Syndesmotic Fixation With Suture Button: Neurovascular Structures at Risk: A Cadaver Study

Abstract

Objectives: The objective of this study was to describe the anatomic variations in the saphenous nerve and risk of direct injury to the saphenous nerve and greater saphenous vein during syndesmotic suture button fixation. Methods: Under fluoroscopic guidance, syndesmotic suture buttons were placed from lateral to medial at 1, 2, and 3 cm above the tibial plafond on 10 below-knee cadaver leg specimens. The distance and position of each button from the greater saphenous vein and saphenous nerve were evaluated. Results: The mean distance of the saphenous nerve to the suture buttons at 1, 2, and 3 cm were 7.1 ± 5.6, 6.5 ± 4.6, and 6.1 ± 4.2, respectively. Respective rate of nerve compression was as follows, 20% at 1 cm, 20% at 2 cm, and 10% at 3 cm. Mean distance of the greater saphenous vein from the suture buttons at 1, 2, and 3 cm was 8.6 ± 7.1, 9.1 ± 5.3, and 7.9 ± 4.9 mm, respectively. Respective rate of vein compression was 20%, 10%, and 10%. A single nerve branch was identified in 7 specimens, and 2 branches were identified in 3 specimens. Conclusion: There was at least one case of injury to the saphenous vein and nerve at every level of button insertion at a rate of 10% to 20%. Neurovascular injury may occur despite vigilant use of fluoroscopy and adequate surgical technique. Further investigation into the use of direct medial visualization of these high-risk structures should be done to minimize the risk. Levels of Evidence: Therapeutic, Level II: Prospective, comparative study

Local Anesthetic Distension to Reduce Medial Soft Tissue Injury and Entrapment During Suture Button Placement in Syndesmosis Injuries: Technique Tip

“…10 Hence, routine medial incision to prevent iatrogenic injury to the medial neurovascular structures and accurate positioning of the medial suture button has been recommended. 2,6,[8][9][10] The complications associated with the medial suture button are not new and the introduction of new suture button deployment devices aimed to reduce risk to medial neurovascular structures and soft tissue while providing accurate implant positioning and reducing the need for a medial incision. 1 A recent cadaveric study had investigated this type of device on 10 specimens with 40 suture buttons at the respective 1.0-to 4.0-cm zone above the ankle mortise using fluoroscopic guidance.…”

“…Syndesmosis injuries have been treated with suture button fixation devices with rising popularity over the last 15 years. [2][3][4][5][6][7][8][9]11 Although there is no consensus on the optimal fixation device for syndesmosis injury, 3 multiple studies have reported advantages such as the dynamicity of fixation to allow anatomical movement of the joint while keeping reduction, obviation of screw breakage, elimination of implant removal, and reduction in risk of late diastasis with the use of the suture button device. 2,3,[6][7][8][9]11 Despite the reported superiority over conventional screw fixation, 3,4,7,11 reports of complications such as stitch granuloma and formation of abscess due to the prominent suture knot, construct loosening, osteomyelitis of the distal tibia, and pathologic fracture through the drill hole have been reported.…”

“…[2][3][4][5][6][7][8][9]11 Although there is no consensus on the optimal fixation device for syndesmosis injury, 3 multiple studies have reported advantages such as the dynamicity of fixation to allow anatomical movement of the joint while keeping reduction, obviation of screw breakage, elimination of implant removal, and reduction in risk of late diastasis with the use of the suture button device. 2,3,[6][7][8][9]11 Despite the reported superiority over conventional screw fixation, 3,4,7,11 reports of complications such as stitch granuloma and formation of abscess due to the prominent suture knot, construct loosening, osteomyelitis of the distal tibia, and pathologic fracture through the drill hole have been reported. 5,10 Additionally, studies have reported the increased risks to medial neurovascular structures (greater saphenous vein and saphenous nerve) by the drilling process and/ or compression of the suture button on the medial aspect of the distal tibia.…”

“…5,10 Additionally, studies have reported the increased risks to medial neurovascular structures (greater saphenous vein and saphenous nerve) by the drilling process and/ or compression of the suture button on the medial aspect of the distal tibia. 2,6,[8][9][10] There is also a concern that soft tissue interposition between medial suture button and medial tibial cortex may undergo necrosis resulting in some loosening of the construct. 4,10 This has led to some authors recommending routine medial incision to allow accurate positioning of the suture button and prevent damage to the medial soft tissue structures.…”

“…4,10 This has led to some authors recommending routine medial incision to allow accurate positioning of the suture button and prevent damage to the medial soft tissue structures. 2,6,[8][9][10] We present a simple technique that aims to lift medial soft tissue structures from the tibial surface and reduce risking their damage. With this technique, we were able to reduce the need for routine medial incision while allowing accurate positioning of the medial suture button against the medial tibial surface.…”