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16-11-14 
Presenter - Dr. Sunil Poonia 
Moderator – Dr. Vikas Agarwala 
Assistant professor, Deptt. of Orthopaedics 
Silchar Medical College
INTRODUCTION 
The distal tibiofibular syndesmosis is a critical structure in 
maintaining the congruency of the ankle mortise, and the 
ligamentous structures account for more than 90% of the 
resistance to lateral fibular displacement 
5% of all ankle sprain and 23% of all ankle # are a/w 
syndesmotic injury
 Coexistence of osseous or deltoid ligament injuries 
can critically destabilize the ankle. 
 A recent survey of orthopaedic and trauma surgeons 
found disagreement with regard to the treatment of 
syndesmotic injuries
ANATOMY
ANATOMY 
‱ The distal tibiofibular joint comprises the convex distal aspect of 
the fibula and the concave lateral aspect of the distal end of the 
tibia, and is defined as a syndesmotic articulation without 
articular cartilage. 
‱ Normal motion of the ankle requires rotation, translation, and 
migration of the fibula at the syndesmosis to accommodate the 
trapezoidal shape of the talus. 
‱ The distal tibiofibular syndesmosis comprises four distinct 
ligaments including the interosseous ligament, the anterior 
inferior tibiofibular ligament, the posterior inferior tibiofibular 
ligament, and the inferior transverse ligament
ANATOMY 
The anterior inferior tibiofibular ligament originates from the 
anterolateral tubercle of the tibia and inserts at the anterior tubercle 
of the fibula. 
The posterior inferior tibiofibular ligament originates from the 
posterior tubercle of the tibia and inserts at the posterior edge of 
the lateral malleolus. 
The fibro cartilaginous inferior transverse ligament forms the distal 
portion of the posterior inferior tibiofibular ligament, and is often 
considered the same ligament.
Vascular anatomy at the distal tibiofibular syndesmosis, showing the peroneal artery (A) and an 
anterior branch (B) of the peroneal artery. 
Van Heest T J , and Lafferty P M J Bone Joint Surg Am 
2014;96:603-613 
©2014 by The Journal of Bone and Joint Surgery, Inc.
MECHANISM OF INJURY 
Type C-1 Type C-2 
Pronation external rotation injuries
MECHANISM 
Isolated syndesmotic injuries, without bony injury, are 
thought to occur mainly from forced dorsiflexion 
and external rotation in combination with and 
axial load 
Bony injury does not always reliably reveal the 
underlying ligamentous injury - stress tests including 
external rotation of the foot and stressing the fibula with 
a bone hook
DIAGNOSIS 
generally present with acute ankle instability, pain, 
and functional deficits. 
The history should include the mechanism of injury, 
previous injuries or surgical procedures, and 
symptoms of instability.
external rotation stress test entails stabilization of the leg with the 
knee in 90° of flexion, followed by external rotation of the foot 
squeeze test entails compression of the proximal part of the fibula 
to the tibia, separating the two bones distally 
crossed-leg test entails crossing the injured leg over the uninjured 
leg while the patient is seated, followed by gentle downward 
pressure to the knee of the injured leg 
forced dorsiflexion test entails forcing the ankle into dorsiflexion, 
and then repeating this manoeuvre while compressing the distal 
end of the tibia and fibula together either manually or with 
athletic tape. Decreased pain with compression suggests 
syndesmotic injury.
Three radiographic parameters have been defined for the diagnosis 
of syndesmotic injury. 
The tibiofibular overlap should normally be >6 mm in the 
anteroposterior radiograph and >1 mm in the mortise radiograph 
as measured 1 cm proximal to the tibial plafond. 
Tibiofibular clear space should be <6 mm in both the 
anteroposterior and mortise radiographs as measured 1 cm 
proximal to the tibial plafond. 
Medial clear space should be less than or equal to the clear space 
between the talar dome and the tibial plafond 
Tibiofibular clear space is the most reliable measure because it is 
not affected by the position of the leg relative to the x-ray beam
Gravity or external rotation stress radiographs can differentiate 
between frank diastasis (evident on static radiographs) and latent 
diastasis (evident only on stress radiographs). 
Diastasis occurs primarily with posterior displacement of the 
fibula and is best visualized in the lateral radiograph. 
