Presentation from EFAS meeting, Munich, December 2011

1. ANKLE SYNDESMOSIS TIGHTROPE
Brian Thornes, MCh, FRCSI, MBA
Dublin, Ireland

2. BROKEN SYNDESMOSIS SCREWS

3. LOSS OF SCREW FIXATION

4. COMPLICATIONS REMOVING 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

5. 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 DVT
N=1 occult broken screw
TOTAL: 26% complication rate

6. 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

7. SYNDESMOSIS SCREWS

8. SYNDESMOSIS SCREWS

9. 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

10. 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?

11. SYNDESMOSIS INJURIES
Better Questions:
1. What is the healing time for syndesmosis ligaments?

12. SYNDESMOSIS INJURIES
Better Questions:
1. What is the healing time for syndesmosis ligaments?
2. Is rigid fixation the correct environment to promote healing?

13. 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?

14. 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 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

15. ORIGINAL SUTURE-ENDOBUTTON

16. COMPARATIVE CT SCAN

17. TIGHTROPE

18. TIGHTROPE

19. 18YR OLD, 120KG WEIGHT...?NWB

20. CLINICAL SERIES
2009: Cottom JM
Transosseous 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

21. CLINICAL SERIES
2009: Coetzee JC
Treatment 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

22. CLINICAL SERIES
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 button/suture knot...
elective removal without difficulty

23. CLINICAL SERIES
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.
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.”

24. CLINICAL SERIES
2012 (in press): Naqvi GA, Shafqat A, Awan N
Tightrope 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

25. CURRENT CONTOVERSIES
1. Mal-Reduction
2. Mid-diaphyseal Fibular Fractures
3. Osteoporotic bone

26. MAL-REDUCTION
25 screw patients
52% incongruity of fibula within
incisura on postop CT scan
2006: Gardner M, et al
Malareduction of the Tibiofibular Syndesmosis in Ankle Fractures

27. REDUCTION IN INCISURA

28. 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

29. OSTEOPOROTIC ANKLE #’S INCREASING

30. OSTEOPOROTIC ANKLE #’S INCREASING

31. OSTEOPOROTIC ANKLE #’S INCREASING

32. 81YR OLD, OSTEOPOROTIC LADY...?NWB

33. NEXT TIME...

34. THANK YOU
www.ankletightrope.com