How to cite this article: Elsayed Shaheen. What is the Effective Technique for Syndesmotic Stabilization Tight Rope or Screw?. Ortho & Rheum Open
Access J 2018; 13(3): 555862. DOI: 10.19080/OROAJ.2018.13.555862.
Background: Complex syndesmotic ankle injuries (SAI) require restoration of normal biomechanics aiming to minimize expected complications.
Aim: The purpose of this study was to compare tightrope (Arthrex) technique in syndesmotic injury versus 3.5 mm tricortical trans-syndesmotic screw in terms of accuracy and syndesmosis reduction.
Methods: prospective clinical for twenty-two patients presented by SAI randomly allocated into two groups. Group A was fixed using tightrope technique, while group B fixed using 3.5 mm trans-syndesmotic cortical screw. All patients underwent clinical examination, radiological investigations, functional evaluation using American Orthopedic Foot and Ankle Society (AOFAS); preoperative, 6th, 12th and 17th months as follow up. SPSS was used for statistical analysis.
Results: The mean participants’ age was (39.4±3.7) years and mean follow up was (15.7±3.4) months. The study showed that AOFAS scores were better in Tightrope group (P value < 0.018); with faster weight bearing (4.9 weeks), which required 6 weeks in tricortical trans-syndesmotic screw group. Along follow up period, tightrope group was shown higher range of motion (ROM) than group B (P value < 0.042). Moreover, tightrope group not required secondary implant removal. Conclusion: Tightrope technique provides alternate safe, efficient SAI fixation and advantageous early weight bearing, plus long-term stability that radiologically confirmed as well shown higher AOFAS scores.
SAI may occur in 10 up to 15% in patients presented with ankle fractures commonly associated with pronated, external rotated ankle injuries,  or Weber C fractures, and around 20% of ankle fractures require surgical stabilization . Most misdiagnosed SAI complicated by chronic ankle pain, rapid degeneration, functional disabilities, instability and latent diastasis [3,4]. Evidence gap still prove a specific and standard care for SAI; fixation technique, screws size and numbers of cortices and weight bearing progression. On the other hand, drawbacks of SAI fixation presented some complications including limited ankle mobility, delayed weight bearing, risk of screw breakage and necessity of its removal [5,6], which may complicate by wound infection, screw breakage or syndesmotic diastasis .
Numerous studied confirmed that tightrope SAI fixation is a minimal invasive technique, which allows micro syndesmosis motion throughout reduction with least pain, and longer stability that permits early patients mobility, weight bearing and faster return to work. Furthermore, it was advised for osteoporosis (snowshoe, hold on cortical bone), while screw fixation may lead to cut out due to low screw breakage risk or need for its removal [8,9]. Otherwise, loose tightrope may lead to later
syndesmosis diastasis . Recently, tightrope technique was highly recommended for SAI, as well for isolated syndesmosis separations. The purpose of the current study was to compare tightrope procedure (Arthrex, Naples, FL, USA) versus 3.5 mm tricortical trans-syndesmotic screw in terms of accuracy and adequate syndesmosis reduction.
Twenty-two patients were management in this prospective study from February 2016 to July 2017. The eligible patients mean ages was (39.4±3.7), were included if have SAI that are sustained distal tibiofibular (tibiofibular clear space “TFCS” >6 mm on A/P or mortise radiographs or tibiofibular overlap “TFOL” <6 mm on A/P radiographs or <1mm on mortise radiographs, or medial clear space “MCS” >5mm on A/P radiographs) , syndesmotic diastasis with or without ankle fractures less than 4 weeks. Patients were excluded if they had polytrauma or open fracture, open growth plates, uncontrolled diabetes mellitus and neuropathic arthropathy.
Each patient had signed a written informed consent then all patients were randomized allocated into two groups. Every patient underwent complete clinical examination and preoperative, 6th,
12th and 17th months follow up specific radiological investigations;
functional evaluation using American Orthopedic Foot and Ankle
Society (AOFAS), total 100 points divided into nine items grouped
into three categories; (pain: 40 points, functional abilities: 50
points, alignment) .
Tightrope implant (Arthrex, Naples, FL, USA) consists of
two-button construct (titanium or stainless steel), and two No.5
braided fibre suturing wire, when tensioned provide ankle mortise
stability, where previous clinical trials reported its equivalent
strength that improve clinical outcomes .