Comparisons with radiographs of the contralateral limb are 
helpful if there is doubt about the presence of diastasis.
SYNDESMOTIC INJURIES WITH 
ASSOCIATED MALLEOLAR 
FRACTURES 
One study has found that 39% of Weber type-B SER-4 ankle fractures 
demonstrated syndesmotic instability 
standard radiographs and biomechanical criteria are inadequate for 
diagnosing syndesmotic disruptions in malleolar fractures 
Diagnosis relies increasingly on intraoperative stress-testing 
following malleolar fixation. 
Tornetta et al. found that 45% of operatively treated SER-4- 
equivalent fractures demonstrated syndesmotic instability on 
intraoperative stress examination
Two commonly used intraoperative stress tests are the 
hook test and the external rotation test under fluoroscopy. 
Hook test - the surgeon pulls the lateral malleolus with a 
bone hook while stabilizing the tibia. Lateral movement of 
the fibula of >2 mm of indicates a positive hook test. 
External rotation stress test - the tibia is stabilized while 
the foot is externally rotated under fluoroscopy. Increased 
medial clear space indicates a positive external rotation 
stress test
a cadaveric study found that any lateral forces of >100 N do 
not substantially increase tibiofibular clear space in 
specimens with dissected syndesmotic ligaments, suggesting 
that 100 N of lateral force serves as a good benchmark for a 
standardized hook test. Evidence also suggests that the 
accuracy of the hook test may improve by applying force in 
the sagittal plane and assessing the amount of displacement 
in the lateral radiograph
TREATMENT
CONSERVATIVE 
Most isolated syndesmotic injuries can be treated 
conservatively 
Williams et al. proposed a three-phase treatment plan 
Phase I focuses on protecting the ankle and managing 
pain and edema with immobilization, limited weight-bearing, 
light ankle motion exercises, rest, ice, 
compression, and elevation.
Phase II includes strength and proprioceptive exercises, 
progressing from low-intensity exercises with high 
repetitions to high-intensity exercises with low repetitions 
Phase III includes rigorous strengthening exercises and 
sports-specific movements.
OPERATIVE 
Traditionally, all SER-type ankle fractures. 
evidence suggests that SER-4 ankle fractures can be treated without 
syndesmotic fixation. 
Pakarinen et al. performed a stress test on SER-4 ankle fractures 
intraoperatively following osseous fixation. If the stress test was 
positive, the patient was randomized to either syndesmotic fixation 
or no syndesmotic fixation. At the one-year follow-up, no significant 
differences existed in functional outcomes between the groups.
In the past, internal fixation of all syndesmotic injuries was 
considered mandatory 
(1) syndesmotic injuries associated with proximal fibular 
fractures for which fixation is not planned and that involve a 
medial injury that cannot be stabilized and 
(2) syndesmotic injuries extending more than 5 cm proximal 
to the plafond.
REDUCTION 
A cadaveric study found that variations in the angulation of 
reduction clamps and subsequent syndesmotic screw 
placement can cause iatrogenic syndesmotic malreduction. 
Clamps placed at 15° and 30° of angulation in the axial plane 
displaced the fibula in external rotation and caused over 
compression of the syndesmosis. 
A cadaveric study found that clamp placement in neutral 
anatomical axis reduced the syndesmosis most accurately
Cadaveric data suggest that fixation of the fibula in as much as 30° of 
external rotation may go undetected using intraoperative 
fluoroscopy. 
The most common malreduction was fibular malpositioning, 
followed by malreductions of the fracture 
it was recommended to maximally dorsiflex the ankle during 
syndesmotic fixation to prevent postoperative limitation of motion; 
however, there are data refuting this finding and noting that maximal 
dorsiflexion may induce an external rotation moment risking 
malreduction
FIXATION METHODS
SYNDESMOTIC SCREW 
syndesmotic screw fixation entails the placement of 
screw(s) across the syndesmosis from the lateral 
aspect of the fibula into the tibia 
Fixation can be achieved with single or double screws, 
metal or bioabsorbable screws, 3.5-mm or 4.5-mm 
screws, transsyndesmotic or suprasyndesmotic 
screws, and with tricortical or quadricortical fixation
Double screws and 4.5-mm screws provide stronger 
mechanical fixation. 
