Biomechanical Comparison of 3 Syndesmosis Repair Techniques With Suture Button Implants

Abstract

Background:Suture button fixation of syndesmotic injury is growing in popularity, as it has been shown to provide adequate stability in a more cost-effective manner than screw fixation while allowing more physiologic distal tibiofibular joint motion. However, the optimal repair technique and implant orientation have yet to be determined.Purpose/Hypothesis:The purpose of this study was to biomechanically compare 3 suture button construct configurations/orientations for syndesmosis fixation: single, parallel, and divergent. The authors hypothesized that all 3 methods would provide adequate stabilization but that the divergent technique would be the most stable.Study Design:Controlled laboratory study.Methods:The fixation strengths of 3 stabilization techniques with suture button devices were compared with 10 cadaveric legs each (N = 30). Ankle motion under cyclic loading was measured in multiple planes: first in the intact state, then following simulated syndesmosis injury, and then following fixation with 1 of 3 randomly assigned constructs—1 suture button, 2 suture buttons in parallel, and 2 divergent suture buttons. Finally, axial loading with external rotation was applied to failure.Results:All syndesmotic fixation methods provided stability to the torn state. There was no statistically significant difference among the 3 fixation techniques in biomechanical stability. Failure most commonly occurred through fibular fracture at supraphysiologic loads.Conclusion:Suture button implant fixation for syndesmotic injury appears to provide stability to the torn syndesmosis, and the configuration of the fixation does not appear to affect the strength or security of the stabilization.Clinical Relevance:This study provides further insight into the biomechanics and optimal configuration of suture button fixation of the torn syndesmosis. Based on these results, the addition of a second suture button may not significantly contribute to immediate postoperative stability.

Hybrid Fixation Restores Tibiofibular Kinematics for Early Weightbearing After Syndesmotic Injury

“…This study does not take into account the effect of cyclic loading, which may provide insight into the durability of the constructs, but previous biomechanical studies have shown that there may not be significant differences between fixation methods with increasing cyclic loading. 17 The findings from this study will serve as a foundation to support in vivo kinematic testing to further evaluate which fixation technique is best for early weightbearing after syndesmotic injury.…”

“…1,26 Suture button fixation has potential advantages over screw fixation, such as allowing for physiological tibiofibular motion while maintaining reduction, decreasing the need for implant removal, and allowing earlier rehabilitation. 17 Further, divergent suture button fixation has the theoretical advantage of controlling tibiofibular motion in 2 planes, especially in the sagittal plane, which has been an issue with single suture button constructs in some previous biomechanical studies. 2 Regardless of which fixation method is used, anatomic reduction of the syndesmosis is critical in order to achieve good functional outcomes after surgery.…”

Medicina basada en la evidencia. Conclusiones

“…Trabajos realizados en los últimos años que analizan los resultados de métodos de fijación dinámica frente a los tradicionales tornillos transindesmales reflejan leve superioridad con menor porcentaje de casos de mala reducción posquirúrgica. Asimismo, la tasa de reintervención y de pérdida de reducción es menor en el grupo de fijación dinámica, especialmente si el en grupo de pacientes sometidos a fijación con tornillo transindesmal se procede a la retirada sistemática del mismo (Tabla 2) (41)(42)(43)(44)(45)(46) .…”

“…En relación con la fijación dinámica, recientes estudios biomecánicos en cadáver que analizan diferentes opciones técnicas en cuanto al número y la disposición de los implantes no han evidenciado diferencias significativas, por lo que la colocación de un segundo dispositivo sería electiva y, aunque proporcionaría mayor seguridad en cuanto a la fiabilidad de la fijación ante la eventual pérdida de uno de ellos, podría obviarse en aquellos casos en los que las lesiones asociadas en peroné distal dificulten la colocación de un segundo implante (46) .…”

Sistemas de estabilización de la sindesmosis

“…Si bien los tornillos siempre demostraron ser superiores en estudios biomecánicos, ya contamos con diversos trabajos que han demostrado que el sistema TightRope® es comparable a un tornillo tricortical de 3,5 mm (7) . Respecto a la configuración, un reciente estudio en cadáver compara la fijación dinámica simple, la doble paralela y la doble divergente, sin encontrar que ninguna configuración sea superior a otra, aunque recomendando el uso de doble sistema salvo en fracturas conminutas de peroné (23) .…”