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SYNDESMOSIS INJURIES




Brian Thornes, MCh, FRCSI, MBA
        Dublin, Ireland
ArthroLondon TightRope
PROBLEM: SYNDESMOSIS SCREWS
2011: Schepers T, et al
              Complications of Syndesmosis Screw Removal




76 patients

N=7 (9%) wound infection
N=5 (7%) recurrent diastasis
N=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 DVT
N=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 E
Suture-Button Syndesmosis Fixation. Accelerated
Rehabilitation and Improved Outcomes




        2006: Thornes B, McCartan D
        Ankle Syndesmosis Injuries Treated with
        the TightRope Suture-Button Kit
ArthroLondon TightRope
ArthroLondon TightRope
ArthroLondon TightRope
ArthroLondon TightRope
2009: Cottom JM
                  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
2009: Coetzee JC
                  Syndesmoses 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 al
                     Outcomes 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
2011: DeGroot H, et al
                  Outcomes 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.

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.”
2012: Naqvi GA, Shafqat A, Awan N
              Tightrope 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
ArthroLondon TightRope
CURRENT DEBATE




1.   Mal-Reduction
2.   Mid-Diaphysis Fibula Fractures
3.   Osteoporosis & Diabetes
2006: Gardner M, et al
                 Malreduction of the Tibiofibular Syndesmosis in
                 Ankle Fractures




52% incongruity of fibula within
incisura on postop CT scan
ArthroLondon TightRope
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
ArthroLondon TightRope
ArthroLondon TightRope
ArthroLondon TightRope
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

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ArthroLondon TightRope

  • 1. SYNDESMOSIS INJURIES Brian Thornes, MCh, FRCSI, MBA Dublin, Ireland
  • 4. 2011: Schepers T, et al Complications of Syndesmosis Screw Removal 76 patients N=7 (9%) wound infection N=5 (7%) recurrent diastasis N=5 (7%) occult broken screw TOTAL: 22% complication rate
  • 5. 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 DVT N=1 occult broken screw TOTAL: 26% complication rate
  • 6. 2007: Wahlquist M. Late Diastasis following Syndesmotic Screw Removal 21 patients Average 2mm widening of tibio-fibular clear space 38% of patients symptomatic
  • 7. 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
  • 8. 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
  • 9. 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 E Suture-Button Syndesmosis Fixation. Accelerated Rehabilitation and Improved Outcomes 2006: Thornes B, McCartan D Ankle Syndesmosis Injuries Treated with the TightRope Suture-Button Kit
  • 14. 2009: Cottom JM 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
  • 15. 2009: Coetzee JC Syndesmoses 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
  • 16. 2011: DeGroot H, et al Outcomes 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
  • 17. 2011: DeGroot H, et al Outcomes 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. 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.”
  • 18. 2012: Naqvi GA, Shafqat A, Awan N Tightrope 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
  • 20. CURRENT DEBATE 1. Mal-Reduction 2. Mid-Diaphysis Fibula Fractures 3. Osteoporosis & Diabetes
  • 21. 2006: Gardner M, et al Malreduction of the Tibiofibular Syndesmosis in Ankle Fractures 52% incongruity of fibula within incisura on postop CT scan
  • 23. 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
  • 27. 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)