Two-hole locking plates (with 3.2-mm screws) provide 
greater stability to torque compared with 4.5-mm 
quadricortical fixation in Maisonneuve fractures. 
However, while the strength of fixation stabilizes the 
joint, it eliminates normal motion between the tibia and 
fibula
SYNDESMOSTIC SCREWS
If the screw is placed too far proximally, it may deform the 
fibula and cause the mortise to widen. 
If the screw is not parallel to the joint, the fibula may shift 
proximally. 
If the screw is not perpendicular to the tibiofibular joint, 
the fibula may remain laterally displaced. 
The AO group recommended a fully threaded syndesmotic 
screw in a neutralization mode
SUTURE BUTTON 
Suture-button fixation represents a promising alternative. 
Following reduction, a hole is drilled through the fibula 
and tibia parallel to the ankle joint. 
Polyester suture is then passed through and secured at 
both ends with buttons. Although this does not provide 
fixation as rigid as syndesmotic screws, 
it may facilitate motion of the distal tibiofibular joint.
POSTERIOR MALLEOLAR 
FIXATION 
Recent evidence indicates that fixation of the posterior 
malleolus with an intact posterior inferior tibiofibular 
ligament adequately stabilizes the syndesmosis. 
The posterior malleolus can be fixed utilizing 
percutaneous anterior-to-posterior screws when the 
fragment is minimally displaced. 
An open posterolateral surgical approach to the ankle with 
antiglide plate placement is required for large fragments or 
if substantial displacement of the articular surface exists.
OUTCOMES AND 
COMPLICATIONS
CONSERVATIVE 
TREATMENT 
A systematic review by Jones and Amendola identified six clinical studies 
evaluating outcomes after conservative treatment. All studies showed 
prolonged recovery in syndesmotic sprains compared with lateral ankle 
sprains. 
While none of these studies utilized functional outcome measures, 
Nussbaum et al. found that injury to the interosseous membrane proximal to 
the ankle joint correlated with a longer time to return to activity after 
conservative treatment compared with lateral ankle sprains. 
Taylor et al. reported an average time to full activity of thirty-one days for 
football players following conservative treatment
OPERATIVE FIXATION
SYNDESMOTIC SCREW 
There are no major differences in functional outcomes 
between single and double screws, tricortical and 
quadricortical screws, transsyndesmotic and 
suprasyndesmotic screws, stainless steel and titanium 
screws, or metal and bio absorbable screws.
SUTURE BUTTON 
A recent systematic review found that suture-button fixation 
yielded American Orthopaedic Foot & Ankle Society (AOFAS) 
scores at twelve and twenty-eight months similar to those for screw 
fixation. 
Patients with suture-button fixation also returned to work earlier 
and had less frequent need for implant removal compared with 
those who had screw fixation. 
While a suture button is more expensive than screws and lacks 
conclusive evidence of superiority, the decreased need for surgical 
removal may make this technique more cost-effective
POSTERIOR MALLEOLUS 
FIXATION 
Gardner et al. randomly assigned ten cadaveric 
specimens with replicated fracture patterns to either 
posterior malleolar fixation or syndesmotic fixation. 
Posterior malleolar fixation restored stiffness to 70%, 
and syndesmotic fixation restored stiffness to 40% of 
that noted in the intact specimens.
Miller et al. prospectively treated thirty-one unstable ankle fractures with 
preoperatively confirmed syndesmotic injuries and an intact posterior 
inferior tibiofibular ligament 
(1) open posterior malleolar fixation whenever the posterior malleolus 
was fractured, regardless of fragment size 
(2) locked syndesmotic screws in the absence of posterior malleolar 
fracture 
(3) combined fixation in fracture-dislocations and severe soft-tissue 
injury to the other ankle ligaments
COMPLICATION
MALREDUCTION 
Anatomic reduction of the syndesmosis is essential for improving functional outcomes 
and avoiding posttraumatic osteoarthritis 
A prospective study by Sagi et al. found that, at the time of the two-year follow-up, 
individuals with a malreduced syndesmosis had significantly worse functional 
outcomes than individuals with anatomic reductions 
a study comparing suture-button and screw fixation found that malreduction was the 
only variable that affected clinical outcomes 
Recent studies have noted syndesmotic malreduction in 25.5% to 52% of patients
Direct visualization of the tibiofibular joint can reduce the malreduction rate 
from approximately 50% to 15%. 
