A New Method of Nice Knot Elastic Fixation for Distal Tibiofibular Syndesmosis Injury

Abstract

Objective: The distal tibiofibular syndesmosis (DTS) is a fretting joint and it is still a hot issue how to satisfy strong internal fixation while allowing fretting. This study described and evaluated a new method for elastic fixation of DTS injury with Nice Knot.

Methods: The study was designed as a retrospective study. Between June 2020 and June 2021, 31 patients who were diagnosed with ankle fracture and DTS injury without additional orthopedic injuries were enrolled in this case series. The study included 22 males and nine females, with an average age of 34.71 ± 14.66 years. All patients were treated with Nice Knot binding for DTS. Surgical time, length of stay, time of DTS fixation, total weight-bearing time, complications, imaging parameters, and functional scores at follow-up were recorded. Paired sample t-tests or single factor analyses of variance were used at intra-group comparison.

Results: All patients completed surgery with normal syndesmotic parameters. The recovery of DTS injury was verified by Hook and lateral malleolus rotation tests. The average follow-up time was 15.97 ± 3.30 months. Only one case showed superficial infection after surgery, and the wound healed after symptomatic treatment. In terms of imaging, there were no significant differences in tibiofibular clear space (TFCS), tibiofibular overlap distance (TFOS), medial clear space (MCS), and superior clear space (SCS) immediately and at different follow-up points after surgery. All obtained excellent and good outcomes according to the AOFAS score at least follow-up after surgery.

Conclusions: Nice Knot elastic fixation of DTS injury is firm and stable while maintaining the physiological micromotion of the ankle joint.

Keywords: Ankle joint; Elastic fixation; Physiological micromotion; Syndesmotic parameter.

Fig. 1

Schematic representation of wire crossover. It is used to pull back the suture through the bone marrow canal.

Fig. 2

Analysis of the operation of inferior tibiofibular fixation with Nice Knot. (A) 2.5 mm Kirschner wire clinging to the anterior edge of fibula to make a bone marrow canal. (B) Double strands were introduced laterally to medially through the bone marrow canal. (C) Vascular forceps close to the posterior edge of tibia and pierced medially. (D) Vascular forceps clamping the medial double strands and pulling back to the lateral side. (E) Holding of one thread in both hands, and Nice Knot being made on the lateral side of fibula. (F) After satisfactory tension, 3–4 single‐strand knots being stabilized by Nice Knot

Fig. 3

Schematic diagram of tibiofibular syndesmosis injury under Nice Knot elastic fixation

Fig. 4

Imaging data of a typical case. (A) Preoperative X‐ray positive film showing right ankle fracture with inferior tibiofibular syndesmosis injury. (B) Immediate postoperative X‐ray showing good reduction of the fracture with the inferior tibiofibular syndesmosis having returned to normal. (C–F) X‐rays 1 (C), 3 (D), 6 (E), and 12 (F) months after surgery showing internal fixation and stable position of inferior tibiofibular syndesmosis. (G) Good ankle joint movement at the last follow‐up. (H) Nice Knot was stable when internal fixation was removed.