Maisonneuve fracture treated with suture-button system stabilization combined with plate and arthroscopic assistance (SBPAA): Clinical and radiological evaluation in short-medium period

Abstract

The aim of this study was to estimate the time needed for patients with Maisonneuve fractures to return to routine activities, after treatment with a suture-button system stabilization combined with plate and arthroscopic assistance (SBPAA).

Methods

The study included 13 patients treated at our surgical department from January 2018 to June2022. Specific radiographical follow-up and periodic checks were performed in a short -to-medium term period, to evaluate syndesmosis evolution and tibiofibular overlap with medial clear space (MCS).

Results

Progressive recovery and improvement were observed during follow-up from both radiographic and clinical perspective. Data showed that patients were able to return to full weight-bearing walking around the ninth week and to sport activities in 7.5 months. Long-term complications associated with residual joint stiffness, complex regional pain syndrome, or wound complications were observed in three patients.

Conclusions

Intraoperative arthroscopy represent a valid diagnostic tool to better recognize and evaluate osteochondral lesions in case of syndesmosys. The study demonstrates the importance of intraoperative arthroscopy for recognizing and treating associated osteochondral lesions with proper syndesmosis evaluation. Plate associated to double TightRope represent valid solution to functionally fix and reduce fractures. Additionally, it imitates the normal syndesmosis's anatomy and provides elasticity and robustness, guaranteeing a rapid return to sporting activity. Data and casuistry support these findings.

1. Introduction

Maisonneuve fractures, named after Jules Germain Francois Maisonneuve, were first described in 1840.¹ These fractures account for approximately 5% of all ankle traumas requiring surgical intervention. Maisonneuve complex fractures (MFCs) involve both the proximal fibula and the tibiofibular syndesmosis, a deltoid ligament lesion or an avulsion fracture of the medial malleolus apex. The external pronation rotation of the ankle precisely generates the injury that often occurs during traumatic sporting events such as ice skating, skiing, cycling, running, and dancing.³ Maisonneuve fractures are classified according to the Lauge-Hansen mechanism of injury⁴ and the AO classification system (44. C3). Diagnosis is made through radiographic imaging and clinical evaluation, including specific tests such as the Cotton test, pronation-external rotation test, squeeze test, and crossed-leg test.⁵ Three radiographic projections - anteroposterior (AP), lateral (LL), and internal oblique (Mortise) - are necessary, and tibiofibular overlap and medial clear are evaluated.⁶ MRI and CT scans are primarily used for preoperative planning rather than diagnosis. The grade of the lesion influences the treatment, leading to conservative treatment in low tibiofibular ligament partial injuries or to surgical intervention in case of tibiotarsal joint instability.^7,8 The main operational goal is to reduce and synthesize medial malleolus fractures and repair deltoid ligament injuries. Hereafter, syndesmosis needs to be stabilized with appropriate techniques such as resorbable or non-resorbable trans-syndesmotic screws, suture-button systems, or ligamentoplasty.⁹ The study aims to evaluate the short-to medium-term clinical and radiological outcomes of patients with Maisonneuve fractures treated with a suture-button system stabilization combined with plate and arthroscopic assistance (SBPAA) at our clinic.¹⁰ The objective is to determine the timing to return to routine activities, especially sports practice.

2. Methods

2.1. Patient demographics

All clinical data between 2018 and 2022 were retrospectively reviewed. Clinical information and radiographs of patients treated for Maisonneuve fractures were collected. Inclusion criteria: (1) patients with well-defined Maisonneuve fractures and (2) patients treated with open surgery and subsequent arthroscopic surgery at our hospital. Exclusion criteria for this study were: (1) underlying metabolic syndrome or metabolic bone disease and (2) incomplete treatment records.

2.2. Fracture characteristics

Radiographs from each patient were evaluated and classified according to the AO classification system (or Lauge-Hansen injury mechanism). In addition, fracture Angle, shortening, and displacement were evaluated.

2.3. Surgical procedure

The surgical technique consists of two stages: an open one and a subsequent arthroscopic. The patient is arranged in a supine position. Amplioscopic assistance is mandatory to verify the correct restoration of the syndesmosis joint alignment at the end of the procedure. Image intensification is carried out in an external rotated valgus test (Fig. 1). Periosteum detachment has to be carefully performed, especially approaching the distal fibula fracture via direct lateral approach. Thanks to the scope imaging, a 4-hole 1/3 tubular plate is selected and positioned according to the biometric criteria for syndesmosis stabilization with a posteroanterior inclination of 20° and an application proximal to the tibiotarsal joint. Subsequently stabilization via two “button and suture” traction is performed. These ropes will be tensioned later (Fig. 2, Fig. 3).¹⁰ Therefore, for arthroscopic surgery two different accesses are made in anteromedial and anterolateral region in order to diagnose visible injuries¹¹ and evaluate the degree of syndesmosis's instability (Fig. 4). During this process, lesions can be treated with dedicated toolkits,¹² and important structures, as deltoid ligament integrity, can be better evaluated.¹³ In the latter step the two-traction system are tensioned under arthroscopic guidance to evaluate the correct tibiofibular alignment and restore the overlap sign (OS, Fig. 5). Once the syndesmosis has been stabilized, the deltoid ligament can be arthroscopically reinserted using anchors or treated with mini-open suturing (Fig. 6).

