SLR - July 2022 - Jeffrey Tucci, DPM
Reference: Harris NJ, Nicholson G, Pountos I. Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape. Bone Joint J. 2022 Jan;104-B(1):68-75.Level of Evidence: Level II
Reviewed By: Jeffrey Tucci, DPM
Residency Program: Hennepin Health Care, Minneapolis, MN
Podiatric Relevance:
This study aims to support the idea that direct reduction and stabilization of the anterior inferior tibiofibular ligament using suture tape and interference screws can achieve dynamic stability similar to that of the intact syndesmosis in elite athletes.
Methods:
Prospective study following a group of elite athletes with unstable syndesmotic injuries who had surgery using the InternalBrace. Any patient with widening of the syndesmosis of more than 2 millimeters on weightbearing radiograph, MRI, or CT was defined as having a syndesmotic injury. Nineteen (19) of 20 patients had surgery within two weeks of the index injury, one at 12 weeks following failure of conservative treatment. Concomitant injuries were also addressed during surgery. Post-operative course included plaster cast for 10 days, and then full weightbearing day 11 until week 4 in a below-knee-walker-boot. Statistical analysis data collected post operatively included demographic data, type of injury, and radiological findings. Follow up at two, six, and twelve weeks, with a remote follow up at an average of 27 months post-surgery. Time to return to play was recorded. AOFAS scores at discharge, range of motion (knee to wall distance), were recorded compared to the non-injured side. Authors report no conflict of interest.
Results:
Nineteen (19) male professional sports players with a mean age of 24.5 years were included. A total of 12 patients had isolated unstable syndesmotic injuries, the remaining seven patients had other associated injuries including: fibular fracture, ATFL rupture, medial malleolus fracture, and posterior malleolus fracture. The mean return to play for isolated injuries was 62 days, for those with additional injuries it was 104 days. AOFAS score in all 19 patients returned to 100 post-operatively. Knee-to-wall testing versus the contralateral limb returned to normal in 18 of 19 patients, with one lacking 2 centimeters. One (1) of 19 patients developed a non-union of the medial malleolus, this patient took the longest to return to play and did not regain full dorsiflexion at his last follow up.
Conclusions:
The authors conclude that the described suture tape technique for anatomic reconstruction of the anterior ankle syndesmosis is supported by this study as a safe and efficacious way of returning elite athletes to sport with low complication rates. They argue that this treatment method avoids the need for later hardware removal, while also providing a stronger and more anatomic reduction than commonly used techniques. While the sample size of this study is small, the recruiting and analyzing of surgical data for elite athletes is a fairly unique process. However, the authors’ arguments could be strengthened with a larger sample size utilizing a multicenter approach. While no nerve injuries were reported in this study, I would be cautious with this technique and take added care to avoid the superficial peroneal nerve.