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Management of acute injuries of the tibiofibular syndesmosis

  • Nicholas M. Fort
  • Amiethab A. Aiyer
  • Jonathan R. Kaplan
  • Niall A. Smyth
  • Anish R. KadakiaEmail author
General Review • ANKLE - FRACTURES

Abstract

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11–20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.

Keywords

Ankle fractures Syndesmotic injuries Ligament injury 

Notes

Compliance with ethical standards

Conflict of interest

Author Anish Kadakia has received royalties and speaking fees from Accumed, royalties from Depuy, and consulting fees from Arthrex. Authors Jonathan Kaplan and Amiethab Aiyer have received consulting fees from Paragon 28 and Medline. Authors Niall Smyth and Nicholas Fort have no conflicts of interest to report.

Ethical approval

This article does not contain any studies with human or animal participants performed by any of the authors.

References

  1. 1.
    Ogilvie-Harris DJ, Reed SC, Hedman TP (1994) Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 10(5):558–560CrossRefPubMedGoogle Scholar
  2. 2.
    Fallat L, Grimm DJ, Saracco JA (1998) Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 37(4):280–285CrossRefPubMedGoogle Scholar
  3. 3.
    McCollum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN (2013) Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Trau-matol Arthrosc 21(6):1328–1337CrossRefGoogle Scholar
  4. 4.
    Weening B, Bhandari M (2005) Predictors of functional outcome following trans-syndesmotic screw fixation of ankle fractures. J Orthop Trauma 19(2):102–108CrossRefPubMedGoogle Scholar
  5. 5.
    Purvis GD (1982) Displaced, unstable ankle fractures: classification, incidence, and management of a consecutive series. Clin Orthop Relat Res 165:91–98Google Scholar
  6. 6.
    Sagi HC, Shah AR, Sanders RW (2012) The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma 26(7):439–443CrossRefPubMedGoogle Scholar
  7. 7.
    Wei F, Villwock MR, Meyer EG, Powell JW, Haut RC (2010) Biomechanical investigation of ankle injury under excessive external foot rotation in the human cadaver. J Biomech Eng 132(9):091001CrossRefPubMedGoogle Scholar
  8. 8.
    Lloyd J, Elsayed S, Hariharan K, Tanaka H (2006) Revisiting the concept of talar shift in ankle fractures. Foot Ankle Int 27(10):793–796CrossRefPubMedGoogle Scholar
  9. 9.
    Norkus SA, Floyd RT (2001) The anatomy and mechanisms of syndesmotic ankle sprains. J Athl Train 36(1):68–73PubMedPubMedCentralGoogle Scholar
  10. 10.
    Marvan J, Dzupa V, Krbec M, Skala-Rosenbaum J, Bartoska R, Kachlik D, Baca V (2016) Distal tibiofibular synostosis after surgically resolved ankle fractures: an epidemiological, clinical, and morphological evaluation of a patient sample. Injury 47(11):2570–2754CrossRefPubMedGoogle Scholar
  11. 11.
    Veltri DM, Pagnani MJ, O’brien SJ, Warren RF, Ryan MD, Barnes RP (1995) Symptomatic ossification of the tibiofibular syndesmosis in professional football players: a sequel of the syndesmotic ankle sprain. Foot Ankle Int 16(5):285–290CrossRefPubMedGoogle Scholar
  12. 12.
    Boden SD, Labropoulous PA, McCowin P, Lestini WF, Hurwitz SR (1989) Mechanical considerations for the syndesmosis screw. a cadaver study. J Bone Jt Surg Am 71(10):1548–1555CrossRefGoogle Scholar
  13. 13.
    Dattani R, Patnaik S, Kantak A, Srikanth B, Slvan TP (2008) Injuries to the tibiofibular syndesmosis. J Bone Jt Surg Br 90(4):405–410CrossRefGoogle Scholar
  14. 14.
