Anterior Tibiofibular Ligament Research Articles

Fractures de Tillaux de l’adolescent: Étude d’une série de 19 cas

Purpose of the study Tillaux fractures in adolescents correspond to Salter and Harris type III fractures involving the anterolateral portion of the tibial epiphysis. These are intra-articular fractures. The objective was to determine the circuinstances of these fractures, the radiological signs, and the therapeutic modalities as well as the long-term clinical and radiological outcome. Material and methods We reviewed 19 Tillaux fractures. Ten patients underwent surgical treatment and nine orthopedie treatment following importance of displacement. Results At mean follow-up of 33.8 months, results were rated good in 17 on 19 cases. Discussion This fracture is often observed in teenagers victims of trauma with external rotation of the foot. Closure of distal growth cartilage of the tibia occurs medially to laterally, the anterolateral portion remaining open longer. Forced external rotation of the anterior tibiofibular ligament pulls off an anterolateral fragment of the distal tibial epiphysis. Surgical treatment is indicated for fractures with a displacement of more than 2 mm or a vertical displacement to achieve open reduction and screw fixation. Orthopedie treatment is used for non-displaced fractures. Conclusion The prognosis of Tillaux fractures is good as was observed in our series and in series reported in the literature.

MRI features of tibiofibular joint dislocation

Sir, Isolated anterolateral dislocation of the proximal tibiofibular joint (PTFJ) is an uncommon knee injury that can be treated effectively without surgery if diagnosed early [1]. There are four types of PTFJ dislocations, classified by Ogden: subluxation (type 1), anterolateral dislocation (type 2), posteromedial dislocation (type 3) and superior disloca‐ tion (type 4) [1]. A 35-year-old pregnant woman who was taken to our Emergency Department had fallen downstairs, injuring her right knee. On examination she had tenderness and accentuation of the bony prominence of the fibula head, no effusion and pain in the knee joint itself and full range of movement. The peroneal nerve was intact. Radiographs did not show any fractures but revealed some anterior and lateral translation of the fibula head. It has to be mentioned that the diagnostic value of the X-raytechnique is limited in PTFJ dislocations because films exposed in mild degrees of obliquity are difficult to interpret and there are several anatomical variants of the PTFJ and its dislocations [2, 3]. Because of the patient’s pregnancy, MRI instead of CT was performed. Our images were obtained by a T2-weighted turbo-spin echo (TSE) sequence without and with fat suppression (Fig. 1). They showed the ligament injuries in addition to the dislocated fibula, with a triangular gap between the two articulation surface areas. The fibula was in a lateral and slightly anteriorly displaced position and somewhat rotated internally. The weaker posterior tibiofibular ligament was torn. Intact parts of the injured joint capsule and the anterior tibiofibular ligament inhibited a longer dislocation. Such conditions could potentially lead to misdiagnosis in CT scans. In accordance with Ogden’s clas‐ sification an anterolateral PTFJ dislocation, which is the most common variant [1], was diagnosed. A closed reduction under sedation and fluoroscopy-guided conditions was performed. By forceful pressure on the fibula, with the knee in approximately 70° of flexion, the fibula head was reduced with an audible ‘crunch’. The patient felt immediate resolution of symptoms and was allowed to be mobile using a support bandage. To confirm PTFJ dislocations suspected on plain radiographs, axial CT scanning is recommended. However, in the study by Keogh et al. only 71% of the anterolateral dislocations were detected by CT [3]. That might be the result of not completely disrupted tibiofibular ligaments, which hold the fibula fixed in only a lateral displaced position. In atypical cases a comparison with a CT scan of the opposite PTFJ appears to be necessary to M. Zoller . P. Reittner . G. Schaffler (*) Department of Radiology, University Hospital of Graz, Auenbruggerplatz 9, 8036 Graz, Austria e-mail: gottfried.schaffler@meduni-graz.at Tel.: +43-316-38581716 Fax: +43-316-3853231

Anatomical evaluation and clinical importance of the tibiofibular syndesmosis ligaments

