Das Syndesmosen-TightRope&nbsp;-XP-Implantatsystem weist einen einzigartigen Applikationsmechanismus auf, der es dem Operateur ermöglicht, das Implantat einzusetzen, ohne medial eine Nadel durch die Haut zu führen. Dem Implantatsystem wurden Handgriffe zum Spannen und ein neuer Bohrer mit spezieller Trokarspitze hinzugefügt. Es ist sowohl in Edelstahl als auch in Titan erhältlich. 

Vorteile des Syndesmosen-TightRope®-Implantatsystems:
• Bessere Reposition im Vergleich zu Syndesmosenschrauben1
• Besserer Erhalt der Reposition im Vergleich zu Syndesmosenschrauben2
• Keine routinemäßige Explantation erforderlich
• Erlaubt eine frühzeitige Belastung und eine schnellere Rehabilitation1
• Physiologische Beweglichkeit der Syndesmose nach Reposition und Fixierung
• Bessere Behandlungsergebnisse im Vergleich zu den Berichten in der Literatur über die Anwendung von Syndesmosenschrauben 3 

1. Naqvi et al.&nbsp;Am J Sports Med. 2012;40(12):2828-2835.&nbsp;doi:10.1177/0363546512461480.
2. Cottom et al. J Foot Ankle Surg.&nbsp;2009;48(6):620-630. doi:10.1053/j.jfas.2009.07.013.
3. Laflamme et al.&nbsp;J Orthop Trauma.&nbsp;2015;29(5):216-223. doi:10.1097/BOT.0000000000000245.

Trauma Lower Extremities

Foot and Ankle

Product

Das Syndesmosen-TightRope XP-Implantatsystem verfügt über einen einzigartigen Einbringungsmechanismus, der es dem Chirugen ermöglich, das Implantat über einen Handgriff einzuführen, ohne Notwenigkeit einer medialen Inzision. Dem Implantatsystem wurden Handgriffe zum Spannen und ein neuer Bohrer mit Trokarspitze hinzugefügt, die aus Edelstahl und Titan verfügbar ist.
Die Vorteile des Syndesmosen-TightRope-Implantatsystems:
• Bessere Reposition im Vergleich zu Syndesmosenschrauben1
• Besserer Erhalt der Reposition im Vergleich zu Syndesmosenschrauben2
• Keine routinemäßige Explantation erforderlich
• Erlaubt eine frühzeitige Belastung und beschleunigt die Rehabilitation1
• Physiologische Beweglichkeit der Syndesmose nach Reposition und Fixierung
• Bessere Behandlungsergebnisse bei Patienten im Vergleich zu Syndesmosenschrauben3
Referenzen
1. Naqvi GA, Cunningham P, Lynch B, Galvin R, Awan N. Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med. 2012;40(12):2828-2835. doi:10.1177/0363546512461480
2. Cottom JM, Hyer CF, Philbin TM, Berlet GC. Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases. J Foot Ankle Surg. 2009;48(6):620-630. doi:10.1053/j.jfas.2009.07.013
3. Laflamme M, Belzile EL, Bédard L, van den Bekerom MP, Glazebrook M, Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015;29(5):216-223. doi:10.1097/BOT.0000000000000245

Kaitlin C. Neary, MD (Boise, ID) presents a cost-effectiveness analysis of the Syndesmosis TightRope® implant versus syndesmotic screws for syndesmosis injuries. Dr. Neary looked at 8 years of data comparing second surgery cost, patient outcomes, and quality-of-life measurements.

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Cost-Effectiveness of the Syndesmosis TightRope® Implant for Syndesmotic Injuries

Hank L. Hutchinson, MD (Tallahassee, FL), presents the outcome of a case in which he treated a patient for an ankle fracture revision and a failed Fibulink®* device. In the revision, Dr. Hutchinson used an all-inside construct featuring a FibuLock® nail and TightRope® XP implants.
*Fibulink is a registered trademark of DePuy Synthes.