    Lauge-Hansen N (1950) Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 60(5):957–958CrossRefPubMedGoogle Scholar
  15. 15.
    Am Pankovich (1976) Maisonneuve fracture of the fibula. J Bone Jt Surg Am 58(3):337–342CrossRefGoogle Scholar
  16. 16.
    Weber BG (1972) Die Verletzungen ds Oberen Sprungelenkes. 2nd edn. Verlag Hans Huber, BernGoogle Scholar
  17. 17.
    Stark E, Tornetta P 3rd, Creevy WR (2007) Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma 21(9):643–646CrossRefPubMedGoogle Scholar
  18. 18.
    Williams GN, Jones MH, Amendola A (2007) Syndesmotic ankle sprains in athletes. Am J Sports Med 35(7):1197–1207CrossRefPubMedGoogle Scholar
  19. 19.
    Zalavras C, Thordarson D (2007) Ankle Syndesmotic Injury. J Am Acad Orthop Surg 15(6):330–339CrossRefPubMedGoogle Scholar
  20. 20.
    Beumer A, Swierstra BA, Mulder PGH (2002) Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains. Acta Orthop Scand 73(6):667–669PubMedGoogle Scholar
  21. 21.
    Boytim MJ, Fischer DA, Neumann L (1991) Syndesmotic ankle sprains. Am J Sports Med 19(3):294–298CrossRefPubMedGoogle Scholar
  22. 22.
    Jiang KN, Schulz BM, Tsui YL, Gardner TR, Greisberg JK (2014) Comparison of radiographic stress tests for syndesmotic instability of supination external rotation of ankle fractures: a cadaveric study. J Orthop Trauma 28(6):e123–e127CrossRefPubMedGoogle Scholar
  23. 23.
    Kiter E, Bozkurt M (2005) The crossed-leg test for examination of ankle syndesmosis injuries. Foot Ankle Int 26(2):187–188CrossRefPubMedGoogle Scholar
  24. 24.
    Jones CB, Gilde A, Sietsema DL (2015) Treatment of syndesmotic injuries of the ankle: a critical analysis review. JBJS Rev. doi: 10.2106/JBJS.RVW.N.00083
  25. 25.
    de Cesar PC, Avila EM, de Abreu MR (2011) Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int 32(12):1110–1114CrossRefPubMedGoogle Scholar
  26. 26.
    Sman AD, Hiller CE, Refshauge KM (2013) Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med 47(10):620–628CrossRefPubMedGoogle Scholar
  27. 27.
    Harper MC, Keller TS (1989) A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 10(3):156–160CrossRefPubMedGoogle Scholar
  28. 28.
    Nielson JH, Gardner MJ, Peterson MGE, Sallis JG, Potter HG, Helfet DL, Lorich DG (2005) Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res 436:216–221CrossRefGoogle Scholar
  29. 29.
    Hoshino CM, Nomoto EK, Norheim EP, Harris TG (2012) Correlation of weight bearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int 33(2):92–98CrossRefPubMedGoogle Scholar
  30. 30.
    Nault ML, Hebert Davies J, Laflamme GY, Leduc S (2013) CT scan assessment of the syndesmosis: a new reproducible method. J Orthop Trauma 27(11):638–641CrossRefPubMedGoogle Scholar
  31. 31.
    Vogl TJ, Hochmuth K, Diebold T, Lubrich J, Hofmann R, Stockle U, Sollner O, Bisson S, Sudkamp N, Maeurer J, Haas N, Felix R (1997) Magnetic resonance imaging in the diagnosis of acute injured distal tibiofibular syndesmosis. Investig Radiol 32(7):401–409CrossRefGoogle Scholar
  32. 32.
    Pakarinen H, Flinkkila T, Ohtonen P, Hyvonen P, Lakovaara M, Leppilahti J, Ristiniemi J (2011) 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 Jt Surg Am 93(22):2057–2061CrossRefGoogle Scholar
  33. 33.
    Takao M, Ochi M, Naito K et al (2001) Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 17(8):836–843CrossRefPubMedGoogle Scholar
  34. 34.
    Bonasia DE, Rossi R, Saltzman CL, Amendola A (2011) The role of arthroscopy in the management of fractures about the ankle. J Am Acad Orthop Surg 19(4):226–235CrossRefPubMedGoogle Scholar
