Suture Anchor Augmentation for Acute Unstable Isolated Ankle Syndesmosis Disruption in Athletes

High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment?

Probably one of the most controversial subjects in the orthopedic field is the distal tibiofibular articulation. Even though its most primary knowledge can be a matter of enormous debate, it is in the diagnosis and treatment most of the disagreements reign. Distinguishing between injury and instability remains challenging as well as an optimal clinical decision regarding surgical intervention. The last years presented technology and that was able to bring body to an already well-developed scientifical rationale. In this review article, we aim to demonstrate the current data behind syndesmotic instability in the ligament scenario, whereas using few fracture concepts.

Anatomical Augmentation Using Suture Tape for Acute Syndesmotic Injury in Maisonneuve Fracture: A Case Report

Ankle syndesmosis is crucial to the integrity of the ankle joint and weight-bearing; an injury to this structure can lead to significant disability. The treatment methods for distal syndesmosis injuries are controversial. The representative treatment methods include transsyndesmotic screw fixation and suture-button fixation, and good results with suture tape augmentation have recently been reported. However, an augmentation using suture tape is only possible when the posterior inferior tibiofibular ligament (PITFL) is intact. This study describes the case of an unstable syndesmosis injury, accompanied by anterior inferior tibiofibular ligament (AITFL) and PITFL injuries, which were treated successfully using suture tape. A 39-year-old male patient sustained right ankle damage while skateboarding. His leg and ankle radiographs revealed a widening of the medial clear space, a posterior malleolus fracture, a reduced “syndesmosis overlap” compared with the contralateral side, and a proximal fibula fracture. The magnetic resonance imaging revealed ruptured deltoid ligaments, accompanied by AITFL, PITFL, and interosseous ligament injuries. A diagnosis of a Maisonneuve fracture with an unstable syndesmotic injury was made. The patient underwent an open syndesmotic joint reduction, along with an AITFL and PITFL augmentation. This anatomical reduction was confirmed using intraoperative arthroscopy and postoperative computed tomography (CT). An axial CT that was performed at the 6-month follow-up exam revealed a similar alignment of the syndesmosis between the injured and uninjured sides. There were no surgical complications and the patient did not complain of discomfort in his daily life. At the 12-month follow-up exam, a good clinical outcome was confirmed. As a treatment for unstable syndesmosis injury, ligament augmentation using suture tape shows satisfactory clinical outcomes and can be considered as a useful and reliable method for anatomical restoration and rapid rehabilitation.

Acute Syndesmosis Injuries

Ankle syndesmosis injuries include isolated ligamentous rupture, as well as fractures with ligamentous injury. These injuries can significantly affect athletes in all sports, and lead to prolonged recovery and return to sport. Adequate evaluation and diagnosis of these injuries are imperative for treatment and return to play. Many can be treated nonoperatively, but operative treatment is indicated in fractures with syndesmosis disruption and ligamentous injuries with instability. Anatomic reduction and fixation of these injuries will allow functional rehab and return to sport.

Comparison of Treatment Methods for Syndesmotic Injuries With Posterior Tibiofibular Ligament Ruptures: A Cadaveric Biomechanical Study

Background:

Studies on ankle syndesmosis have focused on anterior inferior tibiofibular ligament (AITFL) and interosseous membrane injuries; however, the characteristics of posterior inferior tibiofibular ligament (PITFL) ruptures remain unclear.

Purpose/Hypothesis:

This study evaluated the biomechanical characteristics of syndesmotic instability caused by PITFL injury and compared various treatment methods. We hypothesized that PITFL injury would lead to syndesmotic internal rotational instability and that the stability would be restored with suture tape (ST) PITFL augmentation.

Study Design:

Controlled laboratory study.

Methods:

Ten uninjured fresh-frozen cadaveric leg specimens were tested via forces applied to the external and internal rotation of the ankle joint. The fibular rotational angle (FRA) related to the tibia, anterior tibiofibular diastasis (aTFD), and posterior tibiofibular diastasis (pTFD) were measured using a magnetic tracking system. Six models were created: (1) intact, (2) AITFL injury; (3) AITFL + PITFL injury; (4) suture button (SB) fixation; (5) SB + anterior ST (aST) fixation; and (6) SB + aST + posterior ST fixation. The FRA, aTFD, and pTFD were statistically compared between the intact ankle and each injury or fixation model.

