Dynamic Syndesmotic Stabilisation and Reinforcement of the Antero-Inferior Tibiofibular Ligament with Internal Brace: Early Results and Clinical Outcome

CATEGORY: Ankle; Arthroscopy; Sports; Trauma INTRODUCTION/PURPOSE: Syndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of dynamic suture buttons compared to screw fixation. Higher rates of malreduction have been reported with screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program. METHODS: Retrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. In all cases arthroscopic assessment confirmed the instability intraoperatively and anatomic reduction with an AO clamp was achieved under direct vision. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardized postoperative rehabilitation protocol was established. Patients were asked to immediately weight bear in a CAM boot for 6 weeks, commence sagittal Range of Motion (ROM) at 2 weeks, cycling at 4 weeks. At 6 weeks patients continued with full ROM and strengthening, running and cutting at 8 weeks and return to sports at 10 weeks. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively and outcome of acute and chronic injuries were compared. RESULTS: The average follow-up was 13 months. The total FAAM score for ADL was 95+-4.9% (range, 83 - 100%) and for sport activities 87+-13.6% (range, 50 - 100%). The rating of mean postoperative function for ADL was 94+-5.5% (range, 80 - 100%) and 90+-13% (range, 35 - 100%) for sportv. The difference between acute and chronic injuries was statistically higher (p<0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p=0.9296 and p=0.1615, respectively). Twenty-seven patients (90%) rated their overall current level of function as normal or nearly normal. CONCLUSION: This technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport as early as 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries. Long term follow up will address long term outcomes, requirement for removal of devices and how well the Internal brace is tolerated.