  35. 35.
    Sman AD, Hiller CE, Rae K, Linklater J, Black DA, Refshauge KM (2014) Prognosis of ankle syndesmosis injury. Med Sci Sports Exerc 46(4):671–677CrossRefPubMedGoogle Scholar
  36. 36.
    Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE (2001) Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med 29(1):31–35PubMedGoogle Scholar
  37. 37.
    Mulligan EP (2011) Evaluation and management of ankle syndesmosis injuries. Phys Ther Sport. 12(2):57–69CrossRefPubMedGoogle Scholar
  38. 38.
    Brosky T, Nyland J, Nitz A, Caborn DNM (1995) The ankle ligaments: consideration of syndesmotic injury and implications for rehabilitation. J Orthop Sports Phys Ther 21(4):197–205CrossRefPubMedGoogle Scholar
  39. 39.
    Samra DJ, Sman AD, Rae K, Linklater J, Refshauge KM, Hiller CE (2015) Effectiveness of a single platelet-rich plasma injections to promote recovery in rugby players with ankle syndesmosis injury. BMJ Open Sports Exerc Med 1:e000033. doi: 10.1136/bmjsem-2015-000033 CrossRefGoogle Scholar
  40. 40.
    Taylor DC, Englehardt DL, Bassett FH 3rd (1992) Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med 20(2):146–150CrossRefPubMedGoogle Scholar
  41. 41.
    Mansour AA, Porter DA, Young JP, Hammer D, Boublik M, Schlegel TF (2013) Corticosteroid injections hasten return to play of National Football League players following stable ankle syndesmosis sprains. Orthop J Sports Med. doi: 10.1177/2325967113S00023
  42. 42.
    Hamoui M, Ali M, Lovas F, Bonnel F (2008) Rotational malalignment of the fibular malleolus after osteosynthesis of ankle fractures. Med Chir Pied 24:155–164CrossRefGoogle Scholar
  43. 43.
    Marmor M, Kandemir U, Matityahu A, Jergesen H, McClellan T, Morshed S (2013) A method for detection of lateral malleolar malrotation using conventional fluoroscopy. J Orthop Trauma 27(12):e281–e284CrossRefPubMedGoogle Scholar
  44. 44.
    Chu A, Weiner L (2009) Distal fibula malunions. J Am Acad Orthop Surg 17(4):220–230CrossRefPubMedGoogle Scholar
  45. 45.
    Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM (2013) Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma 27(2):100–106CrossRefPubMedGoogle Scholar
  46. 46.
    Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL (2012) Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Jt Surg Am 94(24):2255–2261CrossRefGoogle Scholar
  47. 47.
    Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27(10):788–792CrossRefPubMedGoogle Scholar
  48. 48.
    Franke J, von Recum J, Suda AJ, Grutzner PA, Wendl K (2012) Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Jt Surg Am 94(15):1386–1390CrossRefGoogle Scholar
  49. 49.
    Summers HD, Sinclair MK, Stover MD (2013) A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma 27(4):196–200CrossRefPubMedGoogle Scholar
  50. 50.
    Schreiber JJ, As McLawhorn, Dy CJ, Goldwyn EM (2013) Intraoperative contralateral view for assessing accurate syndesmosis reduction. Orthopedics 36(5):360–361CrossRefPubMedGoogle Scholar
  51. 51.
    Lambers KT, van den Bekerom MP, Doornberg JN, Stufkens SA, van Dijk CN, Kloen P (2013) Long-term outcome of pronation-external rotation ankle fractures treated with syndesmotic screws only. J Bone Jt Surg Am 95(17):e1211–e1217CrossRefGoogle Scholar
  52. 52.
    Symeonidis PD, Iselin LD, Chehade M, Stavrou P (2013) Common pitfalls in syndesmotic rupture management: a clinical audit. Foot Ankle Int 34(3):345–350 CrossRefPubMedGoogle Scholar
  53. 53.