The aim of this study was to describe the detailed anatomical arrangement of ligaments of the tibiofibular syndesmosis and to highlight the clinical aspects of fracture dislocations. This study was performed on 42 legs of adult human embalmed cadavers. Tibiofibular syndesmosis ligaments attachments and their mutual relationships were described and their dimensions were measured. The anterior tibiofibular ligament is usually composed of three parts. This ligament runs obliquely at laterodistaly direction making 35 degrees angle with horizontal plane and posteriorly 65 degrees angle with sagittal plane. The posterior tibiofibular ligament runs almost horizontally 20 degrees angle with horizontal plane. The mean thicknesses of tibial and fibular attachments are 6.38+/-1.91 mm and 9.67+/-1.74 mm, respectively. The inferior transverse ligament originates from just below the posterior tibiofibular ligament, which has variations on the shape and dimensions due to its attachment points. The average length is 36.60+/-9.51 mm. The network between the fibular notch and the distal fibula has been filled with the interosseous tibiofibular ligament whose fibers follow the laterodistal and anterior direction from the tibia to the fibula. It lies proximally 30-40 mm from the mortise. At the inferior view of the tibiofibular syndesmosis a pyramidal shaped cartilaginous facet was observed which was attached to the fibula. The length of this cartilage was variable. Some of synovial plicas from the ankle joints synovial membrane were observed at this view. We conclude that the results of this study may be useful to both orthopedic surgeons and radiologists for anatomic evaluation of the tibiofibular syndesmosis area.

Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis: A radiostereometric study of 10 cadaveric specimens based on presumed trauma mechanisms with suggestions for treatment

Background Syndesmotic injuries of the ankle without fractures can result from external rotation, abduction and dorsiflexion injuries. Kinematic studies of these trauma mechanisms have not been performed. We attempted to describe the kinematics of the tibiofibular joint in cadaveric specimens using radiostereometry after sequential ligament sectioning, and resulting from different trauma mechanisms and axial loading, in order to put forward treatment guidelines for the different types of syndesmotic injuries.Methods We assessed the kinematics of the distal tibiofibular joint in fresh–frozen cadaveric specimens using radiostereometry in the intact situation, and after alternating and sequential sectioning of the distal tibiofibular and anterior deltoid ligaments. To assess which of the known trauma mechanisms would create the largest displacements at the syndesmosis, the ankle was brought into the following positions under an axial load that was comparable to body weight (750 N): neutral, dorsiflexion, external rotation, abduction, and a combination of external rotation and abduction.Results In the neutral position, the largest displacements of the fibula consisted of external rotation and posterior translation. Loading of the ankle with 750 N did not apparently increase or decrease the displacements of the fibula, but gave a larger variety of displacements.In every position, sectioning of a ligament resulted in some fibular displacement. Sectioning of the anterior tibiofibular ligament (ATiFL) invariably resulted in external rotation of the fibula. Additional sectioning of the anterior part of the deltoid ligament (AD) gave a larger variety of displacements. In general, sectioning of the posterior tibiofibular ligament (PTiFL) gave the smallest displacements. Combined sectioning of the ATiFL and the PTiFL resulted in a larger variety of displacements in the neutral position. Sectioning of the AD together with the ATiFL and PTiFL resulted in tibiofibular displacements in the neutral situation exceeding the maximum values found in the intact situation, the most important being fibular external rotation.Interpretation Sectioning of the ATiFL results in mechanical instability of the syndesmosis. Of all trauma mechanisms, external rotation of the ankle resulted in the largest and most consistent displacements of the fibula relative to the tibia found at the syndesmosis. Based on our findings and the current literature, we recommend that patients with isolated PTiFL or AD injuries should be treated functionally when no other injuries are present. Patients with acute complete ATiFL ruptures, or combined ATiFL and AD ruptures should be treated with immobilization in a plaster. Patients with combined ruptures of the ATiFL, AD and PTiFL need to be treated with a syndesmotic screw.

Enlarged perforating branch of peroneal artery and extra crural fascia in close relationship with the tibiofibular syndesmosis

We found an extremely large perforating branch of peroneal artery in an 89-year-old female cadaver's left ankle. The anterior tibial artery could not reach to supply the ankle and dorsum of the foot. The perforating branch of peroneal artery continued as the dorsalis pedis after giving off an anterior lateral malleolar artery branch. The posterior tibial artery was thinner than usual. On the anterior side of the ankle, there was an extra crural fascia in addition to the regular crural fascia, under the anterior crural muscles. This strong fascia was tightly overlying the perforating branch of peroneal artery and anterior tibiofibular ligament. It is important to know the relationship of these vessels to the surrounding structures. Surgeons must be careful while dissecting this area since the perforating branch of peroneal artery might be anomalously enlarged as well as crossing in front of the tibiofibular syndesmosis in order to prevent vascular injury.

