Fibulink Syndesmosis Repair System With Early Full-Weight Bearing

Evaluation of Safety and Performance Outcomes of the Fibulink Syndesmosis Repair System With Early Full-Weight Bearing

The purpose of the study is to evaluate the ability of the Fibulink Syndesmosis Repair System to maintain reduction of the ankle syndesmosis. Appropriate reduction of the syndesmosis is critical due the changes in tibiotalar contact pressure observed in cadaveric studies.6,7 Malreduction and instability of the distal tibiotalar joint can lead to chronic instability, increased articular damage and ultimately degenerative arthritis.7,8 Medial to lateral translation of distal tibia and fibula of 2 mm or more has been considered pathologic.9 Earlier biomechanical study demonstrated the Fibulink system is superior in maintaining displacement of less than 2 mm.4 Given the improved strength, we also look to evaluate the outcomes of initiating full weight bearing (100%) with Controlled Ankle Motion (CAM) boot at 4 weeks postoperatively. One of the big limitations for trans-osseous screw fixation is delayed weight bearing due to risk of screw breakage.1 Suture button technique allowed for early weight bearing with average of 6 weeks postoperatively using TightRope.2,10-12By initiating full weight bearing (100%) with CAM boot at 4 weeks postoperatively, this would be a significant improvement in current clinical practice.

Study Overview

• Status: Recruiting
• Conditions: Ankle Fractures; Syndesmotic Injuries; Bimalleolar Fractures; Trimalleolar Fractures; Ankle Dislocation; Bimalleolar Equivalent Fracture; Maisonneuve Fracture
• Intervention / Treatment: Other: Early Weight Bearing; Other: Normal Weight Bearing

Detailed Description

All ankle fractures will be evaluated by the orthopedic team. Standard radiographs including anteroposterior (AP), lateral and mortise view of the ankle will be obtained. Manual or gravity stress view will be performed if needed. Treatment options including nonoperative and operative management will be discussed with the patient including the risks and benefits. An informed decision will be made. Two separate informed consent will be obtained. The first will be an informed consent for the surgery, detailing the planned surgical procedure. The second will be an informed consent for the enrollment of the study, detailing the purpose of the study and the use of the Fibulink Syndesmotic Repair System in any cases of syndesmotic injury.

Should the patient elects to proceed with surgery, the patient will be informed that fixation of the fractures will be performed first. Direct lateral approach to the distal fibular will be used for fixation of the lateral malleolus. If necessary, direct medial approach will be used for fixation of the medial malleolus. Once the fractures have been fixed, the syndesmosis will be stressed intraoperatively under live fluoroscopy. Based on the parameters described in 6.3, a decision will be made whether fixation of the syndesmosis is required if instability is noted. If fixation of the syndesmosis is required, it will be performed through the direct lateral approach.

The research coordinator will be informed of all patients that had the syndesmosis fixed with the Fibulink System. Patients will then be followed at the following time points: 2 weeks, 4-6 weeks, 8-10 weeks, 3 months and 6 months. During each follow-up time points, the tibiofibular overlap, tibiofibular clear space and medial clear space will be measured and recorded. The postoperative protocol will be as follow: Immediately post-op, patient will be placed in a short leg cast. At 2 weeks postop, the short leg cast will be removed. Suture removal will be performed. Patient will be placed in a CAM boot and instructed to perform early active ankle range-of-motion. Depending on the study group, at 4 weeks or 6 weeks postop, full weight bearing (100%) in the CAM boot will be allowed. Physical therapy will begin. At 8-10 weeks postop, full weight bearing (100%) without CAM boot will begin. Patients will continue to follow-up at 3 months and 6 months.

The research coordinator will ensure proper follow-up and will be responsible for data collection and input. After achieving the planned number of participants, the results of the two study sites will be gathered. Appropriate statistical analysis will be performed, and the results will be presented in a full manuscript format.

