Flexible Fixation Devices for the Ankle Syndesmosis Michael J. - - PowerPoint PPT Presentation

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Flexible Fixation Devices for the Ankle Syndesmosis Michael J. - - PowerPoint PPT Presentation

Apr 03, 2023 375 likes •780 views

Flexible Fixation Devices for the Ankle Syndesmosis Michael J. Coughlin, M.D. Anatomy AITFL PITFL Interosseous ligament Anterior and posterior Stability Goal: restore ankle joint contact mechanics! Ramey and Hamilton(1976)

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SLIDE 1

Flexible Fixation Devices for the Ankle Syndesmosis

Michael J. Coughlin, M.D.

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SLIDE 2

Anatomy

  • AITFL
  • PITFL
  • Interosseous

ligament

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SLIDE 3

Anterior and posterior

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Stability

  • Goal: restore ankle joint

contact mechanics!

– Ramey and Hamilton(1976)

  • 42% reduction tibio-talar contact pressure with
  • ne millimeter of lateral talar displacement

– Yablon(1977)

  • Residual lateral mal displacement results in poor
  • utcomes
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SLIDE 5

Type C

  • Successful fixation requires

restoring length and rotation to the fibula.

  • Exact reduction of the fibula into the

fibular notch (incisura fibularis) guarantees a normal ankle mortise. Even small degrees of mal-reduction may lead to DJD

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SLIDE 6

Other times….

  • Stable syndesmotic injury

without diastasis generally does well nonoperatively

– Nussbaum AJSM 2001

  • If unsure, stress examination

– Standing external rotation stress – Manual stress – Gravity stress

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SLIDE 7

Diagnosis: Gravity versus Manual stress exam

  • Both effective
  • Gravity requires tech education
  • Manual requires physician time and

radiation

  • Medial swelling, echymosis,

Tenderness, all unreliable

Michelson et al. CORR 387: 178-82, 2001.

(Schock 2007)

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SLIDE 8

Defining syndesmosis reduction

  • High anatomic variability
  • Traditional radiographs

difficult

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Cotton test

  • Once the fibula is

fixed, intraoperative stress of the fibula can help determine if the syndesmosis is unstable

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Another key point- The posterior malleolus

  • Garner FAI 2006

– 70% of stability restored after posterior malleolus ORIF versus 40% with single syndesmotic screw

  • Miller 2010

– Post malleolus ORIF equal to syndesmotic ORIF

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SLIDE 11

Why syndesmosis screws suck

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Why syndesmosis screws suck

  • 1. Need to be removed

– “No surgeon ever looked good taking out hardware.” – Most normal people don’t like surgery

  • More surgical/anesthetic risks
  • Limited weightbearing
  • More postop visits
  • Higher cost to society
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Why syndesmosis screws suck

Screw

= $380 Drill: $80-$100 Screw: $50-$100 Sterilization for set: $180 Operating Room 30 min: $3,000* Sterile drapes, gloves, and fluoroscopy: $200 Sterilization for screw removal: $180 = $3,380

$3,760 Total

*Jo ur

nal o f Clinic al Ane sthe sia (2010), 22,233-236

2nd surgery for removal

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SLIDE 14

Why syndesmosis screws suck

  • 2. Screws break!

– Don’t forget the broken screw removal set – Leave the screws prominent – Surgeons really don’t look good digging out their broken hardware!

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SLIDE 15

Why syndesmosis screws suck

Diastasis Heterotopic

  • ssification

Loose screw Broken screw Painful broken screw

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SLIDE 16

Why syndesmosis screws suck

  • 3. How do you know your

syndesmosis is reduced???

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SLIDE 17

Why syndesmosis screws suck

  • 3. How do you know your syndesmosis

is reduced???

  • Gardner showed in FAI 2006 that 52%

(13/25) patients had malreduction of the syndesmosis on CT imaging after ORIF using screws.

  • Might as well flip a coin!
  • “Better to be lucky than good!”
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SLIDE 18

How can we do better?

  • Gardner (2006) 52% syndesmosis

mal-reduciton rate on CT

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SLIDE 19

Recent attention on perioperative CT

  • Sagi 2012

– 27/68 (39% malreduction) on post-op CT – At 2 year follow-up, those who were malreduced did worse

–Recommend bilateral post-op CT and open visualization!!!!

