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Syndesmosenverletzungen

Syndesmosis injuries at the ankle

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Zusammenfassung

Hintergrund

Verletzungen der distalen tibiofibularen Syndesmose sind häufig und sorgen in der klinischen Praxis immer wieder für Kontroversen.

Ziel der Arbeit

Dieser Beitrag fasst den aktuellen Wissensstand über Syndesmoseninstabilitäten zusammen und zeigt Empfehlungen in der Behandlung von Syndesmosenverletzungen auf.

Material und Methoden

Auswertung der aktuellen Literatur hinsichtlich Anatomie, Ätiologie, Diagnostik und Therapie von Syndesmosenverletzungen.

Ergebnisse

Stabile rein ligamentäre Verletzungen können frühfunktionell mittels Physiotherapie behandelt werden. Relevante Instabilitäten der Syndesmose resultieren aus einer Ruptur von mindestens 2 Ligamenten und müssen operativ stabilisiert werden. Instabile Syndesmosenrupturen sind häufig mit knöchernen Avulsionen oder Malleolarfrakturen assoziiert. Zur anatomischen Reposition der distalen Fibula in der Inzisur der distalen Tibia und stabilen Fixation werden bevorzugt eine oder mehrere tibiofibulare Schrauben eingebracht. Alternativ werden biodegradierbare oder flexible Implantate verwendet. Es besteht keine einheitliche Meinung in der Literatur über die Dauer der Fixierung. Schrauben und flexible Implantate, die Beschwerden verursachen, müssen entfernt werden. Die häufigste Komplikation ist die Fehlreposition, die sich durch direkte intraoperative Visualisierung und 3D-Darstellung minimieren lässt. Weitere Komplikationen sind Materialversagen, Verwachsungen, tibiofibulare Synostosen, chronische Instabilität und posttraumatische Arthrose.

Schlussfolgerung

Wichtigste Prognosefaktoren nach instabilen Verletzungen der distalen tibiofibularen Syndesmose mit oder ohne Fraktur sind die anatomische, stabile Wiederherstellung der Knöchelgabel und die Einpassung der distalen Fibula in die Tibiainzisur.

Abstract

Background

Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options.

Objective

The aim of this review is to summarize the current knowledge on syndesmotic instability and to present some recommendations for the clinical practice for acute an chronic injuries.

Material and methods

Analysis of the current literature concerning the anatomy, etiology, diagnostics and treatment of syndesmosis injuries.

Results

Purely ligamentous injuries (high ankle sprains) are not associated with a latent or frank tibiofibular diastasis and can be treated with an extended protocol of physiotherapy. Relevant instability of the syndesmosis with diastasis results from rupture of two or more ligaments and requires surgical stabilization. Syndesmotic disruptions are commonly associated with bony avulsions or malleolar fractures. Treatment consists of anatomic reduction of the distal fibula into the corresponding incisura of the distal tibia and stable fixation. The proposed means of fixation are one or more tibiofibular screws or suture button implants. There is no consensus on how long to maintain fixation. Both syndesmotic screws and suture buttons need to be removed if symptomatic. The most frequent complication is syndesmotic malreduction and can be minimized with direct visualization and intraoperative 3D scanning. Other complications include hardware failure, adhesions, heterotopic ossification, tibiofibular synostosis, chronic instability and posttraumatic arthritis.

Conclusion

The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.

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Literatur

  1. Andersen MR, Frihagen F, Hellund JC, Madsen JE, Figved W (2018) Randomized trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg Am 100(1):2–12

    Article  PubMed  Google Scholar 

  2. Bartoníček J (2003) Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat 5:379–386

    Article  Google Scholar 

  3. Bartoníček J, Rammelt S, Kostlivý K, Klika D, Trešl I (2015) Anatomy and classification of the posterior tibial fragment in ankle fractures. Arch Orthop Trauma Surg 135:505–516

    Article  PubMed  Google Scholar 

  4. Bartoníček J, Rammelt S, Tuček M (2017) Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 22(1):125–145

    Article  PubMed  Google Scholar 

  5. Beumer A, Heijboer RP, Fontijne WP, Swierstra BA (2000) Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand 71:519–521

