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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 48-53

The use of suspensory fixation for ankle syndesmotic injuries: A modified technique

1 Department of Orthopedic Surgery, Al-Azhar University Hospitals, Cairo, Egypt
2 Department of Orthopedic and Traumatology, General Shobra Hospital, Cairo, Egypt

Date of Submission08-Mar-2020
Date of Decision20-Apr-2020
Date of Acceptance22-May-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Ahmed I Hammouda
Department of Orthopedic Surgery, Al-Azhar University Hospitals, Cairo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jllr.jllr_2_20

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Background: Ankle injuries are a common presentation to the orthopedic clinic and can be just isolated sprains or associated with ankle fractures; most of these involve distal tibiofibular syndesmotic disruptions. Bony or deltoid ligament injuries can critically destabilize the ankle and affect its function. Suspensory repair is a relatively new and accepted surgical treatment for acute ankle syndesmotic injuries. Objective: This study was conducted to evaluate the results of the use of suspensory fixation by modified TightRope (hand-made suture-button system) after acute ankle syndesmotic injury in adults. The American Orthopedic Foot and Ankle Society (AOFAS) score was used as a functional result in this study. Patients and Methods: This prospective study included 20 patients (mean age, 29.5 ± 9.7 years) with acute syndesmotic injuries treated with a suspensory fixation system between the period of January 2017 and December 2017, with a mean follow-up (FU) of 2 years. Variables recorded and analyzed were the age, sex, fracture type, mechanism of injury, associated injuries, FU, complications, and final outcomes. Results: As regarded twenty patients in this study, the median AOFAS score was 97 (range, 90–100). One patient needed implant removal as a result of persistent skin irritation. Conclusion: A modified technique of suture-button fixation is an alternative optimal treatment for acute syndesmotic injuries, resulting in stable functional ankles with less costs. Level IV: Level II.

Keywords: Ankle joint syndesmosis, modified technique, suture button, TightRope

How to cite this article:
Zayed FH, Hammouda AI, Yasseen IA, Abo Hashim MM. The use of suspensory fixation for ankle syndesmotic injuries: A modified technique. J Limb Lengthen Reconstr 2020;6:48-53

How to cite this URL:
Zayed FH, Hammouda AI, Yasseen IA, Abo Hashim MM. The use of suspensory fixation for ankle syndesmotic injuries: A modified technique. J Limb Lengthen Reconstr [serial online] 2020 [cited 2022 Jul 3];6:48-53. Available from: https://www.jlimblengthrecon.org/text.asp?2020/6/1/48/288565

  Introduction Top

Distal tibiofibular syndesmotic injury (DTFSI) is a common missed orthopedic injury that might present isolate (up to 10% of ankle sprains) or in association with bone injuries (23% of ankle fractures).[1],[2],[3] Surgical treatment of DTFSI includes reduction of the syndesmosis and fixation commonly using either lag screws or suspensory suture-button fixation device.[4]

Although syndesmotic screw fixation had been the gold standard in the treatment of DTFSI, it had been reported with various results with complications such as screw failure, patient incompliance, high revision rate, and subsequent loss of reduction following early screw removal.[5],[6],[7],[8] TightRope implant (TightRope® RT, Arthrex, USA) is a well-known system used to reconstruct and stabilize the ankle syndesmosis. It offers adjustable four-point knotless fixation that resists cyclic displacement.[9]

Potential advantages of using suture-button fixation over conventional screw fixation include the following: it is a simple procedure viable for both isolated DTFSI or associated with ankle fractures, significant reduction for the need of a second surgery for implant removal, flexibility of the device which allowed pulling the fibula into its location in the incisura of the tibia as the suture is tightened leading to improved anatomical reduction of the syndesmosis, and allowing some rotational, proximal-distal, and anterior-posterior motion of the fibula with respect to the tibia. All of these may lead to better patient satisfaction and comfort.[1],[10],[11],[12],[13],[14],[15],[16]

Original tight rope system is considered expensive in the low economic developing countries. The usage of such systems is considered welfare and not properly accepted as a modality of treatment for patients under cover of health insurance companies. This led us to create a new modified TightRope system “called hand-made suture-button system” using readily available and cheap material. This study was operated to evaluate the results of the use of this modified TightRope (hand-made suture-button system) after acute ankle syndesmotic injury in adults. We assume that this modification provides the same radiological and functional results as original TightRope, with less costs and easily available material.

