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. 2019;39(1):21–27.

Anatomic Syndesmotic and Deltoid Ligament Reconstruction with Flexible Implants: A Technique Description

Christina J Hajewski 1,✉, Kyle Duchman 1, Jessica Goetz 1, John Femino 1
PMCID: PMC6604543  PMID: 31413670

Abstract

The optimal fixation method for unstable syndesmosis (SYN) injuries remains a matter of debate between rigid screw fixation that stabilizes all three components of the syndesmosis but prohibits any motion, and flexible implants stabilizing by compression along the axis of the interosseous ligament. More recently additional repairs of the anterior or posterior SYN ligaments have been explored both clinically and biomechanically. The role for deltoid ligament (DL) repair or reconstruction in the setting of SYN injury remains controversial. However, the DL is increasingly recognized as having an important contribution to rotational stability of the ankle. A method of treatment is presented for unstable SYN injuries with flexible implants. An anatomic approach to reconstructing the DL with specific augmentation of the anterior and posterior bands of the deep deltoid ligament (DDL) is described for immediate restoration of medial ankle rotational stability.

Level of Evidence: V

Keywords: syndesmosis, deltoid

Introduction

Syndesmosis injuries occur in over 10% of all ankle fractures and in up to 20% of operative ankle fractures.1,2 Anatomic syndesmosis reduction is known to be essential for better outcomes.3-5 The syndesmosis ligaments consist of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL) and the posterior inferior tibiofibular ligament (PITFL).6 These are largely extra-articular and will heal primarily but require maintenance of anatomic reduction for a matter of months. Historically, rigid fixation with 1-2 syndesmotic screws has been considered the gold standard of treatment. Fixation strategies with more flexible implants, including suture buttons, have been recently investigated, with the rationale that they may allow for more physiologic motion in the syndesmosis with similar biomechanical strength. 7-9 Patient outcomes with suture button implants have been shown to be similar or superior to screw fixation1,5,10-12 and may help ameliorate malreduction.13 Recently, the role of the AITFL in resisting external rotation stress has been highlighted and augmentation suggested for syndesmotic injuries;14 this is likely important in cases of greater instability.15-17 This information serves to guide more anatomic reconstruction techniques.

Although not historically categorized as a component of the syndesmosis ligament complex, the contributions of the deltoid ligament (DL) as an important stabilizer and deterrent to external rotation force have been increasingly recognized.14,18-20 The indications, long-term utility, and optimal technique of treating associated DL instability are controversial and ill defined.21-23 This is due to the complex anatomy and function of the DL, a lack of understanding of the patterns of injury, and lack of definition of clinically important DL instability. The DL consists of the superficial deltoid ligament (SDL) and deep deltoid ligament (DDL). The SDL acts to control the valgus stress associated with hindfoot eversion (tibiocalcaneal and tibiospring bands), anterior translation of the talus (tibionavicular band) and posterior translation of the talus (superficial posterior tibiotalar band in conjunction with the posterior band of the deep deltoid ligament). However, the anatomic presence of each component individually is variable.24 The DDL which is also variable generally consists of an anterior band which primarily resists external rotation and a posterior band which resists posterior translation of the talus as the ankle dorsiflexes.6,25 Figures 1-3 demonstrate the anatomy of the medial and lateral ankle in a cadaveric specimen.

Figure 1.

Figure 1

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Medial view of dissected ankle specimen with flexor retinaculum removed demonstrating the superficial deltoid ligament (SDL). MM = medial malleolus

Figure 3.

Figure 3

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Medial ankle after sectioning of the deep deltoid ligament with superficial deltoid ligament (SDL) intact. T = tibia, Ta = talus

Figure 2.

