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Tightrope surgery accelerates recovery from high-ankle sprains

A runner holds his ankle after an injury.
The tightrope procedure is gaining traction as a commonly used procedure in the orthopedic and sports medicine community.

The surgical procedure has offered athletes like University of Alabama quarterback Tua Tagovailoa and others a quicker return to their game after ankle injuries.

More impressive than the University of Alabama’s stranglehold on college football is that the team will have its starting quarterback on the field as it begins its quest for a sixth national title in the last 10 years.

Tua Tagovailoa will lead the Crimson Tide Saturday night a mere 28 days after suffering a high-ankle sprain in the SEC Championship on December 1. Mr. Tagovailoa immediately had surgery, undergoing ankle arthroscopy as well as an innovative procedure called “tightrope,” which has been used to accelerate recovery from high-ankle sprain injuries.

While the actual severity of his injury is not known, it is believed to be of a more higher-grade sprain, which typically requires at least six to eight weeks to return, and sometimes several months.

The tightrope procedure had Mr. Tagovailoa practicing in just two weeks. And he said this week he is between 80-85 percent heading into the game, and improving very quickly in the post-operative setting.

What is tightrope?

When Tommy John surgery was first performed in 1974, this reconstruction procedure allowed baseball pitchers to salvage careers and return from a devastating elbow ligamentous injury. This landmark procedure has gained immense popularity in recent years, and is well-known to both orthopedic surgeons and sports enthusiasts with a tendon graft functionally replacing the torn and non-healing ligament.

Tightrope is gaining similar traction within the orthopedics and sports medicine community and seems to be on a similar trajectory, although the procedures have some basic differences besides location of injured structures. 

A high-ankle sprain denotes injury to the ligamentous complex bridging the two leg bones, tibia and fibula specifically where they articulate at the ankle joint. The syndesmotic ligaments between the two bones are torn, and in the most severe cases there is increased separation or diastasis between the two bones. In this instance, surgeons anatomically reduce the gap, drill across the two bones and place heavy non-absorbable suture construct with metallic buttons at either end (the “tightrope”) to hold the bones close together. This offers long-term protection and stability, and allows the ligamentous complex to heal in optimal position.

The implanted device actually stabilizes the ankle and serves as a replacement ligament while the native syndesmotic ligaments heal. Although surgeons have been utilizing tightrope for nearly a decade, Mr. Tagovailoa’s injury and surgical treatment has brought it into the national spotlight.

Grades of high-ankle sprains

Syndesmotic (high) ankle sprain injuries take longer to heal than low-ankle ligamentous sprains. There are three grades to high-ankle sprains.

Grade 1 is a simple sprain and involves mild stretching of the ligaments.

Grade 2 is a moderate sprain and means the ligaments have partially and incompletely torn.

Grade 3 is a severe injury where the ligaments have completed ruptured, and in the case of syndesmotic injury there is associated diastasis at the ankle joint requiring surgical intervention.

Distinct advantages

Tightrope’s quicker recovery has made it a very attractive procedure for surgeons and patients. I’ve had patients ask for the procedure because of its distinct advantages.

There are multiple manufacturers that have their own version of the tightrope. Essentially, these devices function as stable ligamentous complex while the patient’s torn ligaments heal. This allows patients to accelerate their rehabilitation with the end goal of returning to the activity or playing field in an expedited fashion.

The gold standard for these injuries has always been the use of rigid trans-syndesmotic screw fixation. The tightrope offers a viable alternative with a durable and flexible construct that allows early restoration of ankle stability, motion and function.

As with all surgical procedures there remain technical pearls to master.  One pitfall during surgery is placing the tightrope with excessive tightness, and this would need to be addressed with a second operative procedure.

Geoffrey Phillips, MD, is a board-certified orthopaedic surgeon, specializing in the non-operative and surgical management of foot and ankle conditions including Achilles tendon and ankle ligament injuries, sports medicine and trauma of the lower extremity, ankle fractures and arthritis, as well as deformity of the foot and ankle. He is also an assistant professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

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