Fig. 1.

Intraoperative radiographic confirmation of syndesmosis injury using an externally rotated valgus test.

Fig. 2.

Application of the SB system that will be tensioned subsequently.

Fig. 3.

Radiographic control of the correct positioning of SB system.

Fig. 4.

Drive-through test to evaluate the degree of instability of the syndesmosis.

Fig. 5.

Tensioning of the SB fixation, subsequent radiographic and arthroscopic evaluation of the correct recovery of tibiofibular joint alignment.

Fig. 6.

Arthroscopic reinsertion of the deltoid ligament using resorbable anchors.

2.4. Complications (described in the methodology)

The suture-button technique is known for its advantages in robustness and elasticity. Surgeons should be aware of its potential complications, such as posterior tibial tendon entrapment, saphenous vein perforation, and soft tissue irritation or wound complications. Sutures that are cut too short may also lead to decubitus or residual joint stiffness. Exposure of the TightRope entry hole site, drilling a larger diameter, or a distal fibula irregular profile may increase the risk of cortical fracture.¹⁴ Chronic instability or untreated cartilage lesions may also lead to complex regional pain syndrome.

2.5. Follow-up

Clinical and radiological evaluation were performed 1-3-6-12 months after surgery. AOFAS score was calculated at 6- and 12-months follow-up.

The collected data were statistically analysed using Student's T-test, P-values <0.05 were considered significant.

3. Results

The study included 13 patients, 9 males and 4 females, treated at our surgical department between January 2018 and June 2022 (see Table 1). Patients were aged between 35 and 63 years old (mean age 49,2).

Table 1.

Patients data and follow up.

Age	Sex	Associated injuries	Full weight-bearing (weeks)	Complications	AOFAS 6 Months	AOFAS 12 Months
56	M	No	8	No	90	96
43	F	No	9	No	92	92
35	M	No	8	No	90	96
42	M	OCL* medial talus	10	No	80	96
40	F	No	8	No	88	92
50	M	OCL* medial talus	11	CRPS**	78	88
37	M	No	8	No	90	98
58	M	No	10	Stiffness	84	96
63	F	No	11	No	90	96
57	M	No	10	No	88	94
58	M	No	9	No	90	97
61	M	No	14	Wound Complications	77	88
40	F	No	10	No	90	96

Mean AOFAS score showed significant increase from 86.7 ± 5.2 s dev at 6 months to 94.2 ± 3.3 at 12 months. Two patients presented osteochondral talar lesions at time of surgery. In these patients, AOFAS score was significantly lower at 6 months (79 ± 1); no statistical difference was highlighted 12 months after surgery, suggesting a slower recovery.

Our findings indicate that patients resumed full weight-bearing walking at 9.1 weeks (mean value, min 8 weeks, max 14 weeks) and sport activities at 7.5 months.

Among the patients, three presented long-term complications, including wound complications, residual joint stiffness, and complex regional pain syndrome. The latter was treated with bisphosphonates (Neridronate) and magnetotherapy. These patients reached complete full weight-bearing and returned to sports activities after 11.6 weeks.

However, based on radiographic follow-ups, overlap sign (OS), and Morton and Weber classification system (MCS), all treated patients achieved a complete recovery with a normal range of movement over time. Due to a wound complication, one patient's prominent suture button on the fibula needed surgical removal after 6 weeks.

4. Discussion

Injuries of tibiofibular syndesmosis are often related to fibular fractures. Typically, they are associated with external rotation movement and tibiotarsal joint dorsiflexion leading to the rotation of the talus in the mortise while the fibula moves posteriorly and externally. The gesture tightens the anteroinferior tibiofibular ligament and the posteroinferior and interosseous tibiofibular ligament.^11,15 Persistent pain or functional limitations might occur due to inadequate treatment or, more frequently, misdiagnosis. In these cases, pain may become a sign of tibiofibular diastasis or early osteoarthritis.^13,16,17

The PRICE protocol (Protection-Rest-Ice-Compression-Elevation) should be employed in case of swelling or pain at first evaluation. A sub-acute radiological and clinical evaluation can help improve the diagnosis of ankle instability. X-rays alone can miss approximately half of the diagnoses at first presentation, needing more accurate methods.¹⁸

