Biomechanical Evaluation of a New Suture Button Technique for Reduction and Stabilization of the Distal Tibiofibular Syndesmosis

Andres Eduardo O’Daly, R. Timothy Kreulen, Sorawut Thamyongkit, Alfred Pisano, Kitchai Luksameearunothai, Erik A. Hasenboehler, Melvin D. Helgeson, Babar Shafiq*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Stabilization methods for distal tibiofibular syndesmotic injuries present risk of malreduction. We compared reduction accuracy and biomechanical properties of a new syndesmotic reduction and stabilization technique using 2 suture buttons placed through a sagittal tunnel in the fibula and across the tibia just proximal to the incisura with those of the conventional method. Methods: Syndesmotic injury was created in 18 fresh-frozen cadaveric lower leg specimens. Nine ankles were repaired with the conventional method and 9 with the new technique. Reduction for the conventional method was performed using thumb pressure under direct visualization and for the new method by tightening both suture buttons passed through the fibular and tibial tunnels. Computed tomography was used to assess reduction accuracy. Torsional resistance, fibular rotation, and fibular translation were evaluated during biomechanical testing. Results: The new technique showed less lateral translation of the fibula on CT measurements after reduction (0.06 ± 0.06 mm) than the conventional method (0.26 ± 0.31 mm), P =.02. The new technique produced less fibular rotation during internal rotation after 0 cycles (new –2.4 ± 1.4 degrees; conventional –5.0 ± 1.2 degrees, P =.001), 100 cycles (new –2.1 ± 1.9 degrees; conventional –4.6 ± 1.4 degrees, P =.01), and 500 cycles (new –2.2 ± 1.6 degrees; conventional –5.3 ± 2.5 degrees, P =.01) and during external rotation after 100 cycles (new 3.9 ± 3.3 degrees; conventional 5.9 ± 3.5 degrees, P =.02) and 500 cycles (new 3.3 ± 3.2 degrees; conventional 6.3 ± 2.6 degrees, P =.03). Fixation failed in 3 specimens. Conclusion: The new syndesmotic reduction and fixation technique resulted in more accurate reduction of the fibula in the tibial incisura in the coronal plane and better rotational stability compared with the conventional method. Clinical Relevance: This new technique of syndesmosis reduction and stabilization may be a reliable alternative to current methods.

Original languageEnglish
JournalFoot and Ankle Orthopaedics
Issue number4
StatePublished - 2020
Externally publishedYes


  • biomechanical study
  • fibula
  • stabilization
  • suture button
  • syndesmosis


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