  Patients and Methods Top

This prospective study was performed at the university hospital after taking all patients' consent and included adult patients with recent ankle syndesmotic injury treated with suspensory fixation by modified TightRope (hand-made suture-button system) [Figure 1] in the period from January 2017 to December 2017. Follow-up (FU) was continued for all patients till July 2019. One senior author performed the surgery for our entire cohort. However, a review of the patient files and assessment of the results had been interpreted by all authors.
Figure 1: The hand-made suture-button system: (a) The titanium button plate. (b) The complete system after assembly

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All patients with DTFSI with or without ankle (malleolus) fractures were included in the study. We excluded patients with associated pilon fracture, diabetes mellitus, neuropathic arthropathy, pathological fractures, chronic injuries, and patients with previous operative treatment at site of injury.

Preoperative management

Preoperative clinical and plain radiological assessment was performed for all patients. Preoperative clinical tests included single-leg hop test, squeeze test, dorsiflexion-external rotation stress test, and local syndesmosis ligament tenderness. However, these tests might be difficult to be performed for patients with fracture.[17] Plain radiological findings for ankle syndesmotic injury included measuring of medial clear space (MCS), tibiofibular clear space (TFCS), and tibiofibular overlap (TFO).[18] Computed tomography (CT) scan was not part of our protocol for diagnosis since we planned to establish syndesmotic injury based on preoperative tests confirmed by intraoperative re-evaluation using C-arm fluoroscopy. All patients received prophylactic thromboembolic and antibiotic medications according to hospital guidelines. Patients were operated as long as soft-tissue condition allowed.

  Modified Tightrope (Hand-Made Suture-Button System) Top

The system is composed of two 1-cm long identical four-holed titanium button plates (one serves as a medial button and the other serves as a lateral button; each is composed of two central and two peripheral holes with equivocal distance apart) and a single long nonabsorbable FiberWire suture size #5, looped twice through the central holes of the buttons. To manually prepare the system, the FiberWire suture end is passed through one of the central holes of both button plates and folded back to pass through the second central holes in the reversed direction. Then, the process is repeated again through the same holes to finally achieve four-stranded FiberWire suture extended and tensioned between both plates and against bone cortices. A long straight needle containing the pull-through suture is attached to the system through one of the peripheral holes of the medial button. This needle will be used to pass the whole system with the buttons through the tibiofibular tunnel [Video 1].

Surgical technique

While supinated position, a patient is draped and sterilized in the appropriate fashion. Associated fibula fracture, if present, is firstly reduced and fixed appropriately. Intraoperative evaluation included hook traction test that is performed and coronal displacement and opening of the syndesmosis that is checked by the C-arm to confirm syndesmosis injury. Placement of a syndesmotic fixation is at a distance of approximately 2 cm proximal to the ankle plafond and in a 25°–30° oblique direction (in the transverse plane) from posterolateral to anteromedial. A 4-mm drill bit is used to drill a hole across the four cortices of the tibia and fibula and should be centered in the fibula to avoid its fracture. Reduction of the syndesmosis should be held with a large fragment bone-holding clamp during drilling and until fixation. The long straight needle with the attached system is then advanced through the drilled bone tunnel from lateral to exit medially. The suture pulls the attached button longitudinally across the tunnel until it emerges medially, and pressure over the needle is released to flip the button and lay it flat adherent, without soft-tissue interposition, to the medial cortex to avoid later loosening of the construction and fixation. Keeping reduction maintained using a large fragment bone-holding clamp and while maintaining the foot plantigrade in neutral position, the two lateral ends of the FiberWire are tensioned and tightened on a lateral button plate. This maintains reduction of the syndesmosis by tightly compressing the medial and lateral buttons using the four-stranded wire system[19] [Figure 2].
Figure 2: Method of fixation: (a) Using reduction clamp applied over the skin to apply compression and reduction of the syndesmosis. (b) Before reduction; note the wide medial clear space. (c) After reduction. (d) The lateral incision with the wire emerging through it. (e) Proper placement of the wire and the buttons with the syndesmosis held reduced

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A postoperative regimen in the form of nonweight-bearing is recommended for the first 6 weeks to allow healing of the ankle syndesmotic ligaments and fractures, if present. Patients were advised for early ankle joint passive flexion and extension exercises. Weight-bearing is then slowly progressed as tolerated and as indicated by the fracture. Functional activities and sports participation can then be allowed when the patient demonstrates this ability. The expected time period to return to functional activities is approximately 12–14 weeks.

