Therapeutic Advances
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Apr 18, 2017; 8(4): 301-309
Published online Apr 18, 2017. doi: 10.5312/wjo.v8.i4.301
Syndesmotic InternalBraceTM for anatomic distal tibiofibular ligament augmentation
Markus Regauer, Gordon Mackay, Mirjam Lange, Christian Kammerlander, Wolfgang Böcker
Markus Regauer, SportOrtho Rosenheim, Praxis für Orthopädie und Unfallchirurgie, 83022 Rosenheim, Germany
Markus Regauer, Mirjam Lange, Christian Kammerlander, Wolfgang Böcker, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Ludwig-Maximilians-Universität München, 81377 Munich, Germany
Gordon Mackay, Faculty of Health Sciences and Sport, University of Stirling, FK9 4LA Stirling, Scotland
Author contributions: Regauer M had the idea of syndesmotic InternalBraceTM, was the treating physician and was responsible for writing the paper and design of illustrations and figures; Mackay G had invented the general InternalBraceTM technique and revised the article critically for important intellectual content and correct English language as a native speaker; Lange M was responsible for acquisition of data and helped to design the illustrations and figures; Kammerlander C and Böcker W revised the article critically for important intellectual content and were responsible for the final approval of the version to be published.
Conflict-of-interest statement: Markus Regauer and Gordon Mackay are paid consultants of Arthrex (Naples, Florida, United States).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Markus Regauer, MD, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, Klinikum der Ludwig-Maximilians-Universität München, Standort Großhadern, Marchioninistraße 15, 81377 Munich, Germany. markus.regauer@med.uni-muenchen.de
Telephone: +49-89-440072427 Fax: +49-89-440075424
Received: September 28, 2016
Peer-review started: October 1, 2016
First decision: November 10, 2016
Revised: December 22, 2016
Accepted: February 8, 2017
Article in press: February 13, 2017
Published online: April 18, 2017
Abstract

Reconstruction of unstable syndesmotic injuries is not trivial, and there is no generally accepted treatment guidelines. Thus, there still remain considerable controversies regarding diagnosis, classification and treatment of syndesmotic injuries. Syndesmotic malreduction is the most common indication for early re-operation after ankle fracture surgery, and widening of the ankle mortise by only 1 mm decreases the contact area of the tibiotalar joint by 42%. Outcome of ankle fractures with syndesmosis injury is worse than without, even after surgical syndesmotic stabilization. This may be due to a high incidence of syndesmotic malreduction revealed by increasing postoperative computed tomography controls. Therefore, even open visualization of the syndesmosis during the reduction maneuver has been recommended. Thus, the most important clinical predictor of outcome is consistently reported as accuracy of anatomic reduction of the injured syndesmosis. In this context the TightRope® system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula cannot be safely limited by use of 1 or even 2 TightRopes®. Therefore, we developed a new syndesmotic InternalBraceTM technique for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments. The InternalBraceTM technique was developed by Gordon Mackay from Scotland in 2012 using SwiveLocks® for knotless aperture fixation of a FiberTape® at the anatomic footprints of the augmented ligaments, and augmentation of the anterior talofibular ligament, the deltoid ligament, the spring ligament and the medial collateral ligaments of the knee have been published so far. According to the individual injury pattern, patients can either be treated by the new syndesmotic InternalBraceTM technique alone as a single anterior stabilization, or in combination with one posteriorly directed TightRope® as a double stabilization, or in combination with one TightRope® and a posterolateral malleolar screw fixation as a triple stabilization. Moreover, the syndesmotic InternalBraceTM technique is suitable for anatomic refixation of displaced bony avulsion fragments too small for screw fixation and for indirect reduction of small posterolateral tibial avulsion fragments by anatomic reduction of the anterior syndesmosis with an InternalBraceTM after osteosynthesis of the distal fibula. In this paper, comprehensively illustrated clinical examples show that anatomic reconstruction with rotational stabilization of the syndesmosis can be realized by use of our new syndesmotic InternalBraceTM technique. A clinical trial for evaluation of the functional outcomes has been started at our hospital.

Keywords: Syndesmosis injury, Rotational instability, Stabilization, Anatomic repair, InternalBraceTM, Surgical technique

Core tip: Reconstruction of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The TightRope® system is reported to have advantages compared to classical syndesmotic screws. However, rotational instability of the distal fibula is not safely eliminated by use of 1 or even 2 TightRopes®. Therefore, we developed a new syndesmotic InternalBraceTM technique using SwiveLocks® for knotless aperture fixation of a FiberTape® at the anatomic footprints of the injured ligaments for improved anatomic distal tibiofibular ligament augmentation to protect healing of the injured native ligaments.