Current Reviews in Musculoskeletal Medicine

, Volume 6, Issue 4, pp 304–312 | Cite as

Syndesmosis injuries

Foot and Ankle (SG Parekh, Section Editor)

Abstract

Traumatic injuries to the distal tibiofibular syndesmosis commonly result from high-energy ankle injuries. They can occur as isolated ligamentous injuries and can be associated with ankle fractures. Syndesmotic injuries can create a diagnostic and therapeutic challenge for musculoskeletal physicians. Recent literature has added considerably to the body of knowledge pertaining to injury mechanics and treatment outcomes, but there remain a number of controversies regarding diagnostic tests, implants, techniques, and postoperative protocols. Use of the novel suture button device has increased in recent years and shows some promise in clinical and cadaveric studies. This article contains a review of syndesmosis injuries, including anatomy and biomechanics, diagnosis, classification, and treatment options.

Keywords

Syndesmosis injury High ankle sprain Pronation external rotation Sports injury TightRope Syndesmotic screws 

Notes

Compliance with Ethics Guidelines

Conflict of Interest

Kenneth J. Hunt declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633–45. Epub 2010/11/26. The article by Hermans et al. is a comprehensive pictorial description of syndesmosis anatomy as it relates to injury biomechanics.PubMedCrossRefGoogle Scholar
  2. 2.
    Bartonicek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surgical Radiol Anat: SRA. 2003;25(5–6):379–86. Epub 2003/09/25.CrossRefGoogle Scholar
  3. 3.
    Kim S, Huh YM, Song HT, Lee SA, Lee JW, Lee JE, et al. Chronic tibiofibular syndesmosis injury of ankle: evaluation with contrast-enhanced fat-suppressed 3D fast spoiled gradient-recalled acquisition in the steady state MR imaging. Radiology. 2007;242(1):225–35. Epub 2006/12/23.PubMedCrossRefGoogle Scholar
  4. 4.
    Takao M, Ochi M, Oae K, Naito K, Uchio Y. Diagnosis of a tear of the tibiofibular syndesmosis. J Bone Joint Surg Br. 2003;85(3):324–9. Epub 2003/05/06.PubMedCrossRefGoogle Scholar
  5. 5.
    McKeon KE, Wright RW, Johnson JE, McCormick JJ, Klein SE. Vascular anatomy of the tibiofibular syndesmosis. J Bone Joint Surg Am. 2012;94(10):931–8. Epub 2012/05/24.PubMedCrossRefGoogle Scholar
  6. 6.
    Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin. 2009;14(2):277–98. Epub 2009/06/09.PubMedCrossRefGoogle Scholar
  7. 7.
    Fritschy D. An unusual ankle injury in top skiers. Am J Sports Med. 1989;17(2):282–5. discussion 5–6. Epub 1989/03/01.PubMedCrossRefGoogle Scholar
  8. 8.
    Norkus S, Floyd R. The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train. 2001;36(1):68–73.PubMedGoogle Scholar
  9. 9.
    Pankovich AM. Maisonneuve fracture of the fibula. J Bone Joint Surg Am. 1976;58(3):337–42. Epub 1976/04/01.PubMedGoogle Scholar
  10. 10.
    Haraguchi N, Armiger R. A new interpretation of the mechanism of ankle fracture. J Bone Joint Surg Am. 2009;91:821–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Wei F, Villwock MR, Meyer EG, Powell JW, Haut RC. A biomechanical investigation of ankle injury under excessive external foot rotation in the human cadaver. J Biomech Eng. 2010;132(9):091001. Epub 2010/09/08.PubMedCrossRefGoogle Scholar
  12. 12.
    Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. J Bone Joint Surg Br. 2008;90(4):405–10. Epub 2008/04/02.PubMedGoogle Scholar
  13. 13.
    Femino JE, Vaseenon T, Phistkul P, Tochigi Y, Anderson DD, Amendola A. Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption: a cadaveric study. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2013;34(2):251–60. Epub 2013/02/16.CrossRefGoogle Scholar
  14. 14.
    Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician. 2001;63(1):93–104. Epub 2001/02/24.PubMedGoogle Scholar
  15. 15.
    Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19(3):294–8. Epub 1991/05/01.PubMedCrossRefGoogle Scholar
  16. 16.
    Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998;19(10):653–60. Epub 1998/11/04.CrossRefGoogle Scholar
  17. 17.