Intraoperative three-dimensional imaging can also accurately detect 
malreduction 
Images of the contralateral, uninjured ankle can be used to assess the accuracy of 
reduction of the syndesmosis 
Song et al. sought to determine the effect of screw removal on the alignment of 
the distal tibiofibular joint. Patients with intact implants and symptomatic 
malreduction may only require simple screw removal rather than extensive 
revisions
HARDWARE FAILURE AND 
IMPLANT REMOVAL 
Syndesmotic fixation limits fibular biomechanics during normal 
motion of the ankle. 
As patients increase weight-bearing and resume activities, shear 
stresses can cause syndesmotic screws to break. 
Screw breakage has been reported to occur in 7% to 29% of patients 
who have had fixation, depending on the time of screw removal. 
Stuart and Panchbhavi found that 3.5-mm screws were significantly 
more likely to break than were 4 mm or 4.5-mm screws
Syndesmotic screw removal at six weeks reduces the rate of implant failure, 
but increases the rate of recurrent diastasis. 
Studies have found no significant difference in outcomes between patients 
with retained screws and those with the screws removed. 
However, several studies have shown that patients with retained broken 
screws had better functional outcome scores than patients with retained 
intact screws 
The findings outlined above suggest that restoration of normal fibular motion 
and alignment of syndesmosis profoundly impact functional outcomes, 
whether through implant removal, loosening, or breakage.
Screw removal is not without risk, however. Schepers et al. 
demonstrated a 22.4% complication rate following routine 
removal of syndesmotic screws, including infection in 9.2% 
and recurrent diastasis in 6.6%
HETEROTOPIC OSSIFICATION 
Several studies have described the development of heterotopic ossification following 
syndesmotic disruption. 
Taylor et al., in a report on fifty syndesmotic sprains in forty-four football players, found 
that 50% of the patients with radiographs developed heterotopic ossification. 
Böstman reported a higher prevalence of heterotopic ossification after fixation with 
bioabsorbable screws 
Heterotopic ossification can lead to ankle synostosis, resulting in pain and abnormal ankle 
kinematics. 
The prevalence of syndesmotic synostosis after an ankle fracture has been reported to range 
from 1.7% to 18.2%..
OVERVIEW 
Despite the amount of research devoted to 
syndesmotic injuries, many unanswered questions 
remain. 
Syndesmotic injuries are difficult to diagnose and 
treat, with malreductions remaining commonplace. 
The effectiveness of the gold-standard syndesmotic 
screw fixation method is being brought increasingly 
into question.
Obtaining anatomic reduction is essential, and the use of 
intraoperative three-dimensional imaging or open visualization may 
be warranted. 
The need for routine screw removal remains controversial. 
Although screw removal restores normal motion of the fibula and 
may allow for spontaneous reduction of malreductions, the data 
remain inconclusive. A complete summary of recommendations for 
care is given in
“Thank you”

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syndesmotic injury mechanism and treatment subject review

  • 1. 16-11-14 Presenter - Dr. Sunil Poonia Moderator – Dr. Vikas Agarwala Assistant professor, Deptt. of Orthopaedics Silchar Medical College
  • 2. INTRODUCTION The distal tibiofibular syndesmosis is a critical structure in maintaining the congruency of the ankle mortise, and the ligamentous structures account for more than 90% of the resistance to lateral fibular displacement 5% of all ankle sprain and 23% of all ankle # are a/w syndesmotic injury
  • 3.  Coexistence of osseous or deltoid ligament injuries can critically destabilize the ankle.  A recent survey of orthopaedic and trauma surgeons found disagreement with regard to the treatment of syndesmotic injuries
  • 5. ANATOMY ‱ The distal tibiofibular joint comprises the convex distal aspect of the fibula and the concave lateral aspect of the distal end of the tibia, and is defined as a syndesmotic articulation without articular cartilage. ‱ Normal motion of the ankle requires rotation, translation, and migration of the fibula at the syndesmosis to accommodate the trapezoidal shape of the talus. ‱ The distal tibiofibular syndesmosis comprises four distinct ligaments including the interosseous ligament, the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, and the inferior transverse ligament
  • 6. ANATOMY The anterior inferior tibiofibular ligament originates from the anterolateral tubercle of the tibia and inserts at the anterior tubercle of the fibula. The posterior inferior tibiofibular ligament originates from the posterior tubercle of the tibia and inserts at the posterior edge of the lateral malleolus. The fibro cartilaginous inferior transverse ligament forms the distal portion of the posterior inferior tibiofibular ligament, and is often considered the same ligament.