    Hoiness P, Stromsoe K (2004) Tricortical versus quadcortical syndesmosis fixation in ankle fractures: a prospective randomized study comparing two methods of syndesmosis fixation. J Orthop Trauma 18(6):331–337CrossRefPubMedGoogle Scholar
  54. 54.
    Se Rao, Muzammil S, Khan AH (2008) Syndesmosis fixation in bimalleolar Weber C ankle fractures; comparison of 3.5 mm and 4.5 mm screws. Prof Med J 15:49–53Google Scholar
  55. 55.
    Markolf KL, Jackson SR, McAllister DR (2013) Syndesmosis fixation using dual 3.5 mm and 4.5 mm scres with tricortical and quadcortical purchase: a biomechanical study. Foot Ankle Int 34(5):734–739CrossRefPubMedGoogle Scholar
  56. 56.
    Sun H, Luo CF, Zhong B, Shi HP, Zhang CQ, Zeng BF (2014) A prospective randomised trial comparing the use of absorbable and metallic screws in the fixation of the distal tibiofibular syndesmosis injuries:mid-term follow-up. Bone Jt J 96-B(4):548–554CrossRefGoogle Scholar
  57. 57.
    Thordarson DB, Samuelson M, Shepherd LE, Merkle PF, Lee J (2001) Bioabsorbably versus stainless steel screw fixation of the syndesmosis in pronation-lateral rotation ankle fractures: a prospective randomized trial. Foot Ankle Int 22(4):335–338CrossRefPubMedGoogle Scholar
  58. 58.
    Beumer A, Campo MM, Niesing R, Day J, Kleinrensink GJ, Swierstra BA (2005) Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury 36(1):60–64CrossRefPubMedGoogle Scholar
  59. 59.
    Boyer BA, Vrabec GA, Njus GO, Feliciano G, Kay DB, Bennett GL (2001) Biomechanical comparison of distal tibiofibular syndesmosis stability with use of screws placed at different distances from the ankle joint. In: Presented as a poster exhibit at the Annual Meeting of the Orthopedi Trauma Association, San Diego, California, Poster no. 49Google Scholar
  60. 60.
    Kukreti S, Faraj A, Miles JNV (2005) Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury 36(9):1121–1124CrossRefPubMedGoogle Scholar
  61. 61.
    Schepers T, van der Linden H, van Lieshout EM, Niesten DD, van der Elst M (2014) Technical aspects of the syndesmotic screw and their effect on functional outcome following acute distal tibiofibular syndesmosis injury. Injury 45(4):775–779CrossRefPubMedGoogle Scholar
  62. 62.
    Moore JA Jr, Shank JR, Morgan SJ, Smith WR (2006) Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int 27(8):567–572CrossRefPubMedGoogle Scholar
  63. 63.
    Wilkeroy AKB, Hoiness PR, Andreassen GS, Hellund JC, Madsen JE (2010) No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures. J Orthop Trauma 24(1):17–23CrossRefGoogle Scholar
  64. 64.
    Inge SY, Pull Ter Gunne AF, Aarts CA, Bemelman M (2016) A systematic review on dynamic versus static distal tibiofibular fixation. Injury 47(12):2627–2634CrossRefPubMedGoogle Scholar
  65. 65.
    Schepers T (2012) Acute distal tibiofibular syndesmosis injury: a systematic review of suture button versus syndesmotic screw repair. Int Orthop 36(6):1199–1206 CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Naqvi GA, Cunningham P, Lynch B, Galvin R, Awan N (2012) Fixation of ankle syndesmotic injuries: comparison of TightRope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med 40(12):2828–2835CrossRefPubMedGoogle Scholar
  67. 67.
    Westermann RW, Rungprai C, Goetz JE, Femino J, Amendola A, Phisitkul P (2014) The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. J Bone Jt Surg Am 96(20):1732–1738CrossRefGoogle Scholar
  68. 68.
    Kim JH, Gwak HC, Lee CR, Choo HJ, Kim JG, Kim DY (2016) A comparison of Screw fixation and Suture-Button Fixation in a Syndesmosis Injury in an Ankle Fracture. J Foot Ankle Surg 55(5):985–990CrossRefPubMedGoogle Scholar