    Article  CAS  PubMed  Google Scholar 

  6. Beumer A, Swierstra BA, Mulder PG (2002) Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains. Acta Orthop Scand 73:667–669

    PubMed  Google Scholar 

  7. Boszczyk A, Kwapisz S, Krümmel M, Grass R, Rammelt S (2017) Anatomy of the tibial incisura as a risk factor for syndesmotic injury. Foot Ankle Surg. https://doi.org/10.1016/j.fas.2017.08.003

    Article  PubMed  Google Scholar 

  8. Boszczyk A, Kwapisz S, Krümmel M, Grass R, Rammelt S (2018) How does incisura anatomy correlate with syndesmotic malreduction? Foot Ankle Int 39(3):369–375

    Article  PubMed  Google Scholar 

  9. Carr JB II, Werner BC, Yarboro SR (2016) An update on management of syndesmosis injury: a national US database study. Am J Orthop (Belle Mead, NJ) 45:E472–E477

    Google Scholar 

  10. Cosgrove CT, Putnam SM, Cherney SM, Ricci WM, Spraggs-Hughes A, McAndrew CM, Gardner MJ (2017) Medial clamp tine positioning affects ankle syndesmosis malreduction. J Orthop Trauma 31(8):440–446

    Article  PubMed  PubMed Central  Google Scholar 

  11. DeGroot H, Al-Omari AA, El Ghazaly SA (2011) Outcomes of suture button repair of the distal tibiofibular syndesmosis. Foot Ankle Int 32:250–256

    Article  PubMed  Google Scholar 

  12. Dingemans SA, Rammelt S, White TO, Goslings Schepers JCT (2016) Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? A systematic review. Bone Joint J 98-B:1497–1504

    Article  CAS  PubMed  Google Scholar 

  13. Fallat L, Grimm DJ, Saracco JA (1998) Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 37(4):280–285

    Article  CAS  PubMed  Google Scholar 

  14. Fort NM, Aiyer AA, Kaplan JR, Smyth NA, Kadakia AR (2017) Management of acute injuries of the tibiofibular syndesmosis. Eur J Orthop Surg Traumatol 27:449–459

    Article  PubMed  Google Scholar 

  15. Frick H (1978) Zur Entstehung, Klinik, Diagnostik und Therapie der isolierten Verletzung der tibiofibularen Syndesmose. Unfallheilkunde 81:542–545

    PubMed  CAS  Google Scholar 

  16. Futamura K, Baba T, Mogami A et al (2017) Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury 48(4):954–959

    Article  PubMed  Google Scholar 

  17. Gardner MJ, Demetrakopoulos D, Briggs SM et al (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27:788–792

    Article  PubMed  Google Scholar 

  18. Geerling J, Mittlmeier T, Richter M, Ochman S, Brunk M, Zech S, Buß F, Haupt C, Rammelt S (2016) Intraoperative dreidimensionale Bildgebung bei Syndesmosenverletzungen – eine Multicenterstudie der AG Fuß der DGU. Fuß Sprunggelenk 14:9–93

    Article  Google Scholar 

  19. Gifford PB, Lutz M (2014) The tibiofibular line—lan anatomical feature to diagnose syndesmosis malposition. Foot Ankle Int 35:1181–1186

    Article  PubMed  Google Scholar 

  20. Grass R, Rammelt S, Biewener A, Zwipp H (2003) Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int 24:392–397

    Article  PubMed  Google Scholar 

  21. Han SH, Lee JW, Kim S et al (2007) Chronic tibiofibular syndesmosis injury: the diagnostic efficiency of magnetic resonance imaging and comparative analysis of operative treatment. Foot Ankle Int 28:336–342

    Article  PubMed  Google Scholar 

  22. Harper MC, Keller TS (1989) A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle 10:156–160

    Article  CAS  PubMed  Google Scholar 

  23. Heim U (1983) Malleolarfrakturen. Unfallheilkunde 86:248–258

    PubMed  CAS  Google Scholar 

  24. Heineck J, Serra A, Haupt C, Rammelt S (2009) Accuracy of corrective osteotomies in fibular malunion: a cadaver model. Foot Ankle Int 30(8):773–777

