Top

Knee Surgery, Sports Traumatology, Arthroscopy

Published in:

01-06-2017 | Ankle

Novel anatomical reconstruction of distal tibiofibular ligaments restores syndesmotic biomechanics

Authors: Jian Che, Chunbao Li, Zhipeng Gao, Wei Qi, Binping Ji, Yujie Liu, Ming Han Lincoln Liow

Published in: Knee Surgery, Sports Traumatology, Arthroscopy | Issue 6/2017

Abstract

Purpose

To date, there is a paucity of literature on syndesmotic reconstruction techniques that restore both anatomic stability and physiologic syndesmotic biomechanics. In this cadaveric study, (1) a novel syndesmotic reconstruction surgical technique using autogenous peroneus brevis tendon was described and (2) the biomechanical properties of the reconstruction was investigated.

Methods

Ten fresh-frozen lower extremities were used in this study. Reconstruction of the anterior and posterior, as well as the interosseous tibiofibular ligaments was performed with a halved peroneus brevis tendon. Biomechanics were assessed using foot external rotation torque and ankle dorsiflexion axial loading tests, which were performed in (a) intact, (b) cut, (c) anatomically reconstructed syndesmotic ligaments, and (d) 3.5 mm tricortical syndesmotic screw fixation. Medial–lateral and anterior–posterior displacements of the distal fibula were recorded during foot external rotation and fibular axial displacement was recorded during ankle axial loading.

Results

The fibula was displaced posteriorly and proximally with respect to the tibia in all specimens during external rotation and axial loading tests, respectively. Significant differences (p < 0.05) were found in distal fibular displacements between anatomically reconstructed ligaments and screw fixation. Tricortical syndesmotic screw fixation resulted in 59% of posterior fibular displacement when compared to intact ligaments. No significant differences (n.s.) in distal fibular displacement were demonstrated between intact ligaments and anatomically reconstructed ligaments.

Conclusion

Anatomical reconstruction of the distal tibiofibular ligaments with the peroneus brevis tendon provides stability and recreates the biomechanical properties of an intact syndesmosis. This new surgical technique may be a viable alternative for the treatment of syndesmotic injuries.

Level of evidence

Bava E, Charlton T, Thordarson D (2010) Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons. Am J Orthop 39(5):242–246PubMed

Bell DP, Wong MK (2006) Syndesmotic screw fixation in Weber C ankle injuries should the screw be removed before weight bearing? Injury 37:891–898CrossRefPubMed

Beumer A, Campo MM, Niesing R, Day J, Kleinrensink GJ, Swierstra BA (2005) Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury 36:60–64CrossRefPubMed

Beumer A, Heijboer RP, Fontijne WP, Swierstra BA (2000) Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand 71:519–521CrossRefPubMed

Degroot H, Al-Omari AA, El Ghazaly SA (2011) Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int 32:250–256CrossRefPubMed

den Daas A, van Zuuren WJ, Pelet S, van Noort A, van den Bekerom MP (2012) Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature. Strateg Trauma Limb Reconstr 7:123–129CrossRef

Ebraheim NA, Hossein E, Padanilam T (2003) Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orth Relat Res 409:260–267CrossRef

Egol KA, Pahk B, Walsh M (2010) Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma 24:7–11CrossRefPubMed

Forsythe K, Freedman KB, Stover MD, Patwardhan AG (2008) Comparison of a novel FiberWire-button construct versus metallic screw fixation in a syndesmotic injury model. Foot Ankle Int 29:49–54CrossRefPubMed

10.

Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27(10):788–792CrossRefPubMed

11.

Grass R, Rammelt S, Biewener A (2003) Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int 24:392–397CrossRefPubMed

12.

Hamid N, Loeffler BJ, Braddy W, Kellam JF, Cohen BE, Bosse MJ (2009) Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg Br 91(8):1069–1073CrossRefPubMed

13.

Hermans JJ, Beumer A, de Jong TA (2010) Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat 217:633–645CrossRefPubMedPubMedCentral

14.

Hsu YT, Wu CC, Lee WC (2011) Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function. Int Orthop 35:359–364CrossRefPubMed

15.

Huber T, Schmoelz W, Bölderl A (2012) Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: a cadaver study. Foot Ankle Surg 18(3):203–209CrossRefPubMed

16.

Jordan TH, Talarico RH, Schuberth JM (2011) The radiographic fate of the syndesmosis after trans-syndesmotic screw removal in displaced ankle fractures. J Foot Ankle Surg 50:407–412CrossRefPubMed

17.