Figure 2

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Lateral view of intact syndesmosis. AITFL = anterior inferior tibiofibular ligament, IOL = interosseous ligament, T = tibia, F = fibula, Ta = talus

Various treatment methods for associated DL instability have been described.26-30 While anatomic repair of the components of the superficial deltoid ligament (SDL) can achieve primary healing, the deep deltoid ligament (DDL), like the anterior cruciate ligament, is an intra-articular ligament with poor likelihood of primary healing. This is due to the effect of synovial cells, which express a gene for alpha smooth muscle actin, inducing myofibroblasts to form on the ends of the ruptured ligament and leading to retraction of the ruptured ends of the ligament.31

We describe a technique of repairing SYN and DL instability using suture button augmentation with flexible implants to anatomically stabilize the IOL and AITFL, with an augmented reconstruction of the DDL and suture anchor repair of the superficial deltoid. This technique describes the method that we currently use with implants made by Arthrex (Naples FL, USA), which include the TightRope suture button device, SwiveLock anchors (4.75 mm and 3.5mm) and FiberTape suture for flexible augmentation. However, there are several other manufacturers who make similar systems.

Surgical Technique

Both medial and lateral exposures are performed initially and the tunnels for the posterior talar, anterior talar and tibial SwiveLock anchors are created while the ankle is maximally unstable. The posterior 3.5 mm SwiveLock anchor is placed with the FiberTape prior to reduction and fixation of the syndesmosis. The medial approach is described below in the technique for augmentation and reconstruction of the DL.

Technique for syndesmosis reduction and placement of suture button.

A longitudinal lateral approach to the distal fibula is made and at the tip of the fibula it is directed toward the base of the 4th metatarsal for 3-4 cm. The superior extensor retinaculum (SER) and anterior compartment fascia are sharply elevated off of the anterior edge of the fibula and the anterior compartment musculature is retracted medially to expose the syndesmosis. The anterior perforating peroneal artery is noted and protected although it is also traumatically disrupted in some cases and can be cauterized as the anterior angiosome is primarily supplied by the anterior tibial artery. The stability and displacement of the fibula are assessed, and the torn interosseous ligament fibers and any fibrinous clot are removed with a synovial rongeur. Care is taken not to strip all of the ligamentous attachments off of the tibia or fibula. In chronic cases, the AITFL fibers may appear intact but with stress can be seen to be attenuated in the reduced position. Fatty degeneration may be apparent on the underside of otherwise intact ligament fibers. These are also pie-crusted to allow for overlap of the ends when reduced. The unstable fibula in lower energy injuries tends to be subluxated in an anterolateral and externally rotated position relative to the incisura. A glide maneuver is performed and the reduced position is confirmed clinically and fluoroscopically.32 A 2.0 mm wire is pre-positioned in the fibula under fluoroscopic guidance at the planned level for the TightRope suture button fixation, approximately 3-4 cm proximal to the tibial plafond; at a level ~5mm proximal to the superior margin of the interosseous portion of the SYN (Figure 4). The Tight-Rope and clamp are not placed too far proximally; as they are compression devices, as opposed to a static device like a screw. The TightRope and/or the clamp can bend the fibula when placed proximally and lead to malreduction due to diastasis of the distal syndesmosis. With manual reduction held and medial-lateral compression the wire is advanced into the tibia in a posterolateral-to-anteromedial trajectory with respect to the axial plane and through the medial tibial cortex in the midline. A medial incision is made over this and the medial soft tissue structures, including the saphenous neurovascular structures, are retracted. The medial periosteum and overlying tibial insertion of the SER are cleared with cautery around the tip of the wire, so that the medial button can be seated directly on the cortical bone. A reduction clamp is then placed across the syndesmosis 4-5mm proximal to the 2.0 wire using a small pre-drilled hole in the fibula to assure stable placement of the pointed reduction clamp. The medial tine is placed 4-5 mm proximal to the tibial exit of the wire and single hand compression is applied with the clamp; there is often a shift of the fibula on the wire as it seats fully into the incisura. The 2.0 wire acts as a guide for medial-lateral compression, preventing any other displacement or rotation, so that the fibula remains in the anatomically reduced position. A smaller diameter wire such as a 1.6mm or 0.062” Kirschner wire may not be strong enough in some cases and could bend. A second 2.0 mm wire is then placed obliquely in the coronal plane, starting 2-3 cm distal to the first wire to hold reduction. The first 2.0 mm wire is then removed and the guide wire for the cannulated drill for the TightRope device is placed through this and then the 3.7 mm cannulated drill for the TightRope device is used over the guide wire. The TightRope is then passed and tensioned by pulling sequentially tighter on the two strands of suture, with longitudinal placement of the suture button medially. The suture strands are not cut until the conclusion of fixation; after the clamp and 2.0 wire are removed the tightrope is finally tightened.