Die Arthrodese des oberen Sprunggelenks über den sog. transfibularen Zugang

Bony fusion between tibia and talus in neutral position of foot. Return to a pain-free function of the lower limb.Extensive loss of articular cartilage accompanied by a painful and considerably limited motion with or without malalignment. Partial avascular necrosis of talar dome or distal tibial epiphysis. Neuroarthropathy (Charcot joint) with progressive malalignment of ankle. Revision surgery after failed total ankle arthroplasty.Acute purulent joint infection. Total avascular necrosis of talus.Posterolateral approach to the distal fibula taking care to preserve the periosteal vessels. Fibular osteotomy from proximal lateral to distal medial. Division of the anterior tibiofibular, anterior fibulotibial, and fibulocalcaneal ligaments. Division of posterior tibiofibular ligament. Transverse planar resection of tibial and talar articular surfaces. Freshening of the medial malleolus. Resection of the tip of medial malleolus through a medial incision. Positioning of talus perpendicular to the tibia, paying attention to the valgus of the hindfoot and external rotation. Temporary fixation with Kirschner wires. Radiographic control in two planes followed by fixation with two or three lag screws. Removal of the medial fibular cortex, freshening of the lateral gutter, and fixation of the distal fibular fragments to tibia and talus with cortical screws.20 arthrodeses in 19 patients were followed up for an average of 39 months (12-69 months). All arthrodeses were fused. In one patient a fibular pseudarthrosis was encountered. All arthrodeses healed in a correct position but one that consolidated with a pes equinus of 3 degrees . The average AOFAS (American Orthopedic Foot and Ankle Society) hindfoot score reached 78.5 points (40-86 points). A marked reduction of symptoms and satisfactory function were reported postoperatively by all patients. All would be willing to undergo surgery again.

Late reconstruction of the anterior tibiofibular syndesmosis for ankle diastasis with talar shift in a 12-year-old boy. A case report

This article describes the reconstruction of the tibiofibular and talocrural joint in a boy with a chronic syndesmotic injury with lateral talar shift. The anterior-posterior radiograph showed a widened medial clear space. MR imaging with an additional double oblique plane depicted an old Wagstaffe's fracture with an intact anterior tibiofibular ligament and a fresh fibular physical fracture, as well as a thickened deltoid ligament and synovitis in the medial joint space. Reconstruction was performed by anthroscopic removal of the synovitis from the medial recessus, followed by fixation of the fibular avulsion of the ATiFL with a staple after a syndesmotic set screw had been placed during compression of the mortise. One year after reconstruction (and removal of the set screw) the talocrural joint is congruent. The boy has fully recovered and has resumed all sporting activities without complaints.

Magnetic resonance arthrographic evaluation of syndesmotic diastasis in ankle fractures.

We examined whether magnetic resonance arthrography (MRA) contributes to the diagnosis of syndesmotic complex disruption in ankle fractures. Patients suffering syndesmotic diastasis according to conventional radiographic criteria were evaluated by MRI and MRA. Fifteen patients (15 ankles) with Denis-Weber type B and C fractures and were suspected of having syndesmotic diastasis considering tibiofibular clear space and tibiofibular overlap measurements in conventional radiographs were prospectively evaluated by MRI and MRA methods. Syndesmotic diastasis was diagnosed by radiographic, MRI, and MRA findings and by intraoperative observation and assessment criteria. Differences between MRI and MRA findings were tested statistically. Conventional radiography, MRI, and MRA results were analyzed by two independent observers, and interobserver concordance was also assessed. In 15 patients regarded to have syndesmotic diastasis on conventional radiography the diagnosis was confirmed in 8 (53.3%) with MRI and 12 (80%) with MRA. Following overall assessment 13 of 15 patients (86.6%) were determined to have diastasis. There were statistically significant differences in diagnosis after MRI and after MRA. There was interobserver concordance in conventional radiographic, MRA assessments, and in assessments for anterior and posterior tibiofibular ligaments separately in MRI. These results suggest that conventional radiography and MRI is not sufficient in assessing syndesmotic disruption, and that MRA can make an important contribution to diagnosis in ankle fractures.