• Study Type: Interventional
• Enrollment (Estimated): 56
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Amr A Abdelgawad, MD PhD MBA; Phone Number: 7182837400; Email: aabdelgawad@maimonidesmed.org
• Study Contact Backup: Name: Ariel N Rodriguez, MD; Phone Number: 7182837400; Email: arrodriguez@maimonidesmed.org

Study Locations

• United States
  • New York
    • Brooklyn, New York, United States, 11219
      • Recruiting
      • Maimonides Medical Center
      • Contact: Antonios Likourezos; Phone Number: 718-283-6896; Email: alikourezos@maimonidesmed.org
      • Principal Investigator: Amr A Abdelgawad, MD PhD MBA
      • Sub-Investigator: Aaron W Lam, MD

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• ankle fracture with syndesmotic disruption as assessed with intra-operative cotton test.

This includes the following injuries:

• Syndesmotic sprain (without fractures)
• Bimalleolar equivalent ankle fractures
• Bimalleolar ankle fractures
• Maisonneuve fractures
• Trimalleolar ankle fractures without the need for posterior malleolus fixation
• Ankle fracture dislocations

Exclusion Criteria:

• 1) previous ankle surgery, 2) active local infection about the ankle, 3) chronic ankle deformity secondary to trauma or congenital, 4) ligamentous laxity, 5) pathologic fractures, 6) peripheral vascular disease, 7) peripheral neuropathy, 8) diabetes neuropathy and charcot, 9) open fractures, 10) poly trauma, 11) inability to provide informed consent, 12) symptomatic ankle osteoarthritis, 12) retained hardware, 13) pregnant, 14) metabolic bone disease, 15) history of chronic steroid use, 16) mal-reduced ankle fractures

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 1) Early Full Weight Bearing; Full weight bearing (100%) initiated at 4 weeks postoperatively	Other: Early Weight Bearing; Full weight bearing (100%) initiated at 4 weeks postoperatively
Active Comparator: 2) Normal Full Weight Bearing; Full weight bearing (100%) initiated at 6 weeks postoperatively	Other: Normal Weight Bearing; Full weight bearing (100%) initiated at 6 weeks postoperatively

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
6 Month Reduction Quality	The primary objective is to evaluate the reduction and maintenance of the reduction of ankle syndesmosis in 6 months after initiating full weight bearing (100%) at 4 weeks or 6 weeks postoperatively. This will be determined based on comparing the tibiofibular overlap, tibiofibular clear space and medial clear space preoperative values.	6 Months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
2 Week Reduction Quality	Reduction and maintenance of the reduction of the ankle syndesmosis at 2 weeks based on the tibiofibular overlap, tibiofibular clear space and medial clear space preop values.	2 Weeks
4-6 Week Reduction Quality	Reduction and maintenance of the reduction of the ankle syndesmosis at 4-6 weeks based on the tibiofibular overlap, tibiofibular clear space and medial clear space preop values.	4-6 Weeks
8-10 Week Reduction Quality	Reduction and maintenance of the reduction of the ankle syndesmosis at 8-10 weeks based on the tibiofibular overlap, tibiofibular clear space and medial clear space preop values.	8-10 Weeks
3 Month Reduction Quality	Reduction and maintenance of the reduction of the ankle syndesmosis at 3 months based on the tibiofibular overlap, tibiofibular clear space and medial clear space preop values.	3 Months
Reoperation or Revision	Unplanned Reoperation or late-stage revision	6 Months
OR Time	Operating Room Time in Minutes	1 Day
Surgical Approach/Procedure Type	Surgical Approach/Procedure Type	1 Day
Type of Additional Fixation	Type of Additional Fixation	1 Day
Intraoperative Complications	Any complications that occurred intraoperatively	1 Day
Postoperative Complications	Any complications that occurred postoperatively within 30 Days	30 Days

Collaborators and Investigators

• Sponsor: Maimonides Medical Center
• Collaborators: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.
• Investigators: Principal Investigator: Amr A Abdelgawad, MD PhD MBA, Vice Chair of Orthopedic Clinical Programs, Director of Pediatric Orthopedic Surgery

