Does the Arthrex TightRope® Provide Maintenance of the Distal Tibiofibular Syndesmosis? A 2-year Follow-up of 64 TightRopes® in 37 Patients

doi:10.1053/j.jfas.2013.04.013

The Journal of Foot and Ankle Surgery

Volume 52, Issue 5, September–October 2013, Pages 563-567

https://doi.org/10.1053/j.jfas.2013.04.013 Get rights and content

Abstract

Syndesmotic diastasis can occur as an isolated injury or with concomitant fractures. A review of 37 patients with 64 TightRopes^® for syndesmotic repair was performed, with a mean follow-up of 23.6 ± 4.3 months, from 2007 to 2011. The patients’ mean age was 40.67 (range 14 to 87) years. The mean initial measurements were as follows: tibiofibular clear space (TFCS) = 4.1 ± 1.1 mm, tibiofibular overlap (TFO) = 7.2 ± 2.7 mm, and medial clear space (MCS) = 2.9 ± 0.5 mm. The mean final measurements were as follows: TFCS = 4.2 ± 1.3 mm, TFO = 7.4 2.8 mm, and MCS = 3.0 0.5 mm. The calculated measurable difference from the initial to final TFCS, TFO, and MCS was significantly less than the maximum threshold for allowable widening of the syndesmosis: TFCS, p < .001; TFO, p < .002; and MCS, p < .001. Complications occurred in 10 patients; 7 (19%) experienced knot irritation and 3 (8%) developed an infection. The mean interval to weightbearing was 33.2 ± 12.7 days. The mean postoperative American Orthopaedic Foot and Ankle Society score was 97 (range 90 to 100). Of 64 suture endobuttons, 4 (6.25%) required removal. The fracture types were as follows: 3 (8%) isolated syndesmotic injuries, 9 (24%) trimalleolar fractures, 10 (27%) bimalleolar fractures, 7 (18%) Weber B fractures, 3 (8%) Weber C fractures, 1 (3%) Salter Harris type 3 fracture, and 4 (11%) Maisonneuve fractures. TightRope^® fixation was advantageous because it rarely required removal, allowed for physiologic motion of the syndesmosis, and resulted in an early return to weightbearing. In addition, we have concluded that the TightRope^® provides long-term stability of the ankle mortise, which was confirmed by the radiographic criteria and excellent American Orthopaedic Foot and Ankle Society scores.

Section snippets

Patients and Methods

A review of 37 patients who had sustained distal tibiofibular disruption from 2007 to 2011 was performed. Diabetic and neuropathic patients were excluded from the present study. The medical charts were reviewed for the following parameters: gender, age, surgical limb, length of follow-up, interval to weightbearing, complications, postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, fracture pattern, number of TightRopes^® used per patient, and number of

Results

A total of 37 patients with 64 TightRopes^® placed met the inclusion criteria of preoperative radiographic evidence confirmed by intraoperative syndesmotic instability 42, 43. The radiographic criteria consisted of decreased TFO and an increase in the MCS and TFCS. The fracture patterns identified were as follows: purely syndesmotic injuries in 3 (8%), Weber B fractures in 7 (18%), Weber C fractures in 3 (8%), bimalleolar fractures in 10 (27%), trimalleolar fractures in 9 (24%), Maisonneuve

Discussion

Recently, DeGroot et al (15) reported on 24 patients with syndesmotic compromise that was fixated with an interosseous suture endobutton. The mean follow-up period was 20 months. The mean AOFAS score was 94. Included in their study was a radiographic analysis of the preoperative, immediately postoperative, and final postoperative images. The TFCS, TFO, and MCS were compared for changes within the syndesmosis. They reported an increase of 0.1 to 0.2 mm from the immediate to the final follow-up

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Cited by (58)

Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace
2023, Foot
Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program.
Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardised postoperative rehabilitation protocol was established. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively.
The average follow-up was 13 months. The total FAAM score for ADL was 95 ± 4.9 % (range, 83 – 100 %) and for sport activities 87 ± 13.6 % (range, 50 – 100 %). The rating of mean postoperative function for ADL was 94 ± 5.5 % (range, 80 – 100 %) and 90 ± 13 % (range, 35 – 100 %) for sportv. The difference between acute and chronic injuries was statistically higher (p < 0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p = 0.9296 and p = 0.1615, respectively). Twenty-seven patients (90 %) rated their overall current level of function as normal or nearly normal.
This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries.
Acute Syndesmosis Injuries
2023, Clinics in Podiatric Medicine and Surgery
Investigating the Radiological Outcomes of Syndesmosis Injuries in Ankle Fracture Patients After Suture Button Fixation
2022, Journal of Foot and Ankle Surgery
Concomitant syndesmotic injury occurs in 10% of ankle fractures. Anatomic reduction and maintenance of this reduction is critical in ensuring ankle stability and preventing long-term complications. This is a retrospective cohort study aimed at evaluating the mid-term radiological outcomes of syndesmotic injuries in ankle fracture patients after surgical fixation with suture button device. The study group included 33 patients. Plain radiographs including anteroposterior, lateral and mortise views of the affected ankle were performed preoperatively, postoperatively and at 3-month follow-up. Anteroposterior views were used to measure the amount of tibiofibular overlap and tibiofibular clear space. Paired Student's t test and linear model regression were performed. Between the immediate postoperative and 3-month follow-up period, there was a mean decrease in tibiofibular overlap of 0.841 (±2.07) mm (p = .0259). There was a mean increase in tibiofibular clear space of 0.621 (±1.46) mm (p = .0201). In addition, we found significant correlation between fracture type and change in tibiofibular clear space (p = .047). Our study showed that there is statistically significant widening of the syndesmosis after suture button fixation at 3-month follow-up as evidenced by reduced tibiofibular overlap and increase in tibiofibular clear space. However, they remain within the maximum threshold for acceptable syndesmotic widening of 1.5 mm. Further correlation between radiological outcomes and patient function is needed to determine clinical significance of these changes.
Biomechanical comparison of screw, tightrope and novel double endobutton in the treatment of tibiofibular syndesmotic injuries
2021, Injury
Adequate reduction and stabilization of the syndesmosis are significant to prevent early degeneration of the ankle joint and get better clinical outcomes. However, the routine surgical methods have diffierent limitations. The purpose of this study was to develop a novel double Endobutton fixation to treat the distal tibiofibular syndesmotic injuries, and determine whether the novel double Endobutton fixation demonstrates a better biomechanical property compare with the intact syndesmosis, the screw fixation and the Tightrope fixation.
Twenty-four normal fresh-frozen ankle specimens with a mean age of 42 ± 8 (range, 28–62) years were randomly divided equally into four groups: (1) the intact group, (2) the screw group, (3) the Tightrope group, (4) the Endobutton group. 3D printer technology was used to establish the personalized distal tibiofibular syndesmotic navigation modules to determine the accurate bone tunnel. Axial loading was applied in five ankle positions: neutral position, dorsiflexion, plantar flexion, varus and valgus. Rotation torque was applied in two ankle rotation of the neutral position: internal and external.
In most situations, the displacements of the intact group were larger than the screw group, the Tightrope group and the Endobutton group (P < .05), and the displacements of the screw group were smaller than other three groups (P < .05). The displacements of the double Endobutton group were slightly larger than the Tightrope group but no significant differences were found between these two groups except in the dorsiflexion position of axial loading experiments (P < .05). The novel double Endobutton fixation was steadier than intact syndesmosis and more micromotional than screw fixation.
Our study demonstrated that the novel double Endobutton can be considered as the better fixation in treatment of distal tibiofibular syndesmotic injuries.
Level III, retrospective comparative study
Biomechanical evaluation of syndesmotic fixation techniques via finite element analysis: Screw vs. suture button
2021, Computer Methods and Programs in Biomedicine
Tibiofibular syndesmotic injuries may cause degenerative changes, reduction in ankle function and compromising ankle stability. Different fixation techniques try to restore its functionality. Screw-fixation is the gold-standard. Recently, suture-button fixation has aroused the attention because it allows for physiologic micromotion while maintaining an accurate reduction. The aim of this study is to compare the biomechanical behaviour of both fixation techniques using the finite element method.
A three-dimensional finite element model of the tibiofibular joint was reconstructed simulating the intact ankle and the injured syndesmosis. Then, different methods of syndesmosis fixation were analysed: screws (number of cortices, number of screws and distance between screws) and suture buttons (single, double parallel and double divergent with a sensitivity analysis on the pretension forces) configuration. Ligaments and cartilages were included and simulated as spring elements. Physiological loads during stance phase were simulated.
Syndesmosis widening and von Mises stresses were computed. Syndesmosis widening in the injured configuration compromised joint stability (2.06 mm), whereas using a single quadricortical screw (0.18 mm) stiffened the joint. Syndesmosis widening using suture-buttons were closer to syndesmosis widening of the intact ankle configuration (0.97 mm). Von Mises stresses were higher for the titanium screws than for the suture buttons.
A detailed biomechanical comparison among different syndesmotic fixation was performed. Suture buttons have advantages with regard to syndesmosis widening in comparison to screw fixation. This fact supports the good long-term clinical results obtained with suture buttons fixation. The proposed methodology could be an efficient tool for preoperative planning.
Functional outcome of fusion versus ligament reconstruction in patients with a syndesmosis injury: A narrative review
2021, Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology
Injury to distal tibiofibular syndesmosis is commonly associated with ankle fractures. The surgical treatment especially in isolated chronic syndesmosis instability is still debated. This article has reviewed literature identified from PubMed, EMBASE and Cochrane from year 2000 onwards and compared the functional outcomes between syndesmosis fusion and ligament reconstruction based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen studies were included. All the included papers described a good-to-excellent post-operative functional outcome without major complications. No significant difference between the two surgical interventions could be concluded. Further studies of better quality shall be conducted in the future.