Klitzman R, Zhao H, Zhang LQ, Strohmeyer G, Vora A (2010) Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis. Foot Ankle Int 31:69–75CrossRefPubMed

18.

Laflamme M, Belzile EL, Bedard L (2015) A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma 29:216–223CrossRefPubMed

19.

Lui TH (2010) Tri-ligamentous reconstruction of the distal tibiofibular syndesmosis: a minimally invasive approach. J Foot Ankle Surg 49:495–500CrossRefPubMed

20.

Manjoo A, Sanders DW, Tieszer C, MacLeod MD (2010) Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma 24:2–6CrossRefPubMed

21.

Markolf KL, Jackson S, Mcallister DR (2012) Force and displacement measurements of the distal fibula during simulated ankle loading tests for high ankle sprains. Foot Ankle Int 33:779–786CrossRefPubMed

22.

Michelson JD, Helgemo SL Jr (1995) Kinematics of the axially loaded ankle. Foot Ankle Int 16:577–582CrossRefPubMed

23.

Miller AN, Paul O, Boraiah S, Parker RJ, Helfet DL, Lorich DG (2010) Functional outcomes after syndesmotic screw fixation and removal. J Orthop Trauma 24:12–16CrossRefPubMed

24.

Moravek JE, Kadakia AR (2010) Surgical strategies: doubled allograft reconstruction for chronic syndesmotic injuries. Foot Ankle Int 31:834–844CrossRefPubMed

25.

Morris MW, Rice P, Schneider TE (2009) Distal tibiofibular syndesmosis reconstruction using a free hamstring autograft. Foot Ankle Int 30:506–511CrossRefPubMed

26.

Norkus SA, Floyd RT (2001) The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train 36:68–73PubMedPubMedCentral

27.

Ramsey PL, Hamilton W (1976) Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg 58-A:356–357CrossRef

28.

Schepers T (2012) Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop 36(6):1199–1206CrossRefPubMedPubMedCentral

29.

Schepers T, Van Lieshout EM, de Vries MR (2011) Complications of syndesmotic screw removal. Foot Ankle Int 32:1040–1044CrossRefPubMed

30.

Song DJ, Lanzi JT, Groth AT, Drake M, Orchowski JR, Shaha SH, Lindell KK (2014) The effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint: a prospective radiographic study. Foot Ankle Int 35(6):543–548CrossRefPubMed

31.

Storey P, Gadd RJ, Blundell C (2012) Complications of suture button ankle syndesmosis stabilization with modifications of surgical technique. Foot Ankle Int 33:717–721CrossRefPubMed

32.

van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, Denaro V (2016) Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc 24(4):1217–1227CrossRefPubMed

33.

Williams BT, Ahrberg AB, Goldsmith MT (2015) Ankle syndesmosis: a qualitative and quantitative anatomic analysis. Am J Sports Med 43:88–97CrossRefPubMed

34.

Williams BT, James EW, Jisa KA, Haytmanek CT, LaPrade RF, Clanton TO (2016) Radiographic identification of the primary structures of the ankle syndesmosis. Knee Surg Sports Traumatol Arthrosc 24(4):1187–1199CrossRefPubMed

Title: Novel anatomical reconstruction of distal tibiofibular ligaments restores syndesmotic biomechanics
Authors: Jian Che
Chunbao Li
Zhipeng Gao
Wei Qi
Binping Ji
Yujie Liu
Ming Han Lincoln Liow
Publication date: 01-06-2017
Publisher: Springer Berlin Heidelberg
Published in: Knee Surgery, Sports Traumatology, Arthroscopy / Issue 6/2017
Print ISSN: 0942-2056
Electronic ISSN: 1433-7347
DOI: https://doi.org/10.1007/s00167-017-4485-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Novel anatomical reconstruction of distal tibiofibular ligaments restores syndesmotic biomechanics

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Level of evidence

Please log in to get access to this content

Other articles of this Issue 6/2017

Proximal hamstring tendon avulsion surgery: evaluation of the Perth Hamstring Assessment Tool

Kinematics of a bicruciate-retaining total knee arthroplasty

No difference between cemented and cementless total knee arthroplasty in young patients: a review of the evidence

Anatomical variations of flexor hallucis longus tendon increase safety in hindfoot endoscopy

Proprioception after bicruciate-retaining total knee arthroplasty is comparable to unicompartmental knee arthroplasty

Statin-induced calcific Achilles tendinopathy in rats: comparison of biomechanical and histopathological effects of simvastatin, atorvastatin and rosuvastatin