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Improved Reduction of the Tibiofibular Syndesmosis With TightRope Compared With Screw Fixation

Results of a Randomized Controlled Study

Sanders, David MD, FRCSC*; Schneider, Prism MD, PhD, FRCSC; Taylor, Michel MD, MSc, FRCSC*; Tieszer, Christina MSc, CCRP*; Lawendy, Abdel-Rahman MD, PhD, FRCSC* Canadian Orthopaedic Trauma Society;

doi: 10.1097/BOT.0000000000001559
Original Article

Objective: To compare the rate of malreduction after high fibular fractures associated with syndesmosis injury treated with open reduction and internal fixation, with either 2 screws or 1 knotless TightRope device.

Design: Prospective randomized controlled multicenter trial.

Setting: Eleven academic and community hospitals including Level 1 and Level 2 trauma centers across Canada.

Patients/Participants: One hundred three patients with OTA/AO 44-C injuries with demonstrated radiographic syndesmosis diastasis or instability after malleolar bony fixation were followed for 12 months after treatment.

Methods: Open reduction of the syndesmosis was performed in all cases. Fixation was randomized to either TightRope (1 knotless TightRope, group T) or screw fixation (two 3.5-mm cortical positional screws placed across 3 cortices, group S). Surgical techniques and rehabilitation were standardized. All surgeons were trained or experienced in the use of the TightRope device. Follow-up was performed at 2 and 6 weeks, 3, 6, and 12 months.

Main Outcome Measure: Rate of malreduction based on bilateral ankle computed tomography scan results at 3 months after fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ-5D, the Olerud–Molander Ankle Score, the Foot and Ankle Disability Index, and the Work Productivity Activity Impairment Questionnaire. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only.

Results: Overall, the rate of malreduction using screw fixation was 39% compared with 15% using TightRope fixation (P = 0.028, χ2). Analysis of computed tomography results was performed using a 2-mm translation or 10-degree rotation threshold for malreduction and included fibular translation (anterior, posterior); syndesmosis distance (anterior, posterior, and mid); medial compression; and rotation (fibular and articular). Patients in group T had greater anterior translation (5.4 ± 1.8 mm) compared with the contralateral limb (4.3 ± 1.3 mm, P < 0.01) or group S (4.6 ± 1.5 mm, P = 0.05). Group T syndesmoses also had greater diastasis compared with control limb (4.1 ± 1.3 vs. 3.3 ± 1.4 mm, P < 0.01) and less fibular medialization compared with group S (1.04 ± 1.8 vs. 0.3 ± 1.8 mm, P = 0.05). Functional outcome measures demonstrated significant improvements over time, but no differences between fixation groups. Foot and Ankle Disability Index scores at each time interval were 44 ± 22 (T) versus 45 ± 24 (S) (6 weeks), 76 ± 14 versus 73 ± 17 (3 months), 89 ± 10 versus 86 ± 13 (6 months), and 93 ± 9 versus 90 ± 14 (12 months) (all P > 0.2). The reoperation rate was higher in the screw group compared with TightRope (30% vs. 4%, P = 0.02) with the difference driven by the rate of implant removal.

Conclusions: Based on our results, the TightRope device seems to compare favorably with two, 3.5-mm, 3-cortex screw fixation for syndesmosis injuries.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

*Department of Orthopedic Surgery, London Health Sciences Centre, Victoria Hospital, London, ON Canada; and

Department of Orthopedic Surgery, Foothills Medical Centre, Calgary, AB, Canada.

Reprints: David Sanders, MD, FRCSC, Orthopedic Surgery, Western University, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Room E1-326, London, ON N6A 4G5, Canada (e-mail:

Orthopaedic Trauma Association Directed Topic Research Grant: “Prospective Randomized Controlled Trial To Investigate Treatment Of Ankle Syndesmotic Injuries,” Funded by Arthrex Inc.

The authors report no conflict of interest.

This study was presented in part at the Annual Meeting of the Orthopaedic Trauma Association, October, 2017, Vancouver, BC, Canada, and the American Orthopaedic Foot & Ankle Society Annual Meeting, July, 2018, Boston, MA.

Collaborators of the Canadian Orthopaedic Trauma Society are listed in Appendix 1.

Accepted May 22, 2019

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