Ankle Fracture Revision Using a FibuLock® Nail and TightRope® XP Implants

I'm Hank Hutchinson, orthopedic trauma surgeon from Tallahassee, Florida. And today I'll be presenting a case of ankle fracture revision done using the FibuLock and TightRope XP. This is a 48 year old female who is in Colorado and sustained a Webber C fibula fracture with syndesmotic injury and was treated there by a fellowship trained foot and ankle surgeon. She presented to my office six weeks post-op for follow up and hoping to begin weight bearing at that point. I had not seen this particular implant before, as this was early after its introduction to market. I was able to get the OP report and ordered a CT scan to confirm mal reduction. This is a CT scan that shows mal reduction of the syndesmosis and failure of the implant. It appears that it has come loose and is no longer maintaining appropriate reduction in the syndesmosis. With mal reduction of the syndesmosis, there is a significant increase wear on the tibiotalar joint. Significant increase in the probability of syndesmotic arthritis and can be long term ankle instability. Intraoperatively. This case was not fun. It was pretty much a pain. I elected to remove the plate because I suspected a fibular mal reduction based on preoperative X-rays. Once the plate was removed, I used the FiberLink removal kit that had been supplied by the manufacturer. In my hands, I was not able to get it to work. I tried multiple times, and the technique is described as being able to remove the tibial insert through the lateral side, and I could not get this to work. I was able to use a screwdriver and pound it through the tibia and remove it from the medial side of the tibia through a separate incision, which was less than ideal. Once this was done, I was able to clean out the syndesmosis with the lamina spreader to remove all the scar tissue and everything else that would be in the way to prevent an accurate reduction. I was able to anatomically reduce the fibula and place the FibuLock nail. Once the FibuLock nail was placed, I was able to anatomically reduce the syndesmosis under direct visualization and deploy the two TightRope to secure the reduction. This is a c-arm shot that shows our immediate post-operative results with an anatomic reduction of the ankle mortise. Appropriate placement of the FibuLock nail and the two tightropes. The two tightropes are at the level of the syndesmosis and approximately one centimeter proximal to the joint surface as well. At six weeks, she was doing well. Her ankle mortise is well reduced. Her wounds had all healed. She had minimal swelling and was progressing well with PT. She had been working actively on range of motion in her fractured boot and was happy with her results at this point. Here she is at three months. She is currently walking without assistive devices. She has active dorsiflexion to 15 degrees and good plantar flexion. She's got abundant callus formation. You can see secondary bone healing on these x rays, which is something you don't see with plate and screw constructs on the fibula. And she and I are both happy with these results thus far. Post-operatively for this patient, she was non-weight bearing for a total of six weeks. Two weeks. Once her sutures were removed, she was placed immediately into a fracture boot and allowed to begin range of motion on her own at home. At six weeks, she was started with formal physical therapy and made weight bearing as tolerated in the boot for two weeks, and at eight weeks postoperatively, she was allowed to come out of the boot and begin formal physical therapy. Thank you for watching this presentation. I hope it helps you in the future if you have any similar cases.

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Syndesmosis TightRope® XP Implant System

Norman E. Waldrop, III, MD (Birmingham, AL), presents a syndesmosis injury/high ankle sprain case treated with the Syndesmosis TightRope® XP implant system. The Syndesmois TightRope XP Buttress Plate system features a unique delivery mechanism that allows the user to insert the Syndesmosis TightRope implant without pulling a needle through the medial skin.