Outcomes measured were the FU period, preoperative and postoperative MCS, preoperative and postoperative TFCS, preoperative and postoperative TFO, postoperative American Orthopedic Foot and Ankle Society (AOFAS) score,[20] and complications occurred. All clinical and radiological data were examined by two senior authors.

Statistical analysis

Statistical analysis was performed using SPSS version 15 SPSS Inc., Chicago, Ill., USA. The data were organized and analyzed using descriptive statistics: mean, standard deviation, using maximal and minimal values for quantitative values, and using percentage for qualified values. P < 0.05 was considered statistically significant.

  Results Top

In this prospective study, twenty adult patients with recent ankle syndesmotic injury were treated with suspensory fixation by modified TightRope (hand-made suture-button system). The mean operative time for insertion of suture button was 10 min. The average age of all patients was 29.5 ± 9.7 (range, 18–48) years. Ten patients (50%) were males and ten (50%) were females. The left ankle was affected in 11 patients (55%), whereas the right ankle was affected in 9 patients (45%). Injury occurred due to twisting trauma in 50%, road traffic accident in 25%, and direct trauma to the ankle in 25% of the studied patients. Thirteen patients (65%) were associated with lateral malleolus fracture, two patients (10%) were associated with medial malleolus fracture, four patients (20%) were associated with bimalleolar fracture, and one patient (5%) was without ankle fracture. Seventeen patients (75%) were Class C, whereas three patients (25%) were Class B as regards Weber classification [Table 1].

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The mean FU period was 2.1 years (range, 1.7–2.5 years). The preoperative mean value for MCS was 11.8 ± 3.9 mm, TFCS was 9.2 ± 1.6 mm, and TFO was 2.2 ± 4.7 mm. While the FU mean MCS was 3.3 ± 0.4 mm, TFCS was 3.2 ± 0.4 mm, and TFO was measured as 11.9 ± 1.2 mm (all were statistically significant with P < 0.001). The mean AOFAS score was recorded at 3, 6, and 9 months postfixation and increased from 64.5 at 3 months to 97.0 ± 3.8 (range, 90–100) at 9 months [Table 2]. Only one patient required removal of the implant 5 months after fixation because of a prominent lateral knot that led to painful skin irritation. At the removal of the implant, the ankle remained stable on the radiographs.
Table 2: Clinical and radiological data of the patients presented as mean and standard deviation

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  Discussion Top

Despite the huge research conducted on syndesmotic injuries, still, DTFSI reduction and fixation is a point of debate. The pros and cons of different methods of fixation exist between authors; however, all agree that anatomic reduction is mandatory for the long-term ankle function.[21],[22] Suture-button fixation using a TightRope is a successful method for fixing DTFSI either alone or associated with ankle fractures. It had been developed as an alternative to avoid the complications of usual fixation using cortical screws.[10] The biomechanical property of the TightRope suture that it allows motion under tension while resists diastasis of the ankle syndesmotic joint, compared to the syndesmotic screw. The nonabsorbable suture material renders it an effective permanent stabilizing system with no need for a second surgery for removal.[23] The aim of the current study is to evaluate the results obtained with the use of suspensory fixation by modified TightRope (hand-made suture-button system) after acute ankle syndesmotic injury in adults. We believe that this modification is simple, reasonably inexpensive, and effective compared to the original TightRope suture.

Suture-button fixation showed similar AOFAS outcome scores, when compared to syndesmotic screw fixation, with a 2.2 times longer FU in the screw group.[11] Thornes et al. reported a significantly better AOFAS score, and patients returned to work earlier in the suture-button fixation group than in the screw group.[12] Degroot et al. reported a range from good to excellent clinical outcomes with a mean AOFAS score of 94.2 points after a mean FU of 20 months in 24 patients with posttraumatic DTFSI and concomitant ankle fractures and were treated with TightRope.[10] Slightly better results were observed in the current study after treating 20 patients with modified TightRope technique, with the mean AOFAS score being 97 points in 9-month FU period.

Different studies were conducted in trying to confirm the effectiveness of the suture-button fixation system in treating and maintaining DTFSI and reduction. Teramoto et al.,[24] in 2011, conducted their experimental study by examining different forces applied to normal fresh-frozen cadaver legs. They concluded the lack of multidirectional syndesmotic stability with suture-button technique. Furthermore, they evaluated single versus double suture-button fixation, and they observed very little additive strength with the second suture which was still significantly less than an intact syndesmosis. The limitation of their study was whether the rotational forces applied were similar to physiologic loads applied in the live patients or not.[12],[22] In contrast to these findings, Wang et al.,[25] Klitzman et al.,[26] and Soin et al.,[27] in their biomechanical studies, reported a good syndesmosis function with the suture-button fixation systems. Furthermore, Förschner et al.[19] reported great patient satisfaction and an early return to sports rate in their study of 19 patients with isolated DTFSI and underwent fixation using suture-button fixation by TightRope.

