Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature

Abstract

Syndesmotic rupture is present in 10 % of ankle fractures and must be recognized and treated to prevent late complications. The method of fixation is classically rigid fixation with one or two screws. Knowledge of the biomechanics of the syndesmosis has led to the development of new dynamic implants to restore physiologic motion during walking. One of these implants is the suture-button system. The purpose of this paper is to review the orthopaedic trauma literature, both biomechanical and clinical, to present the current state of knowledge on the suture-button fixation and to put emphasis on the advantages and disadvantages of this technique. Two investigators searched the databases of Pubmed/Medline, Cochrane Clinical Trial Register and Embase independently. The search interval was from January 1980 to March 2011. The search keys comprised terms to identify articles on biomechanical and clinical issues of flexible fixation of syndesmotic ruptures. Ninety-nine publications met the search criteria. After filtering using the exclusion criteria, 11 articles (five biomechanical and six clinical) were available for review. The biomechanical studies involved 90 cadaveric ankles. The suture-button demonstrated good resistance to axial and rotational loads (equivalent to screws) and resistance to failure. Physiologic motion of the syndesmosis was restored in all directions. The clinical studies (149 ankles) demonstrated good functional results using the AOFAS score, indicating faster rehabilitation with flexible fixation than with screws. There were few complications. Preliminary results from the current literature support the use of suture-button fixation for syndesmotic ruptures. This method seems secure and safe. As there is no strong evidence for its use, prospective randomized controlled trials to compare the suture-button to the screw fixation for ankle syndesmotic ruptures are required.

Biomechanical comparison of bionic, screw and Endobutton fixation in the treatment of tibiofibular syndesmosis injuries

“…The widely used screw fixation has been reported to have several drawbacks: the prolonged immobilization and related complications, late syndesmotic widening after screw removal, screw loosening, screw breakage, and the need for a second operation to remove the screw [21,22]. The more recent development is the Endobutton fixation and its use is rapidly increasing; potentially, this technique has the following advantages: allows physiologic micromotion at the syndesmosis and thus an earlier return to weightbearing was possible, lessens the risk of hardware pain and the implant removal will not be necessary, without the risk of screw breakage and subsequent recurrent syndesmotic diastasis [15,[23][24][25]. However, this method still has some defects such as the suture loop may relax under weightbearing conditions, local irritation, osteolysis of the bone and subsidence of the device into the bone (as was occasionally observed), and its relatively high cost and complexity [17,26].…”

“…The screw fixation is a simple method and provides rigidity of the distal tibiofibular syndesmosis, and it has been considered the standard management [10]; however, this rigid fixation method may be problematic in allowing physiologic motion of the syndesmosis and sometimes screw breakage may occur [11][12][13]. More recently, flexible fixation using the suture button device has been applied, which allows physiologic motion in the tibiofibular joint and, meanwhile, maintains the reduction of the ankle [14][15][16]. However, this method still has some drawbacks such as the suture between buttons can gradually relax under weightbearing conditions [17], and it has a relatively high cost and complexity.…”

Economic impact of syndesmosis hardware removal

“…Syndesmotic disruptions occur with 10% of ankle fractures [1]. Although there is disagreement over the optimal operative fixation construct for these types of injuries, there is an additional debate in regard to postoperative syndesmotic hardware removal.…”

Caso Clínico: Fractura de Tobillo Weber B, Tratamiento Quirúrgico con Doble Sistema Tightrope®

“…También hay menor necesidad de realizar una segunda cirugía para la extracción del implante, pronto retorno a la actividad física y alta satisfacción del paciente [16,19,20].…”