Skeletal Radiology

, Volume 45, Issue 3, pp 333–338 | Cite as

Targeted computerised tomography scanning of the ankle syndesmosis with low dose radiation exposure

  • Rahul KotwalEmail author
  • Narendra Rath
  • Vishal Paringe
  • Sandeep Hemmadi
  • Rhys Thomas
  • Kath Lyons
Scientific Article



To devise a new protocol for targeted CT scanning of the distal tibiofibular syndesmosis with minimal radiation exposure to patients. We also aimed to correlate the reduction of the syndesmosis as seen on CT scans with the functional outcome of patients.

Materials and methods

Prospective study. Forty adults undergoing surgical stabilisation of an acute distal tibiofibular syndesmosis injury were recruited. A targeted five-cut computerised tomography scan protocol was developed. The radiation exposure to the patient with this protocol was only 0.002 mSv. Scans were performed 12 weeks after surgery. The contralateral ankle of every patient was used as a control to determine the accuracy of the reduction of the syndesmosis for that individual patient. American Orthopaedic Foot and Ankle Society (AOFAS) scores were obtained at a minimum of 1 year after surgery.


After considering the exclusions, 36 patients formed the study group. A wide variation was observed in the anatomy of the normal syndesmosis. If we considered a difference of more than 2 mm between the normal and injured syndesmosis relationship as significant, 15 (41.6 %) of our patients had a significant difference between the injured and normal sides. AOFAS scores were available for 13 of these patients and were good to excellent in 11(84.6 %).


Our study describes a reliable new CT scanning technique for the distal tibiofibular syndesmosis using only five cuts and a low-radiation-dose protocol. Clinical correlation of the findings on the scan with functional outcomes suggests that routine post-operative CT of the syndesmosis is probably not justified.


Ankle syndesmosis Computed tomography 


Source of funding


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Hopkinson WJ, St.Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10(6):325–30.PubMedCrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures—an increasing problem? Acta Orthop Scand. 1998;69(1):43–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19(2):102–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788–92.PubMedGoogle Scholar
  5. 5.
    Mukhopadhyay S, Metcalfe A, Guha AR, Mohanty K, Hemmadi S, Lyons K, et al. Malreduction of syndesmosis—are we considering the anatomical variation? Injury. 2011;42(10):1073–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Hermans JJ, Wentink N, Beumer A, Hop WC, Heijboer MP, Moonen AF, et al. Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skelet Radiol. 2012;41(7):787–801.CrossRefGoogle Scholar
  7. 7.
    Cheung Y, Perrich KD, Gui J, Koval KJ, Goodwin DW. MRI of isolated distal fibular fractures with widened medial clear space on stressed radiographs: which ligaments are interrupted? AJR Am J Roentgenol. 2009;192(1):W7–12.PubMedCrossRefGoogle Scholar
  8. 8.
    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;18(11):693–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA. Computed tomography of normal distal tibiofibular syndesmosis. Skelet Radiol. 2010;39(6):559–64.CrossRefGoogle Scholar
  10. 10.
    George D, Mallery P. SPSS for windows step by step: a simple guide and reference. 11.0 update. 4th ed. Boston: Allyn & Bacon; 2003.Google Scholar
  11. 11.
    Kline P. The handbook of psychological testing. 2nd ed. London: Routledge; 1999.Google Scholar
  12. 12.
    Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10(3):156–60.PubMedCrossRefGoogle Scholar
  13. 13.
    Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int. 2012;33(10):870–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Rasi AM, Kazemian G, Omidian MM, Nemati A. Syndesmotic malreduction after ankle ORIF; is radiography sufficient? Arch Bone Joint Surg. 2013;1(2):98–102.Google Scholar
  15. 15.
    Gifford PB, Lutz M. The tibiofibular line: an anatomical feature to diagnose syndesmosis malposition. Foot Ankle Int. 2014;35(11):1181–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26(7):433–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Nault M, Hébert-Davies J, Laflamme G, Leduc S. CT scan assessment of the syndesmosis: a new reproducible method. J Orthop Trauma. 2013;27(11):638–41.PubMedCrossRefGoogle Scholar
  18. 18.
    Lepojärvi S, Pakarinen H, Savola O, Haapea M, Sequeiros RB, Niinimäki J. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma. 2014;28(4):205–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Chen Y, Qiang M, Zhang K, Li H, Dai H. A reliable radiographic measurement for evaluation of normal distal tibiofibular syndesmosis: a multi-detector computed tomography study in adults. J Foot Ankle Res. 2015;8:32.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Hermans JJ, Beumer A, De Jong TAW, Kleinrensink G. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633–45.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Ser A. 1976;58(3):356–7.Google Scholar

Copyright information

© ISS 2015

Authors and Affiliations

  • Rahul Kotwal
    • 1
    Email author
  • Narendra Rath
    • 2
  • Vishal Paringe
    • 3
  • Sandeep Hemmadi
    • 3
  • Rhys Thomas
    • 3
  • Kath Lyons
    • 3
  1. 1.Princess of Wales HospitalBridgendUK
  2. 2.Royal Gwent HospitalNewportUK
  3. 3.University Hospital of WalesCardiffUK

Personalised recommendations