Ankle TightRope Sports Update with Steven Martin, MD
Q. What compelled you to use the TightRope on elite athletes with syndesmotic injuries?
A. Several factors, but first and foremost, I was never satisfied with the delayed weight-bearing status after traditional transosseous screw fixation of the syndesmosis. After any major injury, an athlete’s first question is when can I return to play? Our traditional short-term and long-term outcome measures of ankle fracture surgery all apply to the elite athlete but return to play time is extremely important as well. Second, the elite athlete, especially a skilled player position, needs a loaded range of ankle dorsiflexion of more than 20 degrees. The TightRope allows for more physiological motion at the distal tibiofibular joint. As a result of earlier weight-bearing and more normal joint kinematics, more ankle dorsiflexion range-of-motion is generally achieved. This is important for elite athletic performance.
Q. When utilizing the TightRope, what features have you found most valuable?
A. First, I think you have to evaluate all implants on performance. The TightRope has allowed me to achieve immediate rotational stability of the ankle and lets me push earlier weight-bearing. Second, the implant has to be surgeon friendly from a technical standpoint. Insertion of the TightRope is quick, reproducible, and without any major technical problems.
Q. We sometimes hear “I always use screws for syndesmosis injuries.” What would be your response to those conversations?
A. I think any time you use the term “always” in medicine you can be setting yourself up for potential failure. Single or double three and four cortices metal screws is, and has been for the last two decades, the gold standard treatment of displaced syndesmosis injuries. The problems associated with this technique however are numerous. Postoperative CT scans confirm malalignment of the syndesmosis in up to 50 percent of cases. Immediate weight-bearing is usually discouraged with the screws in place and screw breakage rates, if not removed, are also significant. Even though screws are still the gold standard, I think we must, at minimum, rethink our overall treatment strategy for these difficult ankle fracture patterns with syndesmotic injury. The TightRope has opened my eyes to a better understanding of the injury patterns seen and a treatment strategy that is more anatomically based.
Q. Can you describe your return-to-play factor with the TightRope compared to screws?
A. Every case, from a rehabilitation standpoint, has to be individualized. With my current surgical treatment of these injuries, which includes TightRope fixation of the syndesmosis and repair of the anterior inferior tibia fibular ligament, I am able to accelerate the rehabilitation and return-to-play timeline in a minimum 3 – 4 weeks. I can push the early postoperative rehabilitation protocol because I do not leave the operating room until I have achieved enough rotational stability to allow immediate weight loading.
Q. What is your rehabilitation protocol with the TightRope?
A. I follow a fairly simple rehabilitation protocol using my intraoperative assessment of fixation stability, pain, swelling, and range-of-motion as a guide to progression. The first two weeks, the patient is in a well-padded splint to maximize anti-swelling and early soft tissue healing. They are on crutches 30 – 50 lbs. partial weight-bearing. At two weeks, after suture removal, I place them in a pneumatic CAM Walker boot, begin range-of-motion and use of a stationary bicycle. Weight-bearing is allowed as comfort permits, with most athletes being full weight-bearing by four weeks. At four weeks, if they have greater than 10 degrees of dorsiflexion and are full weight-bearing, they start progressive resistive exercises and running in an aqua treadmill with the water at chest level. More aggressive proprioreceptive exercises and transition into a standard AFO occurs at around eight weeks. Flat inline running at 10 weeks and full agility and sports specific activities at 12 – 14 weeks. This program can be accelerated if immediate rotational stability is achieved in the operating room. Depending on fixation and stability on the medial side of the ankle, specifically the deep deltoid, this program, especially weight-bearing may need to be delayed 3 – 4 weeks.
Q. When you spoke at the 2014 NFL Combine about ankle, injuries what excited the audience?
A. Foot and ankle injuries are a huge problem in the NFL. The number of player days missed, secondary to high ankle sprains and ankle fractures is tremendous. I think any treatment advances that allow earlier player return is looked on with excitement. High ankle sprains are another big impact area. There is potential for the TightRope and InternalBrace™ Ligament Augmentation Repair to have a role in the higher-grades of ankle sprain injuries. The current difficulty is identifying which injuries, in which player positions and at what time in season would benefit from surgical intervention.