  • not at my hospital!!!
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SLIDE 20

Why flexible syndesmosis fixation rocks

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Why flexible syndesmosis fixation rocks

  • 1. The distal tib-fib

joint is a joint

– Flexible syndesmotic fixation allows for natural motion of the distal tibiofibular joint

  • Normal function requires

articular congruity

– All three are integrally related » Tibia-talus articulation » Fibula-talus articulation » Tibia-fibula articulation

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Location

  • 2.0 cm above joint line

McBryde FAI 1997 Less widening compared to 3.5cm

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Why flexible syndesmosis fixation rocks

  • 2. No reoperation

– Does not require hardware removal – Complications are low – Cottom FAS 2006 showed that in 8-10 months postop

  • Screws were removed in 68% of patients
  • No Tightrope devices were removed
  • Tightrope avoided late diastasis of the distal

tibiofibular joint where following screw removal diastasis occurred

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SLIDE 24

Why flexible syndesmosis fixation rocks

  • 3. More

forgiving distal syndesmosis reduction

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SLIDE 25

Why flexible syndesmosis fixation rocks

  • 4. More forgiving distal syndesmosis reduction
  • Naqvi in AJSM 2012 demonstrated a 22%

malreduction rate on CT imaging of syndesmosis injuries fixed with screws compared with 0% with Tightrope fixation – They also showed that late diastasis occurred with screw fixation and did not occur using Tightrope

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SLIDE 26
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SLIDE 27

PRE-DISSECTION- SCREW FIXATION-BUTTON FIXATION

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Why flexible syndesmosis fixation rocks

  • 5. Flexible syndesmotic

fixation is stronger

– 2012 Arthrex R&D

  • 4.5 mm stainless steel screw failed after 11844

cycles

  • Tightrope didn’t fail

–They gave up after 27000 cycles!

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  • Pt. #89-left
  • 18 yr old all-

state linebacker

  • High ankle

sprain on left as junior

  • No fibula

fracture

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  • Pt. #89
  • Broke

screws 4 months post

  • p
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Pt- #89 left

  • Hardware

removal and placement

  • f tightrope
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JS-right

  • Senior, second

game, high ankle sprain on right

  • No fibula

fracture

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Final follow-up

One year

Two extra surgeries (hardware removal x@, and redo- Cost $13,000)

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Why flexible syndesmosis fixation rocks

  • 2015: A Prospective Randomized

Multicentric Trial Comparing a Static Implant to a Dynamic Implant in the Surgical Treatment of Acute Ankle Syndesmosis Rupture

  • Mélissa Laflamme, MD1 ; Etienne L. Belzile, MD1 ; Luc

Bédard, MD1 ; Michel van den Bekerom, MD2 ; Mark Glazebrook, MD3 ; Stéphane Pelet, MD, PhD1 ; 1 CHU de

Québec, Quebec City, Quebec, Canada; 2 Spaarne Ziekenhuis - Locatie Hoofddorp, Hoofddorp, The Netherlands; 3 Dalhousie University, Halifax, Nova Scotia, Canada

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Why flexible syndesmosis fixation rocks

  • In Dr. Glazebrook’s prospective

randomized mulitcenter study:

– Higher Olerud-Molander score at 3, 6 and 12 months – Higher AOFAS scores at 3, 6, and 12 months – Greater plantarflexion at all time points with flexible fixation – Flexible fixation also:

  • Lower implant failure
  • Less reoperation (6% vs 33%)
  • No loss of reduction (0% vs 11%)
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Why flexible syndesmosis fixation rocks

  • The article concludes:

– “Dynamic fixation of acute ankle syndesmosis rupture with the TightRope gives better functional outcomes at short and intermediate terms. The implant offers adequate syndesmosis stabilization without breakage or loss of reduction and reoperation rate is significantly lower than with the conventional screw fixation.”

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Proximal fracture with inadequate

  • reduction. (see medial widening)

Final advice-

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ORIF prox. fracture, screw and/or tightrope

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Thank you!