Tightrope fixation of ankle syndesmosis injuries: Clinical outcome, complications and technique modification
Introduction
Injuries to the distal tibiofibular syndesmosis are complex and remained controversial with regard to diagnosis and management. In UK, ankle fractures are the most common fractures amongst patients aged between 20 and 65 years with the annual incidence reported as 90,000,1 20% of ankle fractures requiring internal fixation2 or 10% of all ankle fractures being associated with syndesmosis disruption.3 Although accurate reduction and surgical stabilisation of syndesmosis is essential to prevent talar shift and later long-term complications,4 treatment of syndesmotic injuries is divisive. Traditionally, this has been achieved with screw fixation but controversy exists with regard to the size and number of screws, number of cortices engaged, level of screw placement above the tibial plafond, need for routine removal and the timing of the screw removal.5, 6 Problems associated with syndesmosis screw fixation include screw loosening, breakage, stiffness, prolonged period of protected weight bearing, need for second operation and the risk of late diastasis after early removal or breakage of the screw.7, 8, 9
Tightrope is a relatively new technique for syndesmosis fixation. It comprises of a non-absorbable FibreWire held tight between two cortical metal buttons. As the tightrope provides semirigid fixation of syndesmosis, it obviates the need for routine removal of the implant and allows early weight bearing. Few studies have reported on the clinical outcomes of Tightrope but most of them have small number of cases and short-term follow-up.10, 11 The largest case series, published so far, reported on 25 cases with a mean follow-up of 10.8 months.10 Although the short-term clinical reports are promising, there have been few cases of complications, requiring removal of the implant.12, 13 The major complication reported is soft-tissue irritation over the prominent lateral knot.
We present the largest series of ankle syndesmosis stabilisation with Arthrex Tightrope.™ This study was approved by the research ethics committee. The operative technique was slightly modified by the senior author to avoid the soft-tissue complications and the primary aim of this study is to assess the complications related to the tightrope technique and the effect of the author's modification in reducing the complications.
Section snippets
Materials and methods
We reviewed the data for all patients with ankle diastases treated with Arthrex Tightrope™ between January 2007 and December 2009 in our regional trauma unit. Those patients with open fracture, multiple trauma, neuropathic arthropathy and the associated pilon fracture were excluded. Fifty-four patients fulfilled the criteria for inclusion. Diagnosis of tibiofibular diastasis was based on careful clinical examination, consideration of the fracture pattern and radiographic parameters including
Results
This study included 49 patients with an average age of 37.7 ± 11.6 (range 18–69) years. Eighteen patients were operated with the standard technique whilst 31 with the modified technique. Patients’ demographics and the classification of fractures are presented in Table 1. Three out of 18 cases in the standard technique group required removal of implant whilst none of the modified technique group reported any complication to date (Fisher's exact test, p = 0.04). Overall, mean time to full weight
Discussion
Arthrex Tightrope is a relatively new surgical implant based on the suture endobutton design. It is a low profile system comprised of a No. 5 FiberWire® loop which, tensioned and secured between metallic buttons placed against the outer cortices of the tibia and fibula, provides physiologic stabilisation of the ankle mortise and obviates the need for a second procedure for removal; therefore late diastasis is unlikely.14 Biomechanical testing and clinical trials have shown equivalent strength
Conclusion
Arthrex Tightrope™ provides a valid option for the treatment of tibiofibular diastasis and obviates the need for a second surgery for routine hardware removal. The technique is simple and minimally invasive but surgeons must be aware of potential complications that may require removal of the implant. We recommend our modified technique to bury the knot sub-periostealy, to reduce and potentially eliminate soft-tissue irritation. Our results with this technique are satisfactory and further
Conflict of interest
None of the authors has received any funding from any commercial or non-commercial agency with regard to the preparation of this article.
References (19)
- et al.
Epidemiology of fractures in England and Wales
Bone
(2001) - et al.
An evaluation of the Weber classification of ankle fractures
Injury
(1998) - et al.
Syndesmotic screw fixation in Weber C ankle injuries—should the screw be removed before weight bearing?
Injury
(2006) - et al.
Outcome and complications of treatment of ankle diastasis with tightrope fixation
Injury
(2009) - et al.
Adult ankle fractures—an increasing problem?
Acta Orthop Scand
(1998) - et al.
Changes in tibiotalar area of contact caused by lateral talar shift
J Bone Joint Surg Am
(1976) - et al.
Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation
J Orthop Trauma
(2004) - et al.
Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws
Foot Ankle Int
(2000) - et al.
Malleolar fractures with ankle joint instability—experience with the positioning screw
Unfallchirurgie
(1993)