  69. 69.
    Schepers T, van Zuuren WJ, van den Bekerom MP, Vogels LM, van Lieshout EM (2012) The management of acute distal tibio-fibular syndesmotic injuries: results of a nationwide survey. Injury 43(10):1718–1723Google Scholar
  70. 70.
    Welck MJ, Ray P (2013) Tibialis anterior tendon entrapment after ankle TightRope fixation. Foot Ankle Spec 6(3):242–246CrossRefPubMedGoogle Scholar
  71. 71.
    Hohman DW et al (2011) Pathologic tibia/fibula fracture through suture button screw tract: case report. Am J Sport Med 39(3):645–648CrossRefGoogle Scholar
  72. 72.
    Citak M et al (2011) Distal tibial fracture post syndesmotic screw removal: an adverse complication. Arch Orthop Trauma Surg 131(10):1405–1408CrossRefPubMedGoogle Scholar
  73. 73.
    Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG (2006) Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 447:165–171 CrossRefPubMedGoogle Scholar
  74. 74.
    Odak S, Ahluwalia R, Unnikrishnan P, Hennessy M, Platt S (2016) Management of posterior malleolar fractures: a systematic review. J Foot Ankle Surg 55(1):140–145CrossRefPubMedGoogle Scholar
  75. 75.
    Drijfhout Van Hoof CC, Verhage SM, Hoogendoorn JM (2015) Influence of fragment size and post-operative joint congruency on long term outcome of posterior malleolar fractures. Foot Ankle Int 36(6):673–678Google Scholar
  76. 76.
    Schepers T, Van Lieshout EM, Van der Linden HJ, De Jong VM, Goslings JC (2013) Aftercare following syndesmotic screw placement: a systematic review. J Foot Ankle Surg 52(4):491–494CrossRefPubMedGoogle Scholar
  77. 77.
    Huber T, Schmoelz W, Bolderl A (2012) Motion of the fibula relative to the tibia and its alterations with syndesmosis screws: a cadaver study. Foot Ankle Surg 18(3):203–209CrossRefPubMedGoogle Scholar
  78. 78.
    Hamid N, Loeffler BJ, Braddy W, Kellam JF, Cohen BE, Bosse MJ (2009) Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Jt Surg Br 91(8):1069–1073CrossRefGoogle Scholar
  79. 79.
    Egol KA, Pahk B, Walsh M, Tejwani NC, Davidovitch RI, Koval KJ (2010) Outcome after unstable ankle fracture: effect of syndesmotic stabilization. J Orthop Trauma 24(1):7–11CrossRefPubMedGoogle Scholar
  80. 80.
    Manjoo A, Sanders DW, Tieszer C, Macleod MD (2010) Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma 24(1):2–6CrossRefPubMedGoogle Scholar
  81. 81.
    Kellett JJ (2011) The clinical features of the ankle syndesmosis injuries: a general review. Clin J Sports Med 21(6):524–529Google Scholar
  82. 82.
    Weening B, Bhandari M (2005) Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Ortho Trauma 19:102–108Google Scholar
  83. 83.
    Stuart K, Panchbhavi VK (2011) The fate of the syndesmotic screws. Foot and Ankle Int 32(5):S519–S525Google Scholar
  84. 84.
    Dingermans SA, Rammelt S, White TO, Goslings JC, Schepers T (2016) Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? A systematic review. Bone Jt J 98-B(11):1497–1504CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France 2017

Authors and Affiliations

  • Nicholas M. Fort
    • 1
  • Amiethab A. Aiyer
    • 1
  • Jonathan R. Kaplan
    • 2
  • Niall A. Smyth
    • 1
  • Anish R. Kadakia
    • 3
    Email author
  1. 1.University of Miami Miller School of MedicineMiamiUSA
  2. 2.Orthopaedic Specialty InstituteOrangeUSA
  3. 3.Northwestern University Feinberg School of MedicineChicagoUSA

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