Figure 4.

Figure 4

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Placement of Kirschner wire in preparation for TightRope application. Arrows demonstrate reduction forces with compression and an internal rotation moment applied over the anterior fibula. T = tibia, F = fibula

In severe cases of gross multidirectional instability we would use screw fixation as the posterior SYN ligamentous sleeve would be completely ruptured off of the tibia or fibula. In most cases the posterior SYN ligaments act as a tension band with reduction of the fibula fracture and SYN; augmentation of the AITFL stabilizes anterior-posterior translation as well as resisting external rotation. Once reduced the posterior ligaments heal primarily.

Technique for augmented reconstruction of the AITFL:

The pointed reduction clamp and oblique wire remain in place during the augmented reconstruction of the AITFL. Augmentation is performed using a flat flexible non-absorbable suture, FiberTape (Arthrex, Naples FL, USA) which is secured to the fibula and tibia with 3.5 mm A and 4.75 mm intramedullary SwiveLock anchors (Arthrex, Naples FL, USA). The technique allows tension to be determined by the surgeon. The previously pie-crusted AITFL ligament ends will overlap to form a scaffold for primary ligament healing at a shorter length after reduction. With flexible interosseous fixation previously performed, a 3.5 mm SwiveLock anchor loaded with FiberTape is placed into the fibula, lateral to the tibial footprint of the AITFL origin; this is placed with a distal direction to utilize the wider metaphyseal bone as the fibular shaft becomes narrow above the syndesmosis and the 3.5mm SwiveLock requires 15mm of bone for placement. A hole is prepared for a 4.75 mm SwiveLock anchor in the tibial footprint, in an oblique direction to avoid violating the concavity of the tibial plafond. Both limbs of the FiberTape are tensioned equally and the anchor is inserted. We have found that this transverse orientation augmenting the more proximal fibers of the AITFL provides the strongest resistance to external rotation and anterior translation. The clamp and oblique 2.0 mm wire are removed and the Tightrope is tightened a final time and tightness is confirmed by stability of the button with hemostat pressure (Figure 5).

Figure 5.

Figure 5

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Complete syndesmotic reconstruction with a suture button (SB) A and AITFL reconstruction with FiberTape. B T = tibia, F = fibula

Technique for completion of flexible augmentation of Deep Deltoid Ligament and Anterior Superficial Deltoid Ligament following application of suture button and AITFL repair):

The initial incision is made longitudinal along the posterior 1/3 of the medial malleolus and at the tip of the malleolus it is then directed toward the navicular on a line dorsal to the posterior tibialis tendon Superficial dissection allows for mobilization and protection of the saphenous vein. In an acute setting the soft tissue dissection is minimal but in a chronic setting the anterior band of the SDL is mobilized laterally with the superomedial band of the inferior extensor retinaculum (IER). In the unstable state the talus is easily mobilized anteriorly to allow placement of a 3.5 mm SwiveLock anchor with associated FiberTape suture into posterior footprint of the DDL on the talus, recreating the direction of the posterior fibers of the DDL (Figure 6). A drill hole for a 4.75 anchor is prepared in the intercollicular groove (more anteriorly than posteriorly) on the inferior surface of the medial malleolus. The reduction and fixation of the syndesmosis is then performed before returning to the DL reconstruction.

Figure 6.

Figure 6

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Position of drill for the placement of 3.5 mm SwiveLock anchor in the talus near the footprint of the posterior insertion of the C deep deltoid for the posterior deep deltoid reconstruction. T = tibia, Ta = talus

Once the syndesmosis reconstruction is completed, the FiberTape strands are placed into the eyelet of a 4.75 mm SwiveLock anchor. The tension is applied with the ankle in approximately 15 degrees of ankle equinus, and the anchor is inserted.