Publications and helpful links

General Publications

• Leeds HC, Ehrlich MG. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. J Bone Joint Surg Am. 1984 Apr;66(4):490-503.
• Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976 Apr;58(3):356-7.
• Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997 Nov;18(11):693-8. doi: 10.1177/107110079701801103.
• Thornes B, Shannon F, Guiney AM, Hession P, Masterson E. Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clin Orthop Relat Res. 2005 Feb;(431):207-12.
• Degroot H, Al-Omari AA, El Ghazaly SA. Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int. 2011 Mar;32(3):250-6. doi: 10.3113/FAI.2011.0250.
• Morellato J, Louati H, Bodrogi A, Stewart A, Papp S, Liew A, Gofton W. The Effect of Varying Tension of a Suture Button Construct in Fixation of the Tibiofibular Syndesmosis-Evaluation Using Stress Computed Tomography. J Orthop Trauma. 2017 Feb;31(2):103-110. doi: 10.1097/BOT.0000000000000737.
• Dynamic and Load-to-Failure Testing of the DePuy Synthes FIBULINK TM Syndesmosis Repair System and Arthrex Syndesmosis TightRope ® XP Implant System Materials and Methods. 2020.
• Desai S. Syndesmosis Repair: 14 Patient Case Series.
• Hunt KJ, Goeb Y, Behn AW, Criswell B, Chou L. Ankle Joint Contact Loads and Displacement With Progressive Syndesmotic Injury. Foot Ankle Int. 2015 Sep;36(9):1095-103. doi: 10.1177/1071100715583456. Epub 2015 May 6.
• Porter DA, Jaggers RR, Barnes AF, Rund AM. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med. 2014 Aug 5;5:173-82. doi: 10.2147/OAJSM.S41564. eCollection 2014.
• Hunt KJ. Syndesmosis injuries. Curr Rev Musculoskelet Med. 2013 Dec;6(4):304-12. doi: 10.1007/s12178-013-9184-9.
• Cottom JM, Hyer CF, Philbin TM, Berlet GC. Transosseous fixation of the distal tibiofibular syndesmosis: comparison of an interosseous suture and endobutton to traditional screw fixation in 50 cases. J Foot Ankle Surg. 2009 Nov-Dec;48(6):620-30. doi: 10.1053/j.jfas.2009.07.013. Epub 2009 Sep 15.
• Thornes, Brian FRCSI; McCartan, Damien MB. Ankle Syndesmosis Injuries Treated with the TightRopeTM Suture-Button Kit. Techniques in Foot & Ankle Surgery 5(1):p 45-53, March 2006.
• Latham AJ, Goodwin PC, Stirling B, Budgen A. Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ Open Sport Exerc Med. 2017 Apr 1;3(1):e000175. doi: 10.1136/bmjsem-2016-000175. eCollection 2017.
• Cotton FJ. Dislocations and Joint-Fractures. Philadelphia: W. B. Saunders Company, 1910.
• Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989 Dec;10(3):156-60. doi: 10.1177/107110078901000308.
• Rigby RB, Cottom JM. Does the Arthrex TightRope(R) provide maintenance of the distal tibiofibular syndesmosis? A 2-year follow-up of 64 TightRopes(R) in 37 patients. J Foot Ankle Surg. 2013 Sep-Oct;52(5):563-7. doi: 10.1053/j.jfas.2013.04.013. Epub 2013 Jun 14.
• Mukhopadhyay S, Metcalfe A, Guha AR, Mohanty K, Hemmadi S, Lyons K, O'Doherty D. Malreduction of syndesmosis--are we considering the anatomical variation? Injury. 2011 Oct;42(10):1073-6. doi: 10.1016/j.injury.2011.03.019. Epub 2011 May 6.

Study record dates

Study Major Dates

• Study Start (Actual): July 13, 2023
• Primary Completion (Estimated): December 31, 2026
• Study Completion (Estimated): December 31, 2026

Study Registration Dates

• First Submitted: October 10, 2023
• First Submitted That Met QC Criteria: October 10, 2023
• First Posted (Actual): October 17, 2023

Study Record Updates

• Last Update Posted (Actual): March 20, 2026
• Last Update Submitted That Met QC Criteria: March 17, 2026
• Last Verified: March 1, 2026

More Information

Terms related to this study

• Keywords: Ankle Fractures; Bimalleolar Fractures; Bimalleolar Equivalent Fracture; Trimalleolar Fractures; Maisonneuve Fractures; Syndesmotic Injuries; Ankle Dislocations
• Additional Relevant MeSH Terms: Wounds and Injuries; Leg Injuries; Fractures, Bone; Fibula Fractures; Ankle Injuries; Ankle Fractures
• Other Study ID Numbers: 2022-08-15-MMC

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No