Medial Structure Injury During Suture Button Insertion Utilizing “Center-Center” Technique for Syndesmotic Stabilization

Abstract

Category: Ankle Introduction/Purpose: The “Center-Center” technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of a flexible suture button is becoming an established means of syndesmotic stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button utilizing the “Center-Center” technique for ankle syndesmotic repair at 3 insertion intervals. Methods: Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the “Center-Center” technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was passed through each drill-hole interval. Using a digital caliper, the distance was measured from each suture button aperture with respect to the anterior tibial tendon, posterior tibial tendon, greater saphenous vein and nerve by single observer. Results: The average distance from the suture button to each anatomic structure was -2.61 ± 3.75 mm for the greater saphenous vein, -3.44 ± 6.82 mm for the saphenous nerve, 15.09 ± 4.02 mm for the anterior tibial tendon, and -21.70 ± 4.89 mm for the posterior tibial tendon. Direct impingement of the greater saphenous vein was seen in 11/30 (36.6%) interval measurements. Six of the 11 (54.5%) entrapment intervals occurred at the 10 mm drill hole. Conclusion: The results of the present study suggest the use of the “Center-Center” technique for syndesmotic repair with suture button application does involve risk of injury to the greater saphenous vein and saphenous nerve. These injuries could manifest as persistent lower extremity edema and paresthesias for injury to the saphenous vein and nerve respectively. The “Center-Center” technique with suture button fixation may warrant a minimal medial open dissection, prior to quadricortical drilling, for optimal placement to prevent neurovascular injury.