October highlighted article Author’s Comment

Anterior Syndesmotic Augmentation Technique Using Nonabsorbable Suture-Tape for Acute and Chronic Syndesmotic Instability

Christopher Kreulen, MD, MS

Associate Professor- Foot and Ankle Surgery
Director of Research, Foot and Ankle Service
Department of Orthopaedic Surgery 
University of California, Davis Medical Center

There has been a growing understanding of the syndesmosis and its associated injuries over the past decade. As Sports Medicine, Trauma, and Foot and Ankle surgeons all continue to treat syndesmotic injuries there is yet to be a consensus on the most effective stabilization technique.  With the growing popularity of transyndesmotic flexible fixation, research on its biomechanics and clinical examples continue to push the treatment algorithm forward.  This has led to the development of suture augmentation repair of the anterior inferior tibiofibular ligament (AITFL).  Recent biomechanical data has suggested that anterior syndesmotic suture augmentation provides improved rotational and translational control of the fibula. 

This article was a collaboration between three academic institutions in the United States that came upon utilizing this technique because, whether chronic or acute, we all felt that there needed to be more fixation outside of the traditional transyndesmotic fixation.  Once the senior authors began to utilize the AITFL InternalBrace technology (Arthrex, FL, USA), it was clearly evident that there was improved stabilization of the syndesmosis. The technique is well described in the article and it is important to remember that this can be performed from a lateral or anterolateral approach.  Some have even begun to place it arthroscopically. The authors believe that the most important technical caution with the technique is to not over tension the suture brace when inserting the second SwiveLock (Arthrex, FL, USA) and cause the fibula to internally rotate.  The technique is a safe augmentation to current repair techniques for the syndesmosis and there is minimal downside to this added stabilization.

Anterior syndesmotic suture augmentation provides another plane of fixation and improves the rotational and sagittal plane stability of the syndesmosis and ankle as a whole. It is believed that flexible fixation allows for improve ligamentous healing by allowing physiologic motion.  Clinically, the addition of the AITFL suture augmentation creates a stronger construct closer to the native syndesmosis which can allow for a quicker rehabilitation protocol, progressing to weightbearing faster, with less fear of complications.

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