    Article  PubMed  Google Scholar 

  25. Höcker K, Pachucki A (1989) Die Incisura fibularis tibiae. Die Stellung der Fibula in der distalen Syndesmose am Querschnitt. Unfallchirurg 92:401–406

    PubMed  Google Scholar 

  26. Hovis WD, Kaiser BW, Watson JT et al (2002) Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg Am 84-A:26–31

    Article  PubMed  Google Scholar 

  27. Kortekangas T et al (2015) A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Adv Orthop 46(6):1119–1126

    Google Scholar 

  28. Laflamme M, Belzile EL, Bédard L, van den Bekerom MP, Glazebrook M, Pelet S (2015) A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma 29(5):216–223

    Article  PubMed  Google Scholar 

  29. Lepojärvi S, Pakarinen H, Savola O et al (2014) Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma 28:205–209

    Article  PubMed  Google Scholar 

  30. Lilyquist M, Shaw A, Latz K, Bogener J, Wentz B (2016) Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int 37(8):882–890

    Article  PubMed  Google Scholar 

  31. Manjoo A, Sanders DW, Tieszer C et al (2010) Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma 24:2–6

    Article  PubMed  Google Scholar 

  32. Marti RK, Raaymakers ELFB, Rammelt S (2009) Rekonstruktion fehlverheilter Sprunggelenkfrakturen. Fuß Sprunggelenk 7:78–87

    Article  Google Scholar 

  33. Miller AN, Barei DP, Iaquinto JM, Ledoux WR, Beingessner DM (2013) Iatrogenic syndesmosis malreduction via clamp and screw placement. J Orthop Trauma 27(2):100–106

    Article  PubMed  Google Scholar 

  34. Mukhopadhyay S, Metcalfe A, Guha AR et al (2011) Malreduction of syndesmosis—are we considering the anatomical variation? Injury 42(10):1073–1076

    Article  CAS  PubMed  Google Scholar 

  35. Naqvi GA, Cunningham P, Lynch B et al (2012) Fixation of ankle syndesmotic injuries: comparison of tightrope fixation and syndesmotic screw fixation for accuracy of syndesmotic reduction. Am J Sports Med 40:2828–2835

    Article  PubMed  Google Scholar 

  36. Ogilvie-Harris DJ, Gilbart MK, Chorney K (1997) Chronic pain following ankle sprains in athletes: the role of arthroscopic surgery. Arthroscopy 13:564–574

    Article  CAS  PubMed  Google Scholar 

  37. Olson KM, Dairyko GH Jr., Toolan BC (2011) Salvage of chronic instability of the syndesmosis with distal tibiofibular arthrodesis: functional and radiographic results. J Bone Joint Surg Am 93:66–72

    Article  PubMed  Google Scholar 

  38. Ovaska MT, Makinen TJ, Madanat R et al (2014) A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation. Int Orthop 38:83–88

    Article  PubMed  Google Scholar 

  39. Pakarinen H, Flinkkila T, Ohtonen P et al (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 Joint Surg Am 93:2057–2061

    Article  PubMed  Google Scholar 

  40. Pelton K, Thordarson DB, Barnwell J (2010) Open versus closed treatment of the fibula in Maissoneuve injuries. Foot Ankle Int 31:604–608

    Article  PubMed  Google Scholar 

  41. Peter RE, Harrington RM, Henley MB et al (1994) Biomechanical effects of internal fixation of the distal tibiofibular syndesmotic joint: comparison of two fixation techniques. J Orthop Trauma 8:215–219

    Article  CAS  PubMed  Google Scholar 

  42. Pettrone FA, Gail M, Pee D et al (1983) Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am 65(5):667–677

    Article  CAS  PubMed  Google Scholar 

  43. Phisitkul P, Ebinger T, Goetz J et al (2012) Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg Am 94:2256–2261

    Article  PubMed  Google Scholar 

  44. Rammelt S, Schneiders W, Grass R et al (2011) Bandverletzungen am oberen Sprunggelenk. Z Orthop Unfall 149:e45–e67

    Article  CAS  PubMed  Google Scholar 

  45. Rammelt S, Zwipp H, Grass R (2008) Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin 13:611–633 (vii–viii)

    Article  PubMed  Google Scholar 

  46. Rammelt S, Marti RK, Zwipp H (2013) Gelenkerhaltende Osteotomien fehlverheilter Sprunggelenk- und Pilonfrakturen. Unfallchirurg 116:789–796