    Teitz CC, Harrington RM. A biochemical analysis of the squeeze test for sprains of the syndesmotic ligaments of the ankle. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998;19(7):489–92. Epub 1998/08/07.CrossRefGoogle Scholar
  18. 18.
    de Cesar PC, Avila EM, de Abreu MR. Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2011;32(12):1110–4. Epub 2012/03/03.CrossRefGoogle Scholar
  19. 19.
    Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227–34. Epub 2004/07/03.PubMedCrossRefGoogle Scholar
  20. 20.
    Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle. 1989;10(3):156–60. Epub 1989/12/01.PubMedCrossRefGoogle Scholar
  21. 21.
    Pakarinen H, Flinkkila T, Ohtonen P, Hyvonen P, Lakovaara M, Leppilahti J, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011;93(22):2057–61. Epub 2012/01/21.PubMedCrossRefGoogle Scholar
  22. 22.
    Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2012;33(10):870–6. Epub 2012/10/12.CrossRefGoogle Scholar
  23. 23.
    Summers HD, Sinclair MK, Stover MD. A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma. 2013;27(4):196–200. Epub 2013/03/27.PubMedCrossRefGoogle Scholar
  24. 24.
    Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003;227(1):155–61. Epub 2003/03/05.PubMedCrossRefGoogle Scholar
  25. 25.
    Gardner M, Demetrakopoulos D, Briggs S, Helfet D, Lorich D. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2006;27(10):788–92.Google Scholar
  26. 26.
    Hunt K, Githens M, Riley G, Kim M, Gold G. Foot and ankle injuries in sport imaging correlation with arthroscopic and surgical findings. Clin Sports Med. 2013;32:525–57.PubMedCrossRefGoogle Scholar
  27. 27.
    Wolf BR, Amendola AA. Syndesmosis injuries in the athlete: when and how to operate. Curr Opin Orthop. 2002;31:151–4.CrossRefGoogle Scholar
  28. 28.
    Scranton Jr PE. Sprains and soft tissue injuries. In: Pfefer G, editor. Chronic ankle pain in the athlete. Rosemont, Il: American Academy of Orthopaedic Surgeons; 2000. p. 3–20.Google Scholar
  29. 29.
    Beumer A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM. A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability. Foot Ankle In/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2003;24(4):358–63. Epub 2003/05/09.Google Scholar
  30. 30.
    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. Epub 2011/10/21.CrossRefGoogle Scholar
  31. 31.
    Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19(2):102–8. Epub 2005/01/29.PubMedCrossRefGoogle Scholar
  32. 32.•
    Hunt KJ, George E, Harris AH, Dragoo JL. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association Injury Surveillance System Data from 2004–2005 to 2008–2009. Clin J Sport Med: Official Journal of the Canadian Academy of Sport Medicine. 2013. Epub 2013/01/24. This report of data from the NCAA injury surveillance system describes the incidence and epidemiology of ligamentous syndesmotic injuries in collegiate football players. Consistent with recent data, about a quarter of ankle sprains include syndesmotic injuries. Google Scholar
  33. 33.
    Kaplan LD, Jost PW, Honkamp N, Norwig J, West R, Bradley JP. Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop (Belle Mead NJ). 2011;40(1):40–4. Epub 2011/07/02.PubMedGoogle Scholar
  34. 34.
    Hopkinson WJ, St Pierre P, Ryan JB, Wheeler JH. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10(6):325–30. Epub 1990/06/01.PubMedCrossRefGoogle Scholar
  35. 35.
    Waterman BR, Belmont Jr PJ, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39(5):992–8. Epub 2011/02/04.PubMedCrossRefGoogle Scholar
  36. 36.
    Wright RW, Barile RJ, Surprenant DA, Matava MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941–5. Epub 2004/12/02.PubMedCrossRefGoogle Scholar
  37. 37.
    Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29(1):31–5. Epub 2001/02/24.PubMedGoogle Scholar
  38. 38.
    Kennedy J. Surgical vs non-surgical treatment of syndesmotic injuries. J Orthop Trauma. 1990;14:232–40.Google Scholar
  39. 39.
    Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833–8. Epub 2007/07/24.PubMedCrossRefGoogle Scholar
  40. 40.
