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Acute Syndesmotic Stabilization via a Continuous-Loop, Double Cortical Button System

March 01, 2019

Contributors: Dylan Lowe, MD; Steven Struhl, MD; Theodore S. Wolfson, BS; Theodore S. Wolfson, BS

Acute injuries to the distal tibiofibular syndesmosis are common. Failure to address syndesmotic instability may lead to altered ankle joint contact forces and accelerated degenerative changes. Screw fixation has long been considered the standard for rigid syndesmotic stabilization. Recently, the use of suture-button devices for dynamic syndesmotic fixation has garnered increased attention. Theoretically, these constructs afford dynamic, anatomic stabilization without the need for routine revision surgery. However, the suture-button constructs that are currently available are associated with several disadvantages, including suture-related issues (variable knot-tensioning, loosening, and creep) and button-related issues (osteolysis, subsidence, and wound complications). To avoid these complications, we have adopted a continuous-loop, double cortical button technique for consistent, durable fixation of the syndesmosis. This video demonstrates acute distal tibiofibular syndesmosis stabilization via a continuous-loop, double cortical button system. The video provides a brief overview of the anatomy, diagnosis, and management of acute syndesmotic disruption followed by a discussion of the surgical considerations and indications for stabilization. The video discusses the case presentation of a 45-year-old woman with an acute bimalleolar ankle fracture and complete syndesmotic diastasis. Standard fracture reduction and plate osteosynthesis were performed, and a stress examination revealed residual syndesmotic instability. Syndesmotic stabilization was performed via the continuous-loop, double cortical button technique. Excellent syndesmotic reduction and fixation were attained intraoperatively. Postoperative imaging studies confirmed near anatomic reduction and implant placement. Excellent clinical outcomes and fracture union were reported. The continuous-loop, double cortical button system is a safe and reliable treatment option for acute fixation of the distal tibiofibular syndesmosis and does not require routine revision surgery or implant removal; however, consistent, durable results are contingent on careful technique.

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