This document discusses syndesmosis injuries and various fixation methods. It summarizes several studies that have found complication rates of 22-26% with syndesmosis screw removal and addresses debates around malreduction, mid-diaphyseal fibular fractures, and fixation in patients with osteoporosis or diabetes. Alternative fixation methods like the TightRope suture-button device are presented as having benefits like lower removal rates, earlier weight bearing, and potential cost savings compared to traditional screw fixation.

1. SYNDESMOSIS INJURIES
Brian Thornes, MCh, FRCSI, MBA
Dublin, Ireland

3. PROBLEM: SYNDESMOSIS SCREWS

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)

28. THANK YOU
www.ankletightrope.com