Association of Periprosthetic Fibula Fracture With Knotless Suture Button (TightRope) Fixation for Ankle Syndesmosis in Elite Athletes

Abstract

Background: Suture button fixation is frequently used to stabilize the distal tibiofibular syndesmosis in athletes sustaining an isolated ligamentous syndesmosis injury.

Purpose: To report on a series of periprosthetic fibula fractures adjacent to the lateral suture button after a subsequent unrelated ankle injury or progressive stress injury after initial ankle syndesmosis stabilization using the knotless TightRope (Arthrex).

Study design: Case series; Level of evidence, 4.

Methods: Eight elite athletes with periprosthetic fibula fractures and stress injuries around the lateral suture buttons were evaluated. In all athletes, the knotless TightRope had been used to stabilize an isolated ligamentous ankle syndesmotic injury, after which all patients recovered and returned to professional sports at their preinjury level. The athletes subsequently developed an acute fibula fracture or a fibula stress fracture related to the 3.7-mm drill hole in the fibula adjacent to the lateral suture buttons after a mean of 14.1 months (range, 5-29 months). The management of these complications was analyzed.

Results: Five athletes sustained a periprosthetic fibula fracture in the form of undisplaced spiral Weber B injuries after a subsequent, unrelated injury. Poor healing response was noted with initial nonoperative treatment for the first 2 athletes, and surgical intervention was performed with successful union of the fracture and return to sports. The subsequent 3 athletes had early surgery with uneventful recovery. Another 3 athletes developed stress injuries adjacent to the fibula suture button without a history of acute trauma. In 2 of the 3 athletes, the position of lateral suture buttons was in the anterior third of the fibula. Initial nonoperative management yielded poor healing response, and subsequent surgical intervention was required to enable healing and return to sports.

Conclusion: Nonoperative management of fractures adjacent to the fibula suture button of a knotless TightRope may lead to a delay in union. Therefore, early surgical intervention should be considered in elite athletes, whose return-to-sports time is critical. Care is needed to ensure that the fibula hole for the suture button is centrally located because the eccentric placement of the fibula hole in the anterior third of the fibula may contribute to the development of a stress reaction or stress fracture. Surgical intervention for a periprosthetic fibula stress fracture leads to satisfactory resolution of symptoms.

Keywords: TightRope; periprosthetic fibula fracture; stress injury; suture button fixation; syndesmosis injury.

Figure 1.

(A-C) CT scans from athlete 3, diagnosed with undisplaced Weber B fracture after an unrelated injury initially treated nonoperatively, with minimal to no healing response at 10 weeks. (D and E) Intraoperative imaging showed open reduction and internal fixation of the fibula with the replacement of the suture button device in a new position because the syndesmosis was noted to be unstable. CT, computed tomography.

Figure 2.

(A and B) Initial radiographs of undisplaced Weber B fibula fracture after an unrelated injury in athlete 1, with the lateral suture button located at the anterior third of the fibula. (C and D) Radiographs at 6 weeks after removal of the suture button device and open reduction and internal fixation of the fibula. The syndesmosis was tested intraoperatively to be stable, and no TightRope replacement was performed.

Figure 3.

(A and B) Coronal and (C and D) axial MRI images of bone marrow edema and stress reaction at the fibula suture button drill hole in athlete 8. MRI, magnetic resonance imaging.

Figure 4.

(A-C) CT scans of stress reaction at the fibula suture button drill hole in athlete 8. (D-F) CT scans of healing response at the drill hole 6 weeks after removal of the suture button device. CT, computed tomography.