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Presentation from EFAS meeting, Munich, December 2011
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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
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