Syndesmosis Injuries: The TightRope® Fixation System Has Changed the Game

My name is Norman Waldrop from Andrews Sports Medicine in Birmingham, Alabama. Today I'm going to talk about a Case Series presentation on Syndesmosis injuries and how the TightRope has changed the game. We're going to talk about aggressive rehabilitation and getting athletes back early in their return to play. In this specific case, we had an offensive lineman go down and he was unable to bear weight on the field. We had immediate x rays taken in the locker room that were negative for fracture, both at the ankle and around the knee. On exam in the locker room, he had tenderness extending nearly eight centimeters above the joint line. Quickly after the injury, he only had mild deltoid pain, but there was certainly concern for a more significant injury. In these cases, I begin to rely on my algorithm, which I developed several years ago when I was a fellow. We initially look at the athletes inability to bear weight if they're unable to bear weight on the field. If they have a positive midshaft fibular squeeze, meaning they have pain at the ankle with midshaft fibular squeeze certainly more indicative of a more significant injury when they have medial sided deltoid tenderness. If they have tenderness extending five centimeters or greater above the ankle and pain with external rotation. We get weight bearing X-rays despite what those weight bearing X-rays say. I think it's necessary that we get an MRI in all of these athletes. Here are this particular athletes weight bearing X-rays. And I think this case is very illustrative of some of the concerns we have. If you look at the left side of the screen, you can see the contralateral comparison views. And his X-rays essentially look identical to the uninjured side. On the right side of the screen, you can see the lateral. And there's perhaps a little concern that the fibula may have shifted posteriorly. But most people would tell you that his ankle is okay, and certainly something that we could treat conservatively based off this. But if you look at his physical exam, I was certainly concerned for for a more significant injury. So I ordered an MRI based off that algorithm that I explained earlier. And you can see here on his MRI, I'm certainly more concerned for a more significant injury. On the left side of the screen, you can see the edema around the syndesmosis and the TfL is completely torn. You can see the fluid extending out of the back of the TfL. When I see the fluid extending out the back, as you can see here in the FHL, I get concerned that there's been a tear posteriorly and there's been a been a compromise to the normal soft tissue posteriorly. On the right side of the screen is the top cut of the MRI. On my MRI series for syndesmosis injuries, I get a higher cut extending higher up the tibia, which allows me to see how high the fluid goes. And in this case, you can see the interosseous membrane is completely torn and the fluid is extending well above the top of the MRI. In my algorithm, if I see two ligaments are injured, I recommend an examination under anesthesia and stress fluoroscopy. In that case with the patient asleep. If they have an unstable ankle, that athlete gets a diagnostic arthroscopy and repair the syndesmosis. If you think back to what I said earlier, that athlete with his normal weight bearing x rays, the x rays looked like the ankle was congruent. If you think about the normal syndesmotic motion, if you injure the atfl, only the external rotation of the normal fibula will increase by about 25%. There will be increase in posterior translation by about two millimeters. But once you include a second ligament and in this case the interosseous membrane, that translation doubles to nearly four millimeters and the external rotation increases by another 35%. If you include the TfL. So you have complete rupture of the syndesmosis, there is greater than four millimeters of millimeters of posterior translation, the external rotation increases 60%. So if you think about this relative to that MRI I showed, if you have two ligaments injured, that is concerning for a dynamically unstable syndesmosis. And I think one that needs to be fixed here is that same athletes stress exam under fluoroscopy while asleep under anesthesia on the left side of the screen. This is what we typically see. This is this particular athletes arthroscopic video. And you can see this is the posterior lateral corner of the of the ankle. And this is typical of what I see when I get in there with the arthroscope. You'll see the TfL is completely torn off and it has a small piece of cartilage with it. I'll pull that out with a grasper. I'll clean up the posterolateral corner and give this an area to heal down to. I'll clean up the TfL portion that's flipped into the joint as well as interosseous membrane. So I use the two hole plate with the most inferior TightRope placed 1.5cm above the joint, and these two TightRope are placed in a slightly divergent manner. I place ACP both in the deltoid and in the joint. I also place it in the injured syndesmosis to expedite the healing. And then finally, once the incisions are closed, I place JumpStart on the incision before placing the placing the dressing and sending the patient to PACU in the rehabilitation process. I think expedited rehabilitation is good for the athlete. It restores normal motion quickly. It reduces chronic pain and disability. Certainly there's a secondary benefit of quick return to play. So in conclusion the anatomic reduction is vital for a good long term outcome. And ultimately that's what we're looking for. For the ankle to last. And these athletes to be confident in what they're doing and be confident in their ankle. The syndesmosis is a synovial joint with mobility in three planes. And that's critical. It's a mobile joint. And it's important for us as surgeons to remember that. That's where a flexible device like the TightRope can allow for that physiologic motion that we're looking for while providing stability, and the TightRope allows us to achieve those goals. Arthroscope the joint, it allows us to assess the cartilage injury and better look at the reduction that we're looking for in these athletes. We can see directly where the fibula is sitting in relation to the tibia. It allows us to get it right every time. Thank you.

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Scientific Updates

Syndesmosis TightRope® XP Implant Scientific Updates

Thomas G. Harris, MD, (Pasadena, CA) demonstrates the surgical technique for the Syndesmosis TightRope® XP implant system which features a unique delivery mechanism allowing the user to insert a Syndesmosis TightRope implant without pulling a needle through the medial skin.