    Article  CAS  PubMed  Google Scholar 

  47. Rammelt S, Obruba P (2015) An update on the diagnosis and treatment of syndemosis injuries. Eur J Trauma Emerg Surg 41:601–614

    Article  CAS  PubMed  Google Scholar 

  48. Sagi HC, Shah AR, Sanders RW (2012) The functional consequence of syndesmotic joint malreduction at a minimum 2‑year follow-up. J Orthop Trauma 26:439–443

    Article  PubMed  Google Scholar 

  49. Schottel PC, Berkes MB, Little MTM et al (2014) Comparison of clinical outcome of pronation external rotation versus supination external rotation ankle fractures. Foot Ankle Int 35(4):353–359

    Article  PubMed  Google Scholar 

  50. Steinmetz S, Puliero B, Brinkert D, Meyer N, Adam P, Bonnomet F, Ehlinger M (2016) Tibiofemoral syndesmosis injury treated by temporary screw fixation and ligament repair. Orthop Traumatol Surg Res 102:1069–1073

    Article  CAS  PubMed  Google Scholar 

  51. Tornetta P, Axelrad TW, Sibai TA et al (2012) Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making. J Orthop Trauma 26(11):659–661

    Article  PubMed  Google Scholar 

  52. Van Zuuren WJ, Schepers T, Beumer A, Sierevelt I, van Noort A, van den Bekerom MPJ (2017) Acute syndesmotic instability in ankle fractures: a review. Foot Ankle Surg 23(3):135–141

    Article  PubMed  Google Scholar 

  53. Vasarhelyi A, Lubitz J, Gierer P et al (2006) Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int 27:1115–1121

    Article  PubMed  Google Scholar 

  54. Vopat ML, Vopat BG, Lubberts B, DiGiovanni CW (2017) Current trends in the diagnosis and management of syndesmotic injury. Curr Rev Musculoskelet Med 10:94–103

    Article  PubMed  PubMed Central  Google Scholar 

  55. Weber BG (1966) Verletzungen des oberen Sprunggelenkes. In: Aktuelle Probleme in der Chirurgie. Huber, Bern, Stuttgart

    Google Scholar 

  56. Weening B, Bhandari M (2005) Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 19:102–108

    Article  PubMed  Google Scholar 

  57. Williams BT, Ahrberg AB, Goldsmith MT, Campbell KJ, Shirley L, Wijdicks CA, LaPrade RF, Clanton TO (2015) Ankle syndesmosis: a qualitative and quantitative anatomic analysis. Am J Sports Med 43(1):88–97

    Article  PubMed  Google Scholar 

  58. Williams GN, Jones MH, Amendola A (2007) Syndesmotic ankle sprains in athletes. Am J Sports Med 35:1197–1207

    Article  PubMed  Google Scholar 

  59. Xenos JS, Hopkinson WJ, Mulligan ME et al (1995) The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am 77:847–856

    Article  CAS  PubMed  Google Scholar 

  60. Zalavras C, Thordarson D (2007) Ankle syndesmotic injury. J Am Acad Orthop Surg 15:330–339

    Article  PubMed  Google Scholar 

  61. Zwipp H (1994) Chirurgie des Fußes. Springer, Wien, New York

    Book  Google Scholar 

  62. Zwipp H, Rammelt S (2016) Rekonstruktion des fehlverheilten Volkmann-Fragmentes. In: Hamel J, Zwipp H (Hrsg) Meistertechniken in der operativen Orthopädie und Unfallchirurgie. Sprunggelenk und Rückfuß. Springer, Berlin, Heidelberg, S 101–109

    Chapter  Google Scholar 

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Authors and Affiliations

  1. UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Deutschland

    S. Rammelt & E. Manke

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Correspondence to S. Rammelt.

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S. Rammelt und E. Manke geben an, dass kein Interessenkonflikt besteht.

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Rammelt, S., Manke, E. Syndesmosenverletzungen. Unfallchirurg 121, 693–703 (2018). https://doi.org/10.1007/s00113-018-0508-5

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