Results:

In the intact state, the changes in FRA and aTFD were 1.09° and 0.33 mm when external rotation force was applied and were 0.57° and 0.41 mm when internal rotation force was applied. In the AITFL injury model, the changes in FRA and aTFD were 2.38° and 1.51 mm when external rotation force was applied, which were significantly greater versus intact (P = .032 and .008, respectively). In the AITFL + PITFL injury model, the changes in FRA and pTFD were 2.12° and 1.02 mm when internal rotation force was applied, which were significantly greater versus intact (P = .007 and .003, respectively). In the SB fixation model, the change in FRA was 2.98° when external rotation force was applied, which was significantly higher compared with intact (P < .001). There were no significant differences between the SB + aST fixation model and the intact state on any measurement.

Conclusion:

PITFL injury significantly increased syndesmotic instability when internal rotation force was applied. SB + aST fixation was effective in restoring syndesmotic stability.

Clinical Relevance:

These results suggest that SB + aST fixation is sufficient for treating severe syndesmotic injury with PITFL rupture.

Anterior Inferior Tibiofibular Ligament Suture Tape Augmentation for Isolated Syndesmotic Injuries

BACKGROUND

The best operative construct and technique for treatment of isolated syndesmotic injuries is highly debated. The purpose of this study was to determine whether the addition of anterior inferior tibiofibular ligament (AITFL) suture repair or suture tape (ST) augmentation provides any biomechanical advantage to the operative repair of an isolated syndesmotic injury.

METHODS

Twelve lower leg specimens underwent biomechanical testing in 6 states: (1) intact, (2) AITFL suture repair, (3) AITFL suture repair + transsyndesmotic suture button (SB), (4) AITFL suture repair + ST augmentation + SB, (5) AITFL suture repair + ST augmentation, and (6) complete syndesmotic injury. The ankle joint was subjected to 6 cycles of 5 Nm internal and external rotation torque under a constant axial load. The spatial relationship between the tibia, fibula, and talus was continuously recorded with a 5-camera motion capture system.

RESULTS

AITFL suture repair and AITFL suture repair + ST augmentation showed no statistically significant change in fibula kinematics compared to the intact state. Compared to native, AITFL suture repair + SB showed increased fibular external rotation (+2.32 degrees, P < .001), and decreased tibiofibular gap (overtightening) (-0.72 mm, P = .007). AITFL suture repair + ST augmentation + SB also showed increased fibular external rotation (+1.46 degrees, P = .013). Sagittal plane motion of the fibula was not significantly different between any states. None of the repairs restored intact state talus rotation; however, the repairs that used ST augmentation reduced the talus external rotation laxity compared to the complete syndesmotic injury.

CONCLUSION

AITFL suture repair and AITFL ST augmentation best restored the rotational kinematics and stability of the fibula and ankle joint in an isolated syndesmotic injury model.

CLINICAL RELEVANCE

AITFL suture repair with or without ST augmentation may be a good operative addition or alternative to SB fixation for isolated syndesmotic disruptions.

Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis

Background:

Syndesmotic ankle sprains are common and challenging injuries for athletes. The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury. The present study seeks to review and report the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in the athletic population.

Methods:

PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcomes were the rate and time to return to play after syndesmotic ankle sprains for both surgical and nonsurgical treatment. Secondary outcomes included short-term complications and recurrence.

Results:

Eighteen articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85), whereas it was 39.33 days (95% CI 28.78, 49.88) for nonsurgically treated cases. A low incidence of recurrence and complications were reported.

Conclusion:

This article reports a high rate of RTP after syndesmotic sprains. Grade of injury and surgical vs conservative management can affect the time to RTP in high-level athletes.

Level of Evidence: Level IV, systematic review and meta-analysis.