    Forsythe K, Freedman KB, Stover MD, Patwardhan AG. Comparison of a novel FiberWire-button construct versus metallic screw fixation in a syndesmotic injury model. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2008;29(1):49–54. Epub 2008/02/16.CrossRefGoogle Scholar
  41. 41.
    Gardner R, Yousri T, Holmes F, Clark D, Pollintine P, Miles AW, et al. Stabilisation of the syndesmosis in the maisonneuve fracture - a biomechanical study comparing two-hole locking plate and quadricortical screw fixation. J Orthop Trauma. 2012. Epub 2012/05/12.Google Scholar
  42. 42.
    Hovis WD, Kaiser BW, Watson JT, Bucholz RW. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg Am. 2002;84-A(1):26–31. Epub 2002/01/17.PubMedGoogle Scholar
  43. 43.
    Thordarson DB, Samuelson M, Shepherd LE, Merkle PF, Lee J. Bioabsorbable versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2001;22(4):335–8. Epub 2001/05/17.Google Scholar
  44. 44.
    Thornes B, Shannon F, Guiney AM, Hession P, Masterson E. Suture-button syndesmosis fixation: accelerated rehabilitation and improved outcomes. Clin Orthop Relat Res. 2005;431:207–12. Epub 2005/02/03.PubMedCrossRefGoogle Scholar
  45. 45.
    Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am. 1995;77(6):847–56. Epub 1995/06/01.PubMedGoogle Scholar
  46. 46.
    Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg. 2007;15(6):330–9. Epub 2007/06/06.PubMedGoogle Scholar
  47. 47.
    Soin SP, Knight TA, Dinah AF, Mears SC, Swierstra BA, Belkoff SM. Suture-button versus screw fixation in a syndesmosis rupture model: a biomechanical comparison. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2009;30(4):346–52. Epub 2009/04/10.CrossRefGoogle Scholar
  48. 48.
    Wikeroy AK, Hoiness PR, Andreassen GS, Hellund JC, Madsen JE. No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma. 2010;24(1):17–23.PubMedCrossRefGoogle Scholar
  49. 49.
    Degroot H, Al-Omari AA, El Ghazaly SA. Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2011;32(3):250–6. Epub 2011/04/12.CrossRefGoogle Scholar
  50. 50.
    Teramoto A, Suzuki D, Kamiya T, Chikenji T, Watanabe K, Yamashita T. Comparison of different fixation methods of the suture-button implant for tibiofibular syndesmosis injuries. Am J Sports Med. 2011;39(10):2226–32. Epub 2011/07/20.PubMedCrossRefGoogle Scholar
  51. 51.
    •• Naqvi GA, Cunningham P, Lynch B, Galvin R, Awan N. Fixation of ankle syndesmotic injuries: comparison of TightRope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med. 2012;40(12):2828–35. Epub 2012/10/12. Well-designed, prospective cohort study indicating that fixation with TightRope provides a more accurate method of syndesmotic stabilization, as compared with syndesmotic screws. Consistent with previous data, syndesmotic malreduction is the most important independent predictor of clinical outcomes.PubMedCrossRefGoogle Scholar
  52. 52.
    Naqvi GA, Shafqat A, Awan N. TightRope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification. Injury. 2012;43(6):838–42. Epub 2011/11/01.PubMedCrossRefGoogle Scholar
  53. 53.
    •• Storey P, Gadd RJ, Blundell C. Complications of suture button ankle syndesmosis stabilization with modifications of surgical technique. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2012;33(9):717–21. Epub 2012/09/22. This retrospective case series of 102 patients describes complications associated with the TightRope method to reduce their incidence.CrossRefGoogle Scholar
  54. 54.
    Markolf KL, Jackson SR, McAllister DR. Syndesmosis fixation using dual 3.5 mm and 4.5 mm screws with tricortical and quadricortical purchase: a biomechanical study. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2013. Epub 2013/02/14.Google Scholar
  55. 55.
    • Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ. Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma. 2010;24(1):7–11. Epub 2009/12/26. This retrospective review of 347 patients showed that those who required syndesmotic stabilization in addition to fracture fixation had poorer outcomes at 12 months, as compared with patients who required malleolar fracture fixation alone.PubMedCrossRefGoogle Scholar
  56. 56.