  • 7. Vascular anatomy at the distal tibiofibular syndesmosis, showing the peroneal artery (A) and an anterior branch (B) of the peroneal artery. Van Heest T J , and Lafferty P M J Bone Joint Surg Am 2014;96:603-613 ©2014 by The Journal of Bone and Joint Surgery, Inc.
  • 8. MECHANISM OF INJURY Type C-1 Type C-2 Pronation external rotation injuries
  • 9.
  • 10.
  • 11.
  • 12.
  • 13. MECHANISM Isolated syndesmotic injuries, without bony injury, are thought to occur mainly from forced dorsiflexion and external rotation in combination with and axial load Bony injury does not always reliably reveal the underlying ligamentous injury - stress tests including external rotation of the foot and stressing the fibula with a bone hook
  • 14. DIAGNOSIS generally present with acute ankle instability, pain, and functional deficits. The history should include the mechanism of injury, previous injuries or surgical procedures, and symptoms of instability.
  • 15. external rotation stress test entails stabilization of the leg with the knee in 90° of flexion, followed by external rotation of the foot squeeze test entails compression of the proximal part of the fibula to the tibia, separating the two bones distally crossed-leg test entails crossing the injured leg over the uninjured leg while the patient is seated, followed by gentle downward pressure to the knee of the injured leg forced dorsiflexion test entails forcing the ankle into dorsiflexion, and then repeating this manoeuvre while compressing the distal end of the tibia and fibula together either manually or with athletic tape. Decreased pain with compression suggests syndesmotic injury.
  • 16.
  • 17. Three radiographic parameters have been defined for the diagnosis of syndesmotic injury. The tibiofibular overlap should normally be >6 mm in the anteroposterior radiograph and >1 mm in the mortise radiograph as measured 1 cm proximal to the tibial plafond. Tibiofibular clear space should be <6 mm in both the anteroposterior and mortise radiographs as measured 1 cm proximal to the tibial plafond. Medial clear space should be less than or equal to the clear space between the talar dome and the tibial plafond Tibiofibular clear space is the most reliable measure because it is not affected by the position of the leg relative to the x-ray beam
  • 18. Gravity or external rotation stress radiographs can differentiate between frank diastasis (evident on static radiographs) and latent diastasis (evident only on stress radiographs). Diastasis occurs primarily with posterior displacement of the fibula and is best visualized in the lateral radiograph. Comparisons with radiographs of the contralateral limb are helpful if there is doubt about the presence of diastasis.
  • 19. SYNDESMOTIC INJURIES WITH ASSOCIATED MALLEOLAR FRACTURES One study has found that 39% of Weber type-B SER-4 ankle fractures demonstrated syndesmotic instability standard radiographs and biomechanical criteria are inadequate for diagnosing syndesmotic disruptions in malleolar fractures Diagnosis relies increasingly on intraoperative stress-testing following malleolar fixation. Tornetta et al. found that 45% of operatively treated SER-4- equivalent fractures demonstrated syndesmotic instability on intraoperative stress examination
  • 20. Two commonly used intraoperative stress tests are the hook test and the external rotation test under fluoroscopy. Hook test - the surgeon pulls the lateral malleolus with a bone hook while stabilizing the tibia. Lateral movement of the fibula of >2 mm of indicates a positive hook test. External rotation stress test - the tibia is stabilized while the foot is externally rotated under fluoroscopy. Increased medial clear space indicates a positive external rotation stress test
  • 21. a cadaveric study found that any lateral forces of >100 N do not substantially increase tibiofibular clear space in specimens with dissected syndesmotic ligaments, suggesting that 100 N of lateral force serves as a good benchmark for a standardized hook test. Evidence also suggests that the accuracy of the hook test may improve by applying force in the sagittal plane and assessing the amount of displacement in the lateral radiograph
  • 23. CONSERVATIVE Most isolated syndesmotic injuries can be treated conservatively Williams et al. proposed a three-phase treatment plan Phase I focuses on protecting the ankle and managing pain and edema with immobilization, limited weight-bearing, light ankle motion exercises, rest, ice, compression, and elevation.
