Elsevier

Injury

Volume 52, Issue 10, October 2021, Pages 2813-2819
Injury

Biomechanical comparison of screw, tightrope and novel double endobutton in the treatment of tibiofibular syndesmotic injuries

https://doi.org/10.1016/j.injury.2021.06.011Get rights and content

Highlights

  • 1

    A new fixation device was developed for the fixation of the inferior tibiofibular syndesmosis injury.

  • 2

    The biomechanical comparison of three fixations for the treatment of tibiofibular syndesmosis injury was made for the first time.

  • 3

    The novel double Endobutton fixation demonstrate a better biomechanical outcome than other fixations.

  • 4

    The novel double Endobutton can maintain the distal tibiofibular syndesmosis joint micro motion and make up for the deficiency of other fixation devices in clinic. To provide a new method for the clinical treatment of tibiofibular syndesmosis injury.

Abstract

Background

Adequate reduction and stabilization of the syndesmosis are significant to prevent early degeneration of the ankle joint and get better clinical outcomes. However, the routine surgical methods have diffierent limitations. The purpose of this study was to develop a novel double Endobutton fixation to treat the distal tibiofibular syndesmotic injuries, and determine whether the novel double Endobutton fixation demonstrates a better biomechanical property compare with the intact syndesmosis, the screw fixation and the Tightrope fixation.

Methods

Twenty-four normal fresh-frozen ankle specimens with a mean age of 42 ± 8 (range, 28–62) years were randomly divided equally into four groups: (1) the intact group, (2) the screw group, (3) the Tightrope group, (4) the Endobutton group. 3D printer technology was used to establish the personalized distal tibiofibular syndesmotic navigation modules to determine the accurate bone tunnel. Axial loading was applied in five ankle positions: neutral position, dorsiflexion, plantar flexion, varus and valgus. Rotation torque was applied in two ankle rotation of the neutral position: internal and external.

Results

In most situations, the displacements of the intact group were larger than the screw group, the Tightrope group and the Endobutton group (P < .05), and the displacements of the screw group were smaller than other three groups (P < .05). The displacements of the double Endobutton group were slightly larger than the Tightrope group but no significant differences were found between these two groups except in the dorsiflexion position of axial loading experiments (P < .05). The novel double Endobutton fixation was steadier than intact syndesmosis and more micromotional than screw fixation.

Conclusion

Our study demonstrated that the novel double Endobutton can be considered as the better fixation in treatment of distal tibiofibular syndesmotic injuries.

Level of Evidence

Level III, retrospective comparative study

Introduction

The annual incidence of distal tibiofibular syndesmotic injuries is 15 per 100,000 people [5], and it is occurred between 1 and 18% of all ankle sprain [3, 6, 16]. The normal stability of the ankle joint is disrupted in distal tibiofibular syndesmotic injuries [7], which leads to changes in weight transmission between the tibia and fibula and posttraumatic arthritis [6, 8]. The timely diagnosis and proper treatment of these injuries are significant to prevent early degeneration of the ankle joint and get better clinical outcomes [13].

Anatomical restoration or operative fixation is usually used to reduce the instability and pain of syndesmosis [2, 23]. The operative fixations usually include syndesmotic screw, staples, hooks and transosseous sutures [22]. Screw fixation is a successful operative technique for chronic syndesmotic injuries with an 87.9% pooled rate of success [16], and has recommended as a standard treatment that provides the syndesmosis with rigidity [5, 21, 24]. But the problems of screw fixation include screw loosening, breakage, stiffness, the period of protected weightbearing is prolonged, the risk of late diastasis after early removal or breakage of the screw, and the second operation for routine device removal [5, 11, 12, 15, 19, 24].

Several recent studies assessed ankle Tightrope fixation is one of the suture-button fixations which provides semi-rigid fixation, allows early weightbearing, avoids conventional removal of the implant and allows start physical exercises earlier [3, 14]. However, during healing, there is the possibility of chronic discharging sinus due to a prominent lateral knot [9, 17] and failed fixation due to the knot slippage [10].

In a word, different limitations exit in these routine operative methods and no consensus about the best treatment in the syndesmosis injuries. Therefore, in this study, we had developed a novel double Endobutton which achieved the goal of providing the ankle with semi-rigid dynamic stabilization as a more physiologic type of fixation in treating the distal tibiofibular syndesmotic injuries. It was a closed-loop construct that avoided the knot slippage and the length of the loop could be flexibly adjusted by rotating the nut. Meanwhile, this study systematically compared the biomechanical characteristics of the novel double Endobutton fixation with the intact syndesmosis, the screw fixation and the Tightrope fixation by analyzing the relevant displacements of syndesmosis on axial loading experiments and rotation torque experiments. We hypothesized that the novel double Endobutton fixation demonstrate a better biomechanical outcome.

Section snippets

Specimen preparation

Twenty-four normal fresh-frozen ankle specimens (15 males, 9 females; 12 left and 12 right) were used and the mean age of healthy adults was 42 ± 8  (range, 28–62) years. Bone density had been determined by X-ray to be a normal specimen (OSTEOCORE-3, Golden, China).

Twenty four specimens were randomly divided into four groups: (1) the intact group; (2) the screw group; (3) the Tightrope group; (4) the Endobutton group. The skin and muscle of specimens were removed and the distal tibiofibular

Displacement in different ankle position

As shown in Table 1, in the neutral position, the displacements of the intact group, the Tightrope group and the Endobutton group were larger than the screw group at all of the seven recording points (100–700 N) (P < .05), and the significant differences were found when the screw group was compared with the intact groups at any of these recording points. There was no significant difference in the displacements among the intact, Tightrope and Endobutton groups at any of these recording points.

Discussion

The result of this study showed whether receiving axial loading or rotation torque, in most situations (Neutral position of screw fixation. All dorsiflexion. Plantar flexion of screw and Endobutton fixation. All varus. Valgus of screw fixation. All internal rotation. External rotation of screw fixation), the displacements of the intact group were larger than the screw group, Tightrope group and Endobutton group (P < .05). Thus, these three operative methods can provide the syndesmosis with more

Conclusion

The biomechanical characteristics of the novel double Endobutton fixation were better than the intact syndesmosis and the screw fixation, and similar to the Tightrope fixation. Considering the potential advantages, the novel double Endobutton fixation may be a better choice in treatment of distal tibiofibular syndesmotic injuries.

Declaration of Competing Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Author contributions statement

Lei Zhang contributed to conception and design. Jixiang Xiong contributed to edit and process articles. Xin Zhou contributed to data collection and picture data processing. Lu-jing Xiong contributed to statistical analysis and picture data processing. Lin Yu contributed to revise the manuscript. All authors read and approved the final manuscript.

Funding

This work was supported by the Health Commission of Sichuan Province Science and Research Project (Popularization and Application Project) (Grant No. 20PJ143), the Luzhou People's Government-Southwest Medical University Shi-zhen Zhong Academician Talent Team Sub-project (Grant No. 2018zszysrctdxm), the Southwest Medical University-Traditional Chinese Medicine Hospital of Luzhou Base Project (Grant No. 2018-LH003), the Luzhou People's Government-Southwest Medical University Science and

Ethics approval and consent to participate

All procedures were approved by the Ethical Committee of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University (No. KY2018043). All patient signed a General Consent of the Ethical Committee of Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University for using and publishing their data for scientific use.

Acknowledgments

The authors extend their appreciation to the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University.

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  • Cited by (0)

    Disclosure: Lei Zhang, Jixiang Xiong, Xin Zhou are the co-first authors.

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