    • Symeonidis P, Iselin L, Chehade M, Stavrou P. Common Pitfalls in Syndesmotic Rupture Management : A Clinical Audit. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2013;34(originally published online 18 January 2013):345. This retrospective comparative series conducted at a level 1 trauma center suggests that the reoperation rate for syndesmotic fixation may be higher than previously thought. The authors emphasize the three important points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically.CrossRefGoogle Scholar
  57. 57.
    Beumer A, Campo MM, Niesing R, Day J, Kleinrensink GJ, Swierstra BA. Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury. 2005;36(1):60–4. Epub 2004/12/14.PubMedCrossRefGoogle Scholar
  58. 58.
    Hansen M, Le L, Wertheimer S, Meyer E, Haut R. Syndesmosis fixation: analysis of shear stress via axial load on 3.5-mm and 4.5-mm quadricortical syndesmotic screws. J Foot Ankle Surg: Official Publication of the American College of Foot and Ankle Surgeons. 2006;45(2):65–9. Epub 2006/03/04.CrossRefGoogle Scholar
  59. 59.
    Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2000;21(9):736–41. Epub 2000/10/07.Google Scholar
  60. 60.
    Nousiainen MT, McConnell AJ, Zdero R, McKee MD, Bhandari M, Schemitsch EH. The influence of the number of cortices of screw purchase and ankle position in Weber C ankle fracture fixation. J Orthop Trauma. 2008;22(7):473–8. Epub 2008/08/02.PubMedCrossRefGoogle Scholar
  61. 61.
    Bragonzoni L, Russo A, Girolami M, Albisinni U, Visani A, Mazzotti N, et al. The distal tibiofibular syndesmosis during passive foot flexion. RSA-based study on intact, ligament injured and screw fixed cadaver specimens. Arch Orthop Trauma Surg. 2006;126(5):304–8. Epub 2006/03/29.PubMedCrossRefGoogle Scholar
  62. 62.
    Tornetta 3rd P, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg Am. 2001;83-A(4):489–92. Epub 2001/04/24.PubMedGoogle Scholar
  63. 63.
    Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26(7):439–43. Epub 2012/02/24.PubMedCrossRefGoogle Scholar
  64. 64.•
    Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg. 2011;131(7):879–83. Epub 2010/12/17. This literature review describes recent data on the role of hardware removal for syndesmotic screws. The current literature suggests that hardware removal should be reserved for intact screws that cause hardware irritation or reduced range of motion after 4–6 months.PubMedCrossRefGoogle Scholar
  65. 65.
    Hamid N, Loeffler BJ, Braddy W, Kellam JF, Cohen BE, Bosse MJ. Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg Br. 2009;91(8):1069–73. Epub 2009/08/05.PubMedGoogle Scholar
  66. 66.
    Manjoo A, Sanders DW, Tieszer C, MacLeod MD. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma. 2010;24(1):2–6. Epub 2009/12/26.PubMedCrossRefGoogle Scholar
  67. 67.
    Schepers T, Van Lieshout EM, de Vries MR, Van der Elst M. Complications of syndesmotic screw removal. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2011;32(11):1040–4. Epub 2012/02/22.CrossRefGoogle Scholar
  68. 68.
    Thornes B, Walsh A, Hislop M, Murray P, O'Brien M. Suture-endobutton fixation of ankle tibio-fibular diastasis: a cadaver study. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2003;24(2):142–6. Epub 2003/03/12.Google Scholar
  69. 69.
    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: Official Publication of the American College of Foot and Ankle Surgeons. 2009;48(6):620–30. Epub 2009/10/28.CrossRefGoogle Scholar
  70. 70.
    Coetzee J, Eberling P. Treatment of syndesmosis disruptions with TightRope fixation. Tech Foot Ankle Surg. 2008;7:196–201.CrossRefGoogle Scholar
  71. 71.
    Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG. The effects of rotation on radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int/American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2002;23(2):107–11. Epub 2002/02/23.Google Scholar

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© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryStanford UniversityRedwood CityUSA

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