Syndesmosis Repair Featuring the Syndesmosis TightRope® XP Implant System

So we're just making the lateral approach to the fibula here, identifying the anterior and posterior margins of the fibula for the placement of the TightRope for a presumed syndesmosis injury. Now, even with the XP, we would still perform the drilling as we normally would. And you want to check under fluoro that you're parallel to the joint in about 30 degrees off axis. The long axis with your hand down. So here we have the TightRope XP. You can see it's got a different insertable inserter than the prior. Tightrope. And what we do is insert it just like we would the normal TightRope. But as soon as we take the medial button through the medial aspect of the tibia and pass the cortex, then we want to realign this such that this portion of the TightRope XP is directed toward the patient's head. And what that allows us to do is when we flip this button, we know that we're in the right plane. We don't want this to be in this plane. Although it would work, it wouldn't be ideal that we want it in either faced toward the patient's head or toward the foot, we find it easier to place it toward the patient's head. Once the button of the TightRope XP is past the medial cortex, you will remove the red safety tab and then pull back on the black button here, pushing it back to that direction while pushing medially with the TightRope XP device to clear of any soft tissues. We will show you how to do that on fluoro, but I wanted you to see what it looks like on the outside as well. So a little further there. Okay, so we're denting out the medial skin but we haven't violated the skin. So at this point you want to orientate the TightRope XP inserter toward the patient's head to rotate that into the correct plane, not quite out the medial cortex there. And then we keep inserting here, and you can really feel and even see visually that it's out the medial cortex now. So we can see that there that prominence. And then on the fluoro we see that we're out there too. And then now we can release the safety button. Which comes out here. And then we'll pull back on here. Let me push it a little bit more. I like the orientation there. And now we'll pull the black button back and this will deploy it. That's good. There we go. We'll hold the very tips of that there like that so it doesn't bunch up on us. And then we'll just slide that button all the way down there. So then we look like we're pretty well down on the bone there. And then we'll tighten this down here. So the XP tensioning handles goes with the XP device. And then we'll pull on this just kind of pulling them into place. We can see that kind of we'll turn it in just a little bit. There we go. See that coming down nicely there. Get out all the slack from the device like that. It's really no slack in the system there. It doesn't cut your hands when doing so. You can see there it's nicely on the the surface of the bone without having to make a medial incision. So we're just making a medial incision here. After that, TightRope has been deployed to make sure that we're on bone, and it's not disrupting any of the soft tissues. You can see here the saphenous nerve and vein right here in close proximity. And our first dissection here, you can see that the TightRope really is sitting just directly on bone. And there's not any interposed periosteum on there. So it's completely on bone. Really in a good position. Couldn't be any closer to the bone in through that area there. The nice part about this was that we didn't have to make that medial incision, and you could see how fluoro, how easy it was to deploy that. And we're directly on bone perfectly there with as much compression as you want to put. And you can see the downside to making an incision here is just how close that saphenous vein and nerve are right there. So really helpful that that's not going to disrupt that in any way.

Syndesmosen-TightRope® XP-Implantatsystem

Das TightRope-Syndesmosen-Implantatsystem wird zur Fixierung von Syndesmosenrupturen mit oder ohne begleitender Sprunggelenksfraktur eingesetzt.

Child (D)

Flexible Produkte zur Fixierung wie das knotenlose Mini TightRope-Implantat bieten Operateur:innen eine Alternative zur herkömmlichen starren Schrauben- oder Schrauben-Platten-Fixierung für die gängigen Fuß- und Sprunggelenkspathologien, einschließlich Hallux valgus, Lisfranc-Verletzungen und Hallux varus. Das Mini TightRope-System bietet ein starkes und reproduzierbares Konstrukt, das die Knochen stabilisiert, ohne dabei das Gelenk zu überlasten.1 Eine Überlastung kann zu einem frühzeitigen Materialversagen führen und eine zweite Operation zur Materialentfernung erforderlich machen.
Dank dieser knotenlosen, spannbaren Technologie wird die Anzahl der erforderlichen chirurgischen Schritte verringert, das Risiko für Weichteilirritationen durch Knotenbündel verringert und die Variabilität beim Spannen des Implantats eliminiert.
Literatur
1. Arthrex, Inc. Data on file (APT-05278, APT-05279, APT-05280). Naples, FL; 2021.&nbsp;

TightRope^®

Syndesmosen-TightRope® XP-Implantatsystem

Mini-TightRope®-Fixierungssystem