Clinical Considerations to Reduce Saphenous Neurovascular Bundle Injury During Suture Button Fixation of Syndesmosis Injuries.

Abstract

OBJECTIVE\nTo document angles, from two difference starting points, or danger zones that should be avoided to minimize risk of injury or irritation to the saphenous neurovascular bundle (SNVB) during suture button (SB) fixation for distal tibiofibular syndesmosis injuries.\n\n\nDESIGN\nRetrospective imaging study.\n\n\nSETTING\nAcademic Level 1 trauma center.\n\n\nPATIENTS\nForty-eight randomly selected patients with healthy ankles and CT scans for non-ankle diagnoses.\n\n\nMAIN OUTCOME MEASURES\nCT scans and 3D reconstructed images were used to define the angle between the SNVB and two different fibular starting points, using the direct lateral (DL) and the posterolateral (PL) starting points. Descriptive analyses were performed to identify angles that should be avoided during suture button fixation. Distances from the SNVB using pre-set angles of 0, 10, 20, and 30-degrees were analyzed. Additionally, the width of the SNVB, the midsubstance angle of the SNVB, and the distance from the 30-degree point to the tibialis anterior (TA) were recorded.\n\n\nRESULTS\nThe mean angle between the SNVB and the standard DL starting point was 13.7±5.0 degrees (p<0.05), while the mean angle using the alternate PL starting point was 17.2±5.3 degrees (p<0.05). The SNVB width was 5.2 mm [range, 2.6-9.1 mm] (p<0.05). The distances from the SNVB were greatest for the DL 30-degree group and the PL 0-degree group.\n\n\nCONCLUSION\nThe results document angles that should be avoided when using suture button fixation for syndesmosis injuries. Device characteristics and surgery related variables may require intra-operative modifications and knowledge of this anatomic relationship may reduce SNVB injury during those situations. Considering our results, we recommend that surgeons place suture buttons from the DL starting point with a 30-degree trajectory to avoid injuries to the SNVB.