Abstract
Introduction Treatment of patients with distal tibiofibular syndesmosis (DTFS) ruptures remains controversial. Ankle fractures accompanied by syndesmosis rupture are associated with worse outcomes. There is no diagnosis and treatment algorithm for such injuries to date. The objective was to summarize the data on diagnosis and treatment of syndesmotic injury alone and in combination with ankle fractures through world literature review. Material and methods A systematic literature search was undertaken using elibrary, PubMed, ResearchGate databases with articles dated 1990 and later. The search depth was 30 years. With preliminary information collected low-relevant articles were excluded. Meta-analysis studies, randomized controlled trials, systematic reviews, cadaveric biomechanical studies were reviewed. Results Screws and suture buttons can be used to fix DTFS, and Volkmann, Shaput and Wagstaff fractures being transosseous injuries to DTFS can be repaired with osteosynthesis. Imaging evaluation of reduction can be produced with radiography, MSCT, MRI and arthroscopy. Partial injuries to the DTFS, if timely detected, can be treated conservatively with transition to surgical stabilization if signs of instability persist. Discussion Conventional radiography has very low diagnostic value for DTFS injury. Bilateral MSCT is recommended for assessment of a syndesmotic injury and MRI of the ankle joint is practical for partial isolated injuries. Concomitant injuries of the fibular notch of the tibia are recommended to address first prior to transsyndesmotic fixation. Open reduction of displaced DTFS is accompanied by a lower risk of fibular malposition and malreduction. Suture buttons are practical for transsyndesmotic fixation. Removal of positional screws does not affect the functional result of treatment. More stable osteosynthesis would be needed for DTFS injury in neuropathy.
Highlights
Treatment of patients with distal tibiofibular syndesmosis (DTFS) ruptures remains controversial
We presented an analysis of 2 randomized studies that compared suture button and positional screw, 14 cohort studies that compared different types of screw fixation of DTFS ruptures, the functional results, the need for osteosynthesis of the broken posterior malleolus and removal of positional screws
We analyzed 4 retrospective studies that evaluated the correlation between functional outcome and residual instability and malposition, 9 studies reporting radiological diagnosis, MSCT diagnosis, MRI diagnosis, arthroscopic diagnosis of DTFS injuries, and 3 biomechanical studies of DTFS, 4 experimental studies evaluating the effect of instability and a step on the articular surface on healing and remodeling of cartilage tissue and the risk of arthrosis in an animal model, and one epidemiological study describing risks of post-traumatic ankle arthritis
Summary
Treatment of patients with distal tibiofibular syndesmosis (DTFS) ruptures remains controversial. Ankle fractures accompanied by syndesmosis rupture are associated with worse outcomes. There is no diagnosis and treatment algorithm for such injuries to date. The objective was to summarize the data on diagnosis and treatment of syndesmotic injury alone and in combination with ankle fractures through world literature review. Material and methods A systematic literature search was undertaken using elibrary, PubMed, ResearchGate databases with articles dated 1990 and later. Posttraumatic arthritis likely results from irreversible cartilage damage sustained at the time of injury and chronic cartilage overloading resulting from articular incongruity and instability [3–6]. A cadaver study showed that an axial load of 300 N in the presence of a 3 mm clear space of 50 % of the area on the articular surface of the ankle joint increased peak loads by 50 %, and a 20 N force applied in the anteroposterior direction (imitation of walking) led to 800 % increase in peak loads [7]
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