997) Ankle fractures; the Lauge-Hansen classification revised. Clin Orthop 345:198-205
  21. Miller CD, Shelton WR, Barret GR et al (1995) Deltoid and syndesmosis ligament injury of the ankle without fracture. Am J Sports Med 23:746-750
  22. Miller RS, Weinhold PS, Dahners LE (1999) Comparison of tricortical screw fixation versus a modified suture construct for fixation of ankle syndesmosis injury: a biomechanical study. J Orthop Trauma 13(1):39-42
  23. Muller ME, Brandi W (1970) Manuel of internal fixation; techniques recommended by the AO group. Springer, New York
  24. Ogilvie-Harris DJ, Reed SC, Hedman TP (1994) Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 10(5):558-560
  25. Pankovich AM (1976) Maisonneuve fractures of the fibula. JBJS Am 58:337-342
  26. Peter RE, Harrington RM, Henley MB et al (2004) Biomechanical effects of internal fixation of the distal tibio-fibular syndesmotic joint: comparison of two fixation techniques. J Orthop Trauma 8(3):215-219
  27. Raahave D (1976) Postoperative wound infection after implant and removal of osteosynthetic material. Acta Orthop Scand 47(1):28-35
  28. Richards RH, Palmer JD, Clarke NM (1992) Observations on removal of metal implants. Injury 23(1):25-28
  29. Roberts RS (1983) Surgical treatment of displaced ankle fractures. Clin Orthop 172:164-170
  30. Sanderson PL, Ryan W, Turner PG (1992) Complications of metalwork removal. Injury 23(1):29-30
  31. Scranton Jr PE, McMaster JG, Kelly E (1976) Dynamic fibular function: a new concept. Clin Orthop Relat Res 118:76-81
  32. Scraton Jr PE, McMaster JG, Kelly E (1976) Dynamic fibular function; a new concept. Clin Orthop 118:76-81
  33. Shoemaker SC, Kl M (1982) In vivo rotary knee stability. Ligamentous and muscular conditions. JBJS Am 64(2):208-216
  34. Sinisaari I, Patiala H, Bostman O et al (1996) Metallic or absorbable implants for ankle fractures: a comparative study of infections in 3,111 cases. Acta Orthop Scand 67(1):16-18
  35. Soin SP, Knight TA, Dinah AF et al (2009) Suture-button versus screw fixation in a syndesmosis rupture model: a biomechanical comparison. Foot Ankle Int 30(4):346-352
  36. Thornes B, McCartan D (2006) Ankle syndesmosis injuries treated with the Tightrope Suture-Button Kit. Tech Foot Ankle Surg. 5:45-53
  37. Thornes B, Walsh A, Hislop M et al (2003) Suture-endobutton fixation of ankle tibio-fibular diastasis: a cadaver study. Foot Ankle Int 24(2):142-146
  38. Thornes B, Shannon F, Guiney AM et al (2005) Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clin Orthop Relat Res 431:207-212
  39. Tornetta P 3rd, Spoo JE, Reynolds FA et al (2001) Overtightening of the ankle syndesmosis; is it really possible? JBJS Am 83-A(4):489-492
  40. Van den Bekerom MPJ, Raven EEJ (2007) Current concepts review: operative techniques for stabilizing the distal tibio-fibular syndesmosis. Foot Ankle Int 28:1302-1308
  41. Veltri DM, Pagnani MJ, O'Brien SJ et al (1995) Symptomatic ossification of the tibio-fibularsyndesmosis in professional football players; a sequela of the syndesmotic ankle sprain. Foot Ankle Int 16:285-290
  42. Willmott HJ, Singh B, David LA (2009) Outcome and complications of treatment of ankle diastasis with tightrope fixation. Injury 40(11):1204-1206
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