Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction.

BACKGROUND: Ankle syndesmotic injuries are complex and require anatomic reduction and fixation to restore the normal biomechanics of the ankle joint and prevent long-term complications. PURPOSE: The aim of this study is to compare the accuracy and maintenance of syndesmotic reduction using TightRope versus syndesmotic screw fixation. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This cohort study included consecutive patients treated for ankle syndesmotic diastases between July 2007 and June 2009. Single slice axial computed tomography (CT) scans of both the ankles together were performed at the level of syndesmosis, 1 cm above the tibial plafond. A greater than 2-mm widening of syndesmosis compared with the untreated contralateral ankle was considered significant malreduction. Clinical outcomes were measured using the American Orthopaedics Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores. RESULTS: Forty-six of 55 eligible patients participated in the study; 23 patients were in the TightRope group and 23 in the syndesmotic screw group. The average age was 42 years in the TightRope and 40 years in the syndesmotic screw group, and the mean follow-up time was 2.5 years (range, 1.5-3.5 years). The average width of normal syndesmosis was 4.03 ± 0.89 mm. In the TightRope group, the mean width of syndesmosis was 4.37 mm (SD, ±1.12 mm) (P = .30, t test) compared with 5.16 mm (SD, ±1.92 mm) in the syndesmotic screw group (P = .01, t test). Five of 23 ankles (21.7%) in the syndesmotic screw group had syndesmotic malreduction, whereas none of the TightRope group showed malreduction on CT scans (P = .04, Fisher exact test). Average time to full weightbearing was 8 weeks in the TightRope group and 9.1 weeks in the syndesmotic screw group. There was no significant difference between the TightRope and syndesmotic screw groups in mean postoperative AOFAS score (89.56 and 86.52, respectively) or FADI score (82.42 and 81.22, respectively). Regression analysis confirmed malreduction of syndesmosis as the only independent variable that affected the clinical outcome (regression coefficient, -12.39; t = -2.43; P = .02). CONCLUSION: The results of this study indicate that fixation with TightRope provides a more accurate method of syndesmotic stabilization compared with screw fixation. Syndesmotic malreduction is the most important independent predictor of clinical outcomes; therefore, care should be taken to reduce the syndesmosis accurately.

Interobserver and intraobserver reliability and validity of the Vancouver classification system of periprosthetic femoral fractures after hip arthroplasty.

The Vancouver classification system of periprosthetic fractures has been revalidated in this study, using the radiographs of 45 patients. Three consultants and 3 trainees reviewed the radiographs independently, on 2 separate occasions, at least 2 weeks apart. Interobserver and intraobserver agreement and validity were analyzed, using weighted κ statistics. The mean κ value for interobserver agreement was found to be 0.69 (0.63-0.72) for consultants and 0.61 (0.56-0.65) for the trainees, both representing substantial agreement. Intraobserver κ values ranged from 0.74 to 0.90, showing substantial agreement. Validity analysis of 37 type B cases revealed 81% agreement within B1, B2, and B3 subgroups with a κ value of 0.68 (substantial agreement). This study has reconfirmed the reliability and validity of the Vancouver classification while it also emphasizes the intraoperative assessment of implant stability.

Tightrope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification.

BACKGROUND: Ankle syndesmotic injuries are complex and require anatomic reduction and fixation. Tightrope fixation is a relatively new technique and we present the largest series of syndesmosis fixation using Arthrex Tightrope™ (Naples, FL, USA). MATERIALS AND METHODS: Forty-nine patients with ankle diastasis, treated with Arthrex tightrope™, were reviewed retrospectively, using American Orthopaedic Foot and Ankle Society (AOFAS) and Foot and Ankle Disability Index (FADI) scores and radiographic parameters for syndesmosis integrity. The operative technique was slightly modified by the senior author in 31 cases to avoid soft-tissue complications requiring removal of the implant. The aim of this study was to assess the rate of hardware removal after tightrope fixation and the effect of the author's modification to avoid soft-tissue complications. RESULTS: The mean age of patients was 37.7 years. Eighteen were performed with standard technique whilst 31 with the modified technique. The mean radiological follow-up was 6 months. Final data were collected using a confidential questionnaire and FADI score at an average of 24 (12-38) months postoperatively. The average time to full weight bearing was 7.7 weeks and to return to normal activities was 11.2 weeks. Postoperative radiographic measurements demonstrated satisfactory reduction of syndesmosis. The Mean AOFAS score was 85.57 (95% confidence interval (CI) 77.96-93.18) and the mean FADI score was 81.20 (95% CI 73.86-88.53). There were three cases of hardware removal in the standard technique group as compared to none in the group with the modified technique. CONCLUSION: Arthrex Tightrope™ provides an effective method of syndesmosis stabilisation, which obviates the need for routine removal of implant and facilitates dynamic stabilisation. The results of this study are satisfactory and comparable to previously reported studies. We emphasise that surgeons must be aware of the potential risk of soft-tissue complications and recommend our modified technique. Further long-term prospective studies should be carried out to resolve this issue.