Both tightrope and screw SAI fixation techniques were almost
similar procedures, where tightrope used one device, but may
augment by another one in highly unstable distal tibiofibular joint
or screw technique used one tricortical screw. Open reduction and
internal fixation of ankle fractures, almost syndesmotic diastasis
reduced spontaneously. While, remaining diastasis were reduced
primary by reduction clamp placed across ankle and compressed
SAI then reduction maintained by the tightrope or screw which
were inserted directly, through fibula or fibular plate`s hole, in
case of fibular fracture.
In tightrope fixation all fractures were stabilized prior to
tightrope insertion. Once a plate fixed to distal fibula, one or more
cortices screw holes (2-5 cm above tibial plat fond using 3.7 mm
drill bit) used for tightrope. A guide wire using cannulated drill
bite was recommended to confirm accurate drill positioning prior
by fluoroscopy, guided suturing along drill holes to intact medial
skin, where button seated direct on medial cortex that confirmed
by C-arm. Flipping was done by transmitting medial pressure
from the needle to fibre wire suture laterally then toggling the
two pairs, which ensured endobutton flat seating preventing
later losing. With reduction clamp in place, both ends of fibre
wire tensioned on lateral side providing compression on buttons
aiming to maintain syndesmosis reduction (Figure 1). In screw
fixation; with ankle in neutral position used a 3.5 mm cortise
screw was inserted into previously drilled 2.5 fibular hole 30°
from posterior to anterior up to lateral tibial cortex, just inferior
to inferior tibiofibular joint, parallel to tibial plafond (Figure 2).
Twenty-two patients with syndesmotic disruption were
management with tightrope or screw, the mean age was (39.4±3.7)
years. There were 17 patients sustained ankle fractures; 9 patients
presented Weber C fracture and 8 patients Weber B fracture, plus
5 patients have been diagnosed isolated syndesmosis diastasis
SD: Standard deviation; Lat M: Lateral Malleolus; Tri M: Trimalleolus; Bi M: Bimalleolus; Delt R: Deltoid Repair
*: (P-value≤0.05). **: (P-value≤0.01).
Per-Op: Pre-Operative; TWt-B: Time to Weight Bearing; AOFAS: American Orthopedic Foot and Ankle Society; NS: Non-significant
In tightrope group A, 6 patients presented by fracture
lateral malleolus associated with syndesmosis diastases were
spontaneously reduced post fracture fixation then tightrope
inserted through fibular plate hole. Other 2 patients presented
isolated syndesmosis disruption, and single tightrope was done.
One case presented with complete torn syndesmotic diastasis
with dislocation at distal tibiofibular joint so added another
tight rope to restore ankle stability and augmented by small
lateral plate without screws (Figure 3), two patients presented
trimalleolar fracture and underwent medial malleolar screws and
one tightrope done. Uneventful complications reported, unless
one case had lateral side superficial infection and another one had
a small stitch irritation on medial side (Table 2). There are two
cases had been evaluated at 6th and 12th months follow up period
but lost after that (Figure 4).
In screw group B, 3 patients presented isolated syndesmosis
diastases managed by one screw tricortical insertion. Another 4
patients underwent standard fibula plate plus syndesmosis screw
fixation. As well, 3 patients presented bimalleolar Potts fractures
and medial malleolar fixation plus tricortical syndesmosis screw
were done. Only one patient underwent deltoid repair (MCS >
5mm). Furthermore, complicated cases at follow up period were
reported as, one patient underwent a large fragment removal due
to prominent screw head, another one broken screw accidentally
discovered throughout routine implant removal and that patient
presented by intermittent lateral ankle pain (Table 2). Other
patient was presented with dehisned wound and superficial
infection after removed of screw.
The mean follow up average was (15.7±3.4) months, and
AOFAS were significantly higher in tightrope group versus screw
group (91:80; 93:83 and 94:86) by 6th, 12th and 17th months follow
up, respectively (P value < 0.018). Average time delayed nonweight
bearing 4.9 weeks (range .3.5-6W) versus 6Weeks (range4-
12W) in screw group (P value < 0.042), and routine screw removal
after 8-12 weeks (Table 2). Finally, the study results shown that
tightrope group had significantly better ROM (P value < 0.054)
than screw group (P value < 0.018), (Table 3).
Tightrope stabilization of a syndesmotic injury has been
shown as an alternative that has significant outcomes and is
more physiological than standard screw techniques . The
dynamic flexible fixation of tight rope permits micro-movement
of the distal tibiofibular joint, which provides better outcomes
in terms of mobility, accelerated ligament healing, earlier return
to full weight-bearing and returns of physical abilities, as well
unnecessary implant removal .
