1. Tightrope Fixation for Syndesmosis Diastasis – What’s the Evidence?
Mark Porte, MD
University of Toronto

2. Case
39 YO active female
External rotation injury to right lower extremity
Fall with leg caught under her
Unable to weight bear post injury
On exam:
Pain at syndesmosis.
+ve squeeze test, +ve external rotation test

3. Presenting Xrays

4. Post Operative Films – 3 Months

5. Follow-up – 3 Months Rehab Protocol Splinted 0-2 weeks
Aircast 2-6 weeks
NWB ROM exercises
Progressive WBAT at 6 weeks
At last f/u good ROM (details not documented)
Pain free weight bearing
Progressing back to regular activities

6. Tightrope – Theoretical Advantages
Preserve physiologic motion?
Reduce hardware pain?
Eliminate need for second surgery?
Earlier return to motion/activity?

7. Evidence? 4 Case Series
Walking a tightrope: Our experience in the treatment of traumatic ankle syndesmosis rupture
D. McMurray, B. Hornung, B. Venkateswaran, Z. Ati
Treatment of syndesmotic disruptions with the Arthrex Tightrope: A report of 25 cases
Cottom JM, Hyer CE, Philbin TM, Berlet GC
Outcome and complications of treatment of ankle diastasis with tightrope fixation
HJS Willmott, B. Singh, LA David
Treatment of syndesmosis disruptions with TightRope fixation
JC Coetzee, P Ebeling

8. Klitzman R, Zhao H, Zhang LQ, Strohmeyer G, Vora A
Klitzman R, Zhao H, Zhang LQ, Strohmeyer G, Vora A. Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis. Foot Ankle Int 2010 Jan;1(1):69-74
8 cadavers, 3 groups
Intact ligaments
Syndesmosis repaired with screw
Syndesmosis repaired with tightrope
Construct cycled under submaximal loads
Syndesmotic gap less after loading (p=0.0004) in screw group compared to control and tightrope
Increased coronal (p=0.0002) and sagital (p=0.005) plane motion after cycling in tightrope group compared to control
Decreased coronal (p= ) and sagital (p= ) plane motion after cycling in tightrope group compared to control
Study conclusions: Tightrope construct more closely mimicked physiologic syndesmotic motion

9. D. McMurray, B. Hornung, B. Venkateswaran, Z. Ati
D. McMurray, B. Hornung, B. Venkateswaran, Z. Ati. Walking a tightrope: Our experience in the treatment of traumatic ankle syndesmosis rupture. Injury Extra 2008;39:182.
Prospective; sequential patients
16 patients
All with associated fractures
Mean follow-up 5.5 months
Mean time to weight bearing 6 weeks
No re-displacement
3 hardware removal (2 infection, 1 soft tissue irritation)

10. Cottom JM, Hyer CE, Philbin TM, Berlet GC
Cottom JM, Hyer CE, Philbin TM, Berlet GC. Treatment of syndesmotic disruptions with the Arthrex Tightrope: a report of 25 cases. Foot Ankle Int 2008 Aug;29(8)
Retrospective review of 25 cases over 2y. Single Hospital
Mean follow-up 10.8 months
21 using single tightrope, 4 using double tight rope
Associated ankle fractures treated according to AO principles
Mean time to weight bearing 5.5wks
No evidence of re-displacement of syndesmosis
No cases of hardware removal
“Considered a good option”

11. Willmott HJS, Singh B, David LA
Willmott HJS, Singh B, David LA. Outcome and complications of treatment of ankle diastasis with tightrope fixation. Int J Care Injured 2009;40:
Retrospective review, single hospital
6 cases met inclusion criterion
5 cases associated with ankle fracture
Mean follow-up 6 months
Mean time to weight bearing 6 weeks
No evidence of re-displacement
2 cases of hardware removal secondary to soft tissue irritation

12. Coetzee JC, Ebeling P. Treatment of syndesmosis disruptions with TightRope fixation. Techniques in Foot and Ankle Surgery. 2008;7(3):
Ongoing RCT
Average follow-up 18.5 months
8 patients per group
AOFAS (Ankle an hindfoot score) 94 vs 88
No evidence of syndesmotic loosening
1 tightrope removal for soft tissue irritation
Trend toward increased ROM in tightrope group however screw not routinely removed

13. Conclusions Limited literature Appears to be a safe option
No published evidence for re-displacement
May necessitate tightrope removal (0-33%)
Better range of motion compared to intact in situ screw in biomechanical testing

14. Conclusions Preserve physiologic motion?
Compared with intact syndesmosis screw. Most likely
Reduce hardware pain?
Maybe?
Eliminate need for second surgery?
Earlier return to motion/activity?
Doesn’t seem to be

15. Clinical Exam – The Classics
2. Squeeze test
1. syndesmotic pain
4. Fibular translation
3. External rotation test

16. Tenderness Length In the absence of diastasis
Length of tenderness measured from tip of lateral malleolus correlates with time to return to sport in sprains with no diastasis
Nussbaum et al (2001)
Measure from tip of fibula

17. Tenderness Length In the absence of diastasis
Measure from tip of fibula
􏰂 5 􏰀 (0.93 􏰁 [tenderness length in centime- ters]) 􏰃 3.72 days
Days Lost = 5 + [0.93xTL(cm)] +/- 3.7
Nussbaum et al (2001)

18. Manjoo A, Sanders DW, Tieszer C, MacLeod MD
Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma Jan;24(1):2-6.
Retrospective review of 106 cases
76 underwent formal testing (mean f/u 23 mo)
Outcomes: Lower Extremity Measure (LEM) and Olerud Molander score (OM)
Decreased functional outcome in patients with intact syndesmosis screws. (LEM, p=0.01; OM, p=0.04)
No functional difference between broken, loose or removed syndesmosis screws