A very important point to be considered, especially in developing countries, is the cost of the device of fixation. Serious economic issues and limitations of resources are a great obstacle to widespread of the original TightRope systems. Health insurance companies and caretakers consider new technology, in spite of more effective, as an additional extra welfare rather than an essential introduction for patient satisfaction. Few articles in literature addressed the point of the cost-effectiveness of the suture-button system versus a traditional syndesmotic screw; they all showed different results dependent on the rate of elective syndesmotic screw removal.[28],[29],[30] Syndesmotic screws were more cost-effective when removal rates were <13.7%, compared to suture-button fixation.[29] The additional costs of a syndesmotic screw removed in day-care surgery in The Netherlands are around 700 Euro, which is approximately the cost of two TightRope systems.[3] Treatment should be simple, reasonably inexpensive, and effective as well. In our study, the material required for treatment is easily available in every trauma center. Our system cost is as follows: the average cost of the titanium button is 25 USD, and one FiberWire suture costs 30 USD, concluding the total average cost of 80 USD per one system. When compared to the cost of original TightRope system (average 350 USD), this means that one original system equals an average of four “hand-made suture-button systems.” In addition, studies showed that original suture-button systems are more cost-effective than traditional syndesmotic screws, provided that the elective screw removal exceeded 10%–17%, which is usually the case.[28],[29] Bearing this fact in mind, our hand-made suture-button systems are considered much cost-effective compared to both original TightRope and traditional screw fixation methods. This would be accepted financially to health-care systems and insurance companies. In our study, syndesmotic fixation by modified TightRope (hand-made suture-button system) has the same preliminary clinical and radiological advantages and effectiveness of the original TightRope system. Our clinical and radiological results support these findings as we present excellent patient satisfaction [Figure 3].
Figure 3: Case example: (a) preoperative anteroposterior and lateral X-rays of 19-year-old male patient show right lateral malleolus fracture with syndesmotic injury. (b) Postoperative anteroposterior view after fracture fixation with still wide syndesmosis. (c) Reduction clamp holding the syndesmosis reduced. (d) Wire and button fixation (the modified technique). (e and f) Range of Motion (ROM) (dorsiflexion and plantarflexion) at the 6th month

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This study has few limitations. A few number of the patients are one of these limitations, and we render this to the specific inclusion criteria. Lack of CT scan assessment could be another limitation. However, this was not our aim of the study which was clearly identifying clinical and simple X-ray assessment after using simple material as a modification of the relatively expensive original TightRope system. Furthermore, we diagnosed syndesmotic injury based on presurgical tests and X-rays, confirmed by intraoperative examination and C-arm imaging. Another limitation is the lack of biomechanical tests comparing our system to commercially available devices. This would be an area of interest where further studies can address. This study is a one-center experience which could be another limitation. However, we believe that every trauma surgeon used to use TightRope can simply reproduce our results with the modified system using end buttons and FiberWire suture.

  Conclusion Top

The results of this study indicate that modified TightRope fixation (hand-made suture-button system) is a valid option for syndesmotic injuries. Technique is simple, and material is available and cheap. It provides syndesmotic stabilization without eliminating normal tibiofibular motion with no need for a second operation for hardware removal. Our system resulted in an excellent AOFAS score suggesting high patient satisfaction and also led to objective clinical and radiographic maintenance of the ankle mortise.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Kim JH, Gwak HC, Lee CR, Choo HJ, Kim JG, Kim DY. A comparison of screw fixation and suture-button fixation in a syndesmosis injury in an ankle fracture. J Foot Ankle Surg 2016;55:985-90.  Back to cited text no. 2
Schepers T. Acute distal tibiofibular syndesmosis injury: A systematic review of suture-button versus syndesmotic screw repair. Int Orthop 2012;36:1199-206.  Back to cited text no. 3
Zhang P, Liang Y, He J, Fang Y, Chen P, Wang J. A systematic review of suture-button versus syndesmotic screw in the treatment of distal tibiofibular syndesmosis injury. BMC Musculoskelet Disord 2017;18:286.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]

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