  • 24. Phase II includes strength and proprioceptive exercises, progressing from low-intensity exercises with high repetitions to high-intensity exercises with low repetitions Phase III includes rigorous strengthening exercises and sports-specific movements.
  • 25. OPERATIVE Traditionally, all SER-type ankle fractures. evidence suggests that SER-4 ankle fractures can be treated without syndesmotic fixation. Pakarinen et al. performed a stress test on SER-4 ankle fractures intraoperatively following osseous fixation. If the stress test was positive, the patient was randomized to either syndesmotic fixation or no syndesmotic fixation. At the one-year follow-up, no significant differences existed in functional outcomes between the groups.
  • 26. In the past, internal fixation of all syndesmotic injuries was considered mandatory (1) syndesmotic injuries associated with proximal fibular fractures for which fixation is not planned and that involve a medial injury that cannot be stabilized and (2) syndesmotic injuries extending more than 5 cm proximal to the plafond.
  • 27. REDUCTION A cadaveric study found that variations in the angulation of reduction clamps and subsequent syndesmotic screw placement can cause iatrogenic syndesmotic malreduction. Clamps placed at 15° and 30° of angulation in the axial plane displaced the fibula in external rotation and caused over compression of the syndesmosis. A cadaveric study found that clamp placement in neutral anatomical axis reduced the syndesmosis most accurately
  • 28. Cadaveric data suggest that fixation of the fibula in as much as 30° of external rotation may go undetected using intraoperative fluoroscopy. The most common malreduction was fibular malpositioning, followed by malreductions of the fracture it was recommended to maximally dorsiflex the ankle during syndesmotic fixation to prevent postoperative limitation of motion; however, there are data refuting this finding and noting that maximal dorsiflexion may induce an external rotation moment risking malreduction
  • 30. SYNDESMOTIC SCREW syndesmotic screw fixation entails the placement of screw(s) across the syndesmosis from the lateral aspect of the fibula into the tibia Fixation can be achieved with single or double screws, metal or bioabsorbable screws, 3.5-mm or 4.5-mm screws, transsyndesmotic or suprasyndesmotic screws, and with tricortical or quadricortical fixation
  • 31. Double screws and 4.5-mm screws provide stronger mechanical fixation. Two-hole locking plates (with 3.2-mm screws) provide greater stability to torque compared with 4.5-mm quadricortical fixation in Maisonneuve fractures. However, while the strength of fixation stabilizes the joint, it eliminates normal motion between the tibia and fibula
  • 33. If the screw is placed too far proximally, it may deform the fibula and cause the mortise to widen. If the screw is not parallel to the joint, the fibula may shift proximally. If the screw is not perpendicular to the tibiofibular joint, the fibula may remain laterally displaced. The AO group recommended a fully threaded syndesmotic screw in a neutralization mode
  • 34. SUTURE BUTTON Suture-button fixation represents a promising alternative. Following reduction, a hole is drilled through the fibula and tibia parallel to the ankle joint. Polyester suture is then passed through and secured at both ends with buttons. Although this does not provide fixation as rigid as syndesmotic screws, it may facilitate motion of the distal tibiofibular joint.
  • 35. POSTERIOR MALLEOLAR FIXATION Recent evidence indicates that fixation of the posterior malleolus with an intact posterior inferior tibiofibular ligament adequately stabilizes the syndesmosis. The posterior malleolus can be fixed utilizing percutaneous anterior-to-posterior screws when the fragment is minimally displaced. An open posterolateral surgical approach to the ankle with antiglide plate placement is required for large fragments or if substantial displacement of the articular surface exists.