No gold standard for surgical treatment of syndesmotic injuries has been posed. The most used techniques include rigid or dynamic systems, with tri- or qua-dricortical screws being used in the former and suture-button fixation in the latter.¹⁹ Surgical intervention aims to reposition the fibula in the tibia's fibular notch, getting proper syndesmosis reduction. However, X-rays alone are insufficient to assess the correct alignment of the tibiofibular joint, and CT scans can be performed only after surgery. A viable alternative is represented by intraoperative arthroscopy, which evaluates associated osteochondral lesions and syndesmosis instability, enabling treatment during the same surgery session.²⁰ During arthroscopy, an instrument with a 2.9 mm diameter can assess ankle instability and syndesmosis or deltoid ligament injury (drive-through sign) by easily passing into the medial recess between the medial malleolus and the talar dome.²¹ Before stabilizing with the suture-button system, a mandatory arthroscopic check of the correct anatomical relationship between the tibia and fibula should be performed. Comparing the most common surgical options, the trans-syndesmotic screws slightly increase the syndesmosis's stability adding rigidity, while the suture button system better reproduces syndesmosis's physiological movements and not reducing its elasticity²²; moreover, suture button system does not show significant displacement difference under axial load and rotational torque stresses.^19,23

The suture-button technique is known for its advantages in robustness and elasticity. surgeons should be aware of its potential complications, such as posterior tibial tendon entrapment, saphenous vein perforation, and soft tissue irritation. Sutures that are cut too short may also lead to decubitus, while exposure of the TightRope entry hole site, drilling a larger diameter, or a distal fibula irregular profile may increase the risk of cortical fracture.¹⁴

To avoid cut-out and improve load distribution, our experience suggests positioning a 1/3 tubular plate on the fibula with a double TightRope passing through the holes, which enhances mechanical strength and reduces tibiofibular movements on the sagittal plane compared to the single suture-button technique.

Ankle immobilization can modify the load and equilibrium of the tibial mortise, leading to joint cartilage degenerative phenomena.²⁴ For this reason, the SBPAA technique, which promotes early mobilization and weight-bearing, is preferred over trans-syndesmotic screws.^25,26

Furthermore, SBPAA is a permanent system that does not need to be removed because it does not affect the tibiotarsal joint's elasticity.²⁷ Thanks to the suture button's natural correction ability for malreduction, loss of syndesmosis reduction is rare in later follow-ups.^28,29

In contrast, trans-syndesmotic screws in the rigid system may cause stiffness, discomfort, loosening, or breakage, and implant failure may lead to a higher risk of syndesmotic diastasis.³⁰

A recent study suggests a two-stage surgical option: a 1/3 tubular plate is placed on the fibula with two trans-syndesmotic screws in the first surgery to improve bone healing with greater rigidity. After six weeks, the screws are replaced with a double TightRope to allow full bearing and articulation, reducing the risk of tibiofibular diastasis while giving the syndesmosis time to repair.31, 32, 33 However, this approach would increase treatment costs and expose patients to higher risks associated with anesthesia and complications from combined procedures.³⁴

5. Conclusions

This study underlines the importance of intra-operative arthroscopy in managing syndesmosis injuries, particularly in athletic patients with MCF. However, it is important to note that limitations may arise from the surgeon's experience with ankle arthroscopy, accurate placement of the SBPAA system, and the potential for complications. Arthroscopy is crucial in identifying and treating osteochondral lesions, allowing for proper syndesmosis repair under direct visualization. Using a double TightRope and a 1/3 tubular plate on the fibula provides a viable treatment option to reduce fractures while maintaining normal ankle anatomy. This approach combines robustness and elasticity, resulting in an excellent functional outcome and a rapid return to daily activities, particularly sports. Furthermore, the SBPAA system does not require removal, resulting in significant cost savings for the healthcare system. We aim to continue improving surgical techniques, reducing operation time and costs, and exploring innovations for the future.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent (Patient/Guardian): Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for publication of all the images in Figures.

Institutional Ethical Committee Approval: This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of University of Sassari approved this study.

Authors contribution

Leonardo Puddu: Conceptualization, Data curation; Fabrizio Cortese: Conceptualization, Methodology, Investigation; Edoardo Fantinato: Writing – review & editing, Formal analysis; Stefano Pescia: Writing – review & editing; Enrico Fiori: Writing – review & editing; Francesco Pisanu: Supervision, Carlo Doria: Supervision; Alessandro Santandrea: Writing – original draft, Supervision; Giovanni Lugani: Supervision; Domenico Mercurio: Supervision; Gianfilippo Caggiari: Project administration, Writing – review & editing.

Declaration of competing interest

None.