SyndesmoticInternalBrace^TMfor anatomic distal tibiofibular ligament augmentation

Abstract

Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the TightRope® system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 TightRopes®. Therefore, we developed a new syndesmotic InternalBraceTM technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The InternalBraceTM technique was developed by Gordon Mackay from Scotland in 2012 using SwiveLocks® for knotless aperture fixation of a FiberTape® at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern, patients can either be treated by the new syndesmotic InternalBraceTM technique alone as a single anterior stabilization, or in combination with one posteriorly directed TightRope® as a double stabilization, or in combination with one TightRope® and a posterolateral malleolar screw fixation as a triple stabilization. Moreover, the syndesmotic InternalBraceTM technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an InternalBraceTM after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic InternalBraceTM technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.

Biomechanical Comparison of Syndesmotic Repair Techniques During External Rotation Stress

“…Given that anatomic reduction of the distal tibiofibular syndesmosis is a key predictor of long-term ankle function, 23,25 the search for optimal treatment of an injured syndesmosis is ongoing. The concept of performing and augmenting repairs of specific syndesmotic ligaments has begun to receive increasing attention clinically 24,33 and in biomechanics research. 1,26 As reproduction of the native soft-tissue constraints represents the best option for reproducing original bony kinematics, this approach holds great potential for improving patient outcomes and reducing complications.…”

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability

“…Syndesmotic reduction with suture-tape augmentation of the AITFL has been described as both a standalone treatment option and as an adjunct to suture-button fixation, particularly for acute instability. 18,20,39,45 Although metal screw fixation has been the historical gold standard, recent studies have demonstrated that suture-button fixation results in either comparable or better outcomes with lower rates of syndesmotic malreduction. 7,15,17,27,41,56 However, no gold standard for the fixation of chronic syndesmotic injury presently exists, although several techniques have been described.…”

“…The use of the InternalBrace (Arthrex, Naples, FL) for ankle lateral ligament reconstruction has been well described in the literature. 1,5,[9][10][11][12]14,25,27,38,47,50,54 Use for syndesmotic injuries may provide similar benefits and was first discussed by Mackay et al 27 in 2015 followed by the first detailed description of its use by Regauer et al 39 in 2017. Nonabsorbable suture-tape (FiberTape, Arthrex, Naples, FL) for syndesmotic augmentation has certain theoretical advantages over tendon graft and has been increasing in popularity.…”

Sporcularda ayak bileği dış yan bağ yaralanmalarında güncel yaklaşımlar

“…Bunlardan birisi, Broström ameliyatının InternalBrace ® (Arthrex Inc., Naples, FL, USA) denilen biyokompozit iki vida arasında uygun şekilde gerilmiş kalınca bir fiber tape ip desteğinin tamiri desteklemek için kullanılmasıdır. [20][21][22][23][24] da negatif ön çekmece testi ve mükemmel stabilite bildirmişlerdir. [32] Ayak bileği artroskopisi ile ilgili olarak, artroskopik anatomi, bağ anatomisi ve güvenli alanlar ortaya kondukça, artroskopik kronik bağ tamirlerine de son yıllarda ilgi artmıştır.…”