  • 37. CONSERVATIVE TREATMENT A systematic review by Jones and Amendola identified six clinical studies evaluating outcomes after conservative treatment. All studies showed prolonged recovery in syndesmotic sprains compared with lateral ankle sprains. While none of these studies utilized functional outcome measures, Nussbaum et al. found that injury to the interosseous membrane proximal to the ankle joint correlated with a longer time to return to activity after conservative treatment compared with lateral ankle sprains. Taylor et al. reported an average time to full activity of thirty-one days for football players following conservative treatment
  • 39. SYNDESMOTIC SCREW There are no major differences in functional outcomes between single and double screws, tricortical and quadricortical screws, transsyndesmotic and suprasyndesmotic screws, stainless steel and titanium screws, or metal and bio absorbable screws.
  • 40. SUTURE BUTTON A recent systematic review found that suture-button fixation yielded American Orthopaedic Foot & Ankle Society (AOFAS) scores at twelve and twenty-eight months similar to those for screw fixation. Patients with suture-button fixation also returned to work earlier and had less frequent need for implant removal compared with those who had screw fixation. While a suture button is more expensive than screws and lacks conclusive evidence of superiority, the decreased need for surgical removal may make this technique more cost-effective
  • 41. POSTERIOR MALLEOLUS FIXATION Gardner et al. randomly assigned ten cadaveric specimens with replicated fracture patterns to either posterior malleolar fixation or syndesmotic fixation. Posterior malleolar fixation restored stiffness to 70%, and syndesmotic fixation restored stiffness to 40% of that noted in the intact specimens.
  • 42. Miller et al. prospectively treated thirty-one unstable ankle fractures with preoperatively confirmed syndesmotic injuries and an intact posterior inferior tibiofibular ligament (1) open posterior malleolar fixation whenever the posterior malleolus was fractured, regardless of fragment size (2) locked syndesmotic screws in the absence of posterior malleolar fracture (3) combined fixation in fracture-dislocations and severe soft-tissue injury to the other ankle ligaments
  • 44. MALREDUCTION Anatomic reduction of the syndesmosis is essential for improving functional outcomes and avoiding posttraumatic osteoarthritis A prospective study by Sagi et al. found that, at the time of the two-year follow-up, individuals with a malreduced syndesmosis had significantly worse functional outcomes than individuals with anatomic reductions a study comparing suture-button and screw fixation found that malreduction was the only variable that affected clinical outcomes Recent studies have noted syndesmotic malreduction in 25.5% to 52% of patients
  • 45. Direct visualization of the tibiofibular joint can reduce the malreduction rate from approximately 50% to 15%. Intraoperative three-dimensional imaging can also accurately detect malreduction Images of the contralateral, uninjured ankle can be used to assess the accuracy of reduction of the syndesmosis Song et al. sought to determine the effect of screw removal on the alignment of the distal tibiofibular joint. Patients with intact implants and symptomatic malreduction may only require simple screw removal rather than extensive revisions
  • 46. HARDWARE FAILURE AND IMPLANT REMOVAL Syndesmotic fixation limits fibular biomechanics during normal motion of the ankle. As patients increase weight-bearing and resume activities, shear stresses can cause syndesmotic screws to break. Screw breakage has been reported to occur in 7% to 29% of patients who have had fixation, depending on the time of screw removal. Stuart and Panchbhavi found that 3.5-mm screws were significantly more likely to break than were 4 mm or 4.5-mm screws
  • 47. Syndesmotic screw removal at six weeks reduces the rate of implant failure, but increases the rate of recurrent diastasis. Studies have found no significant difference in outcomes between patients with retained screws and those with the screws removed. However, several studies have shown that patients with retained broken screws had better functional outcome scores than patients with retained intact screws The findings outlined above suggest that restoration of normal fibular motion and alignment of syndesmosis profoundly impact functional outcomes, whether through implant removal, loosening, or breakage.