The present study has been shown that tightrope technique
provides long standing and accurate syndesmosis reduction,
better mobility, plus faster functional abilities, with significantly
higher in AOFAS scores, range of motion and full-time weight
bearing when compared the screw group along the latest follow
up period. Furthermore, the study reported minor complications
about (18%) one case skin irritation at medial ankle side, and
another case had superficial infection at lateral malleolus when
compared with screw technique about (27%), broken screw,
prominent head of screw and diastasis after removal of screw,
especially within second intervention, while routine implant
The present result coincide with, Thomes et al.  reported
that tightrope technique permitted earlier weight bearing, and
stated its safe, efficient and simple nature versus screw technique,
which required second removal surgery. In terms of functional
abilities, it was reported higher AOFAS in patients underwent
tightrope fixation than screw technique [17,18]. Plus, tightrope
fixation patients were permitted earlier weight bearing (4.1
weeks) with no need for further surgical interventions as reported
by Naqvi et al.  in advance no loading failure or residual
diastasis were reported even with accelerated full weight bearing
Cottom et al.  also reported that it was accelerated early
weight bearing in the tightrope group with no complication
such as implant failure or removal was noted. Degroot et al. 
demonstrated that shorter average time to full weight-bearing of
5.7 weeks using tightrope, with no complication of implant failure
or residual displacement at a follow-up of 2years. On the other
hand, in this study usage of second tight rope was occurring in
highly unstable distal tibiofibular joint with improper fixation
by single device. This agree with Naqvi et al.  usage of extra
tightrope implant to gain accurate syndesmosis reduction was
advised in 26% of population study and 75% as confirmed by
DeGroot et al.  to prevent later enlarged tibial hole or implant
subsidence or in case of oseolysis. This study was undertaken
routine removal of syndesmotic screws range from 8-12 Weeks,
however, did not occur routinely at tight rope group. Moreover,
Schepers et al.  recommended no significant differences when
elective screw removal or not, additionally routine screw removal
procedure as second intervention, commonly associated with
complication more than 20% with both recurrent diastases or wound infection risks , In contrary, tightrope implant removal
was not required, even in case that will be minor invasive with no
definite evidence reported, yet .
In same context with previous studies, screws placement
level determines the protection period prior allowing patient to
weight bearing that directly affects mobility in term of ROM .
Cottom et al.  demonstrated that tightrope technique has a
valid, safe and least cost with low irritation, infection risks. They
also recommended; performing of two suture buttons could also
be more useful for in Weber C or comminuted fibular fractures.
Furthermore, Klitzman et al.  confirmed tightrope permits
more flexibility than screw technique through using suture
button fixation, which was accelerated the physiological healing
of syndesmosis. Moreover, Rigby and Cottom ensured that less
invasive nature of tightrope technique provides advantageous
ankle stability for rediastasis  than screw fixation, where the
later had routine second intervention for implant removal by 8-12
Storey et al.  determined potential the disadvantages of
tightrope such as skin irritation by fibre wire, rediastasis loosening
due to osteolytic reaction, are the most common complications.
They has been recommended to remove the implant just in case
of osteolysis . The current study had some limitation those
should be addressed in future clinical trials, which are small
sample size with absence of control group, plus potential bias
concerning clinical picture and radiological evaluation. Although
satisfactory outcome were reported in all nine-patient treated
by Tightrope stabilization of the distal tibiofibular joint does not
appear to be a major problem this study has shown that. Finally,
Tightrope and screw fixation of the injured syndesmosis provided
effective reduction of the syndesmosis, each with its advantages
and disadvantages .
The dynamic stabilization or flexible fixation was done
by tightrope provides an alternate to static fixation done by
syndesmotic screw features a lot of advantages besides its
complications. It permits remarkable earlier return to work with
longer efficient syndesmosis reduction and better stability, as well
preventable risks and correctable complications. In screw fixation
group achieve rigid fixation with lack of mobility at syndesmosis
to achieve ligament healing, however hardware removed had done
routinely at a later date with minor complications attributable
such as broken, prominent screw and superficial infection.
I cordially appreciate the helps that provided by Dr. Taha
Elsaman consultant of orthopedic and sport injuries at Saudi-
German Hospital, Jeddah, Saudi Arabia. I would like to express MY
gratitude for her help in reviewing and verifying this paper.