View all citing articles on Scopus

: Financial Disclosure: Dr Cottom is a paid consultant for Arthrex, Inc., Naples, FL. Arthrex had no role in the design, data collection, or writing of this paper.

: Conflict of Interest: None reported.

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Original ResearchDoes the Arthrex TightRope® Provide Maintenance of the Distal Tibiofibular Syndesmosis? A 2-year Follow-up of 64 TightRopes® in 37 Patients

Abstract

Section snippets

Patients and Methods

Results

Discussion

Injury Int J Care Injured

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

J Foot Ankle Surg

Chronic instability of the anterior tibiofibular syndesmosis of the ankle: arthroscopic findings and results of anatomical reconstruction

BMC Musculoskelet Disord

The fate of syndesmotic screws

Foot Ankle Int

Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures

J Bone Joint Surg Am

Operative treatment of acute syndesmotic injuries with screw fixation and without direct exposure or repair of the syndesmotic ligaments

Techn Foot Ankle Surg

Biomechanical effects of internal fixation of the distal tibiofibular syndesmotic joint: comparison of two fixation techniques

J Orthop Trauma

Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis

Foot Ankle Int

Dynamic fibular function: a new concept

Clin Orthop Relat Res

Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial

Foot Ankle Int

Ankle syndesmosis injuries treated with the TightRope suture-button kit

Techn Foot Ankle Surg

Comparison of different fixation methods of the suture-button implant for tibiofibular syndesmosis injuries

Am J Sports Med

Comparison of a novel FiberWire-button construct versus metallic screw fixation in a syndesmotic injury model

Foot Ankle Int

Outcomes of suture button repair of the distal tibiofibular syndesmosis

Foot Ankle Int

Suture-button syndesmosis fixation

Clin Orthop Relat Res

Suture-button versus screw fixation in a syndesmosis rupture model: a biomechanical comparison

Foot Ankle Int

Treatment of syndesmotic disruptions with the Arthrex TightRope: a report of 25 cases

Foot Ankle Int

Treatment of syndesmosis disruptions: a prospective, randomized study comparing conventional screw fixation vs TightRope® fiber wire fixation—medium term results

SA Ortho J

Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons

Am J Orthop

Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal

Foot Ankle Int

Original Research
Does the Arthrex TightRope^® Provide Maintenance of the Distal Tibiofibular Syndesmosis? A 2-year Follow-up of 64 TightRopes^® in 37 Patients

Treatment of syndesmosis disruptions: a prospective, randomized study comparing conventional screw fixation vs TightRope^® fiber wire fixation—medium term results