The ankle is then dorsiflexed to neutral, tensioning the posterior augment in the same way the intact posterior DDL is tensioned with ankle dorsiflexion and physiologic talar rollback into the mortise (Figure 7). A tunnel for an additional 4.75mm SwiveLock anchor is made in the anterior portion of the deep deltoid fossa on the talus and the fiberwire strands are then placed into the eyelet of the 4.75 mm SwiveLock anchor, and after tensioning in ankle neutral position, it is then inserted (Figure 8). This provides control of external rotation as the intact anterior fibers of the DDL would. The Fiberwire in the 4.75 anchor in the talus is can then be used to sew the superior tibiospring and tibionavicular bands of the deltoid to the medial talus as a direct repair of these fibers. In cases where the more proximal portion of the SDL is avulsed from the medial malleolus, additional smaller suture anchors can be used to reattach the ligament and overlying retinacular tissues to the convexity of the medial malleolus. These then will heal primarily back to the bone.

Figure 7.

Figure 7

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(A) Anterior posterior (AP) view of the ankle after completion of the posterior deep deltoid reconstruction with Fiber Tape (B) Lateral view of the medial ankle after posterior deep deltoid reconstruction. Dashed line demonstrates the trajectory of the reconstruction which is obscured by the superficial deltoid ligament. T = tibia, Ta = talus

Figure 8.

Figure 8

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(A)Anterior posterior (AP) view of the medial ankle after the anterior deep deltoid reconstruction (B) Lateral view of the medial ankle after anterior deep deltoid reconstruction. Dashed line demonstrates the trajectory of the reconstruction which is obscured by the superficial deltoid ligament. T = tibia, Ta = talus

Discussion

We present a method of reconstruction addressing the AITFL, IOL, DDL with SDL repair, using flexible implants.

These injuries are commonly addressed with one or two syndesmotic screws, but normal ankle kinematics require physiologic syndesmotic motion. Therefore, screw removal, loosening or breakage are deemed important after some months. Recently more flexible suture button implants have been increasingly used and studied with the goal of providing stability for ligament healing and allowing for early restoration of “normal” kinematics. Clinical outcomes are equivalent or improved with these flexible implants.11,12 but biomechanical studies have failed to show restoration of normal kinematics.14 The SYN is notoriously difficult to reduce anatomically and it is established, as outlined earlier, that malreduction leads to worse outcomes. This highlights the paramount importance of the accuracy of reduction with either type of fixation. It has been demonstrated biomechanically that a suture button is able to better compensate for malreduction than screw fixation.13 Perhaps this relates to the findings of improved clinical outcomes in some studies. Excellent outcomes remain elusive with current treatment strategies and recent attention to the importance of the DL and individual components of the SYN have emerged, with the goal of improving outcomes further.15,19,20,33

The DL provides primary multifunctional medial stability to the ankle joint. The role of DL repair in the setting of ankle fractures or syndesmotic injuries is controversial. Biomechanical studies investigating contact pressures after syndesmotic sectioning have shown that abnormal ankle mechanics remain with isolated syndesmotic fixation in the presence of a sectioned deltoid ligament.19 Another biomechanical study showed that there was no significant change in tibiotalar contact area or peak pressure after disruption of the syndesmosis if the deltoid remained intact, yet with the addition of deltoid ligament sectioning there was a 42% increase in peak pressure.34 Both repair and reconstruction techniques for the deltoid ligament have been described in the literature- including direct repair, suture anchor repair, reconstruction with autograft or allograft, and repair with anchor to post suture reinforcement.26, 35-38 The technique described in this article allows for flexible anatomic reconstruction of the IOL, AITFL, SDL and specific anatomic augmentation of the DDL, with an effort to restore the kinematic properties of the anterior and posterior components of the DDL. This reconstruction method uses anatomically oriented augmentations to attempt to further aid reproduction of the stability and kinematics found in intact ankle joint. Future biomechanical and clinical studies will be needed to further investigate this reconstruction technique.

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