  • 48. Screw removal is not without risk, however. Schepers et al. demonstrated a 22.4% complication rate following routine removal of syndesmotic screws, including infection in 9.2% and recurrent diastasis in 6.6%
  • 49. HETEROTOPIC OSSIFICATION Several studies have described the development of heterotopic ossification following syndesmotic disruption. Taylor et al., in a report on fifty syndesmotic sprains in forty-four football players, found that 50% of the patients with radiographs developed heterotopic ossification. Böstman reported a higher prevalence of heterotopic ossification after fixation with bioabsorbable screws Heterotopic ossification can lead to ankle synostosis, resulting in pain and abnormal ankle kinematics. The prevalence of syndesmotic synostosis after an ankle fracture has been reported to range from 1.7% to 18.2%..
  • 50. OVERVIEW Despite the amount of research devoted to syndesmotic injuries, many unanswered questions remain. Syndesmotic injuries are difficult to diagnose and treat, with malreductions remaining commonplace. The effectiveness of the gold-standard syndesmotic screw fixation method is being brought increasingly into question.
  • 51. Obtaining anatomic reduction is essential, and the use of intraoperative three-dimensional imaging or open visualization may be warranted. The need for routine screw removal remains controversial. Although screw removal restores normal motion of the fibula and may allow for spontaneous reduction of malreductions, the data remain inconclusive. A complete summary of recommendations for care is given in

Hinweis der Redaktion

  1. 3 – despite common occurance 4 - With such variation and disagreement in treatment strategies, orthopaedic surgeons need to understand the complex nature of the distal tibiofibular joint, pitfalls associated with treatment, and current evidence regarding management of syndesmotic injuries
  2. The anterior inferior tibiofibular ligament (35%) and deep posterior inferior tibiofibular ligament (33%) contribute the most to ankle stability, followed by the interosseous ligament (22%) and superficial posterior tibiofibular ligament (9%)
  3. 2 - In plantar flexion, the fibula migrates distally, translates anteromedially, and internally rotates. With dorsiflexion, the fibula migrates proximally, translates posterolaterally, and externally rotates. Externally rotating the foot causes medial translation, posterior displacement, and external rotation of the fibula through the syndesmosis 3 --
  4. McKeon et al. examined the vascular components of cadaveric ankle specimens12 (Fig. 2). In 86% of the specimens, the anterior syndesmotic ligaments were predominantly vascularized by the anterior branch of the peroneal artery. In 63% of the specimens, the anterior syndesmotic ligaments were only vascularized by the anterior branch of the peroneal artery. The posterior branch of the peroneal artery provided the predominant blood supply to the posterior syndesmotic ligaments in 100% of the specimens. The anterior branch perforated the interosseous membrane at an average height of 3 cm proximal to the ankle joint. Therefore, the blood supply to the anterior syndesmotic ligaments is at considerable risk of injury.
  5. These forces cause the talus to abduct or rotate externally in the mortise, leading to disruption of the syndesmotic ligaments
  6. Physical examination can be conducted after three to five days of rest, ice, compression, and elevation (RICE) and nonsteroidal anti-inflammatory drugs without sacrificing diagnostic accuracy. However, as many as 20% of syndesmotic injuries may go undetected on clinical examination
  7.  radiographic evaluation often fails to detect subtle syndesmotic injuries, so CT and MRI
  8. While both tests showed excellent interobserver agreement, the sensitivity of both tests was poor, suggesting that many syndesmotic disruptions go undetected.
  9. Patients transition to Phase II when pain and edema are well controlled and the patient can walk with minimal antalgic gait. Patients who do not plan to return to athletics can continue on Phase II until asymptomatic. Patients who desire to resume athletic activities transition to Phase III when they are able to jog or hop without pain
  10. The primary fibular malpositions were anterior displacement and internal rotation of the distal end of the fibula.
  11. The screw should be positioned 2 to 3 cm proximal to the tibial plafond, directed. parallel to the joint surface, and angled 30 degrees anteriorly so that it is perpendicular to the tibiofibular joint
  12.  Postoperative and follow-up Foot and Ankle Outcome Scores were similar in the three groups
  13. Traditional radiographs and fluoroscopy provide inaccurate assessment of syndesmotic reduction, especially concerning fibular external rotatiON
  14. These findings suggest that removal of symptomatic intact screws may be prudent, rather than waiting for breakage or loosening
  15. The pathophysiology of heterotopic ossification and synostosis of the ankle is poorly understood. Additionally, limited data exist with regard to the relationship between heterotopic ossification and functional outcome scores