The Accessory Anteroinferior Tibiofibular Ligament as a Cause of Talar Impingement

Background A distal fascicle of the anteroinferior tibiofibular ligament has been reported as a possible cause of anterolateral ankle impingement. Hypothesis This fascicle represents an independent accessory ligament in the anterior aspect of the inferior tibiofibular syndesmosis. Study Design Descriptive anatomical study. Methods The inferior tibiofibular syndesmosis was exposed in 24 fresh-frozen cadaveric ankles. Morphological characteristics of the inferior tibiofibular ligaments and interactions between the anterior ligaments and the talus were investigated in different degrees of ankle motion. Results A separate accessory anterior ligament was identified in 22 specimens. Its orientation was parallel and distal to the anterior tibiofibular ligament, from which it was separated by a fibrofatty septum. Its length ranged from 17 to 22 mm, its thickness from 1 to 2 mm, and its width from 3 to 5 mm. Impingement of this ligament against the talar dome was documented in all specimens in neutral ankle position, with bending of the ligamentous bands in dorsiflexion. Distraction maneuvers reproducing traction during arthroscopic approaches relieved contact. Conclusions An accessory anteroinferior tibiofibular ligament with distinct anatomical features was recognized. Clinical Relevance Based on its increased incidence in the cadaver ankles, the accessory ligament reflects a normal anatomical finding. Nevertheless, it could lead to anterolateral impingement in cases with coexistent ankle instability.

Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction?

Syndesmotic stability in ankle fractures is usually assessed intraoperatively by pulling on the fibula with a bone hook in the coronal plane (“Hook Test”). Our clinical observations have suggested that instability may be more marked in the sagittal plane. Our aim was to compare movement at the tibio-fibular syndesmosis in the sagittal and coronal planes after sequential ligament division in a cadaver model. Seven specimens were used. The Hook Test was performed in both the sagittal and coronal planes. Movement was assessed by measuring the displacement of parallel k-wires. In all specimens, the anterior tibio-fibular, interosseous and posterior tibio-fibular ligaments were sequentially divided. In three specimens the deltoid ligament was then divided and the interosseous membrane in another three. After division of all three syndesmosis ligaments the mean displacement was 8.8 mm (±3.9) in the sagittal plane and 1.5 mm (±0.4) in the coronal plane. When the deltoid ligament was then divided, the displacement increased to 11.7 mm (±2.4) and 3.2 mm (±0.5), respectively. When the interosseous membrane was divided the measurements were 12.7 mm (±4) and 3.1 mm (±1.5). Movements were consistently greater in the sagittal plane than the coronal plane and we conclude that distal tibio-fibular instability should be assessed in the sagittal plane.

The evaluation of the proximal tibiofibular joint for patients with lateral knee pain

In contrast to important functions of the proximal tibiofibular joint (PTFJ), there appear a few clinical and radiological studies concerning the PTFJ pathologies. Although almost all of the joints have been investigated in detail by MRI, review of the literature reveals none on the pathologies of PTFJ. Thirty-eight knees of 32 patients with lateral knee pain were evaluated clinically and radiologically. All had tenderness over the PTFJ and lateral hamstring tightness. MRI examination revealed effusion of the PTFJ in 22 knees and partial ruptures of anterior or posterior tibiofibular ligament, lateral collateral ligament or biceps femoris tendon in 25 knees. All patients were treated by manipulative physiotherapy of the PTFJ and strengthening and stretching exercises of the surrounding structures. All patients were followed-up 12–36 months (mean 28 months) after the treatment protocol, and complete relief of the symptoms was recorded in 28 of the 38 knees. Although spontaneous pain was not present in five patients, there was tenderness over the PTFJ by palpation. No change in the symptoms was recorded in five patients. These results suggest that PTFJ pathologies should be kept in mind in the evaluation of lateral knee pain and MRI examination provides useful information.

Anatomy of the tibiofibular syndesmosis and its clinical relevance.

The purpose of the present study was to describe the anatomical structure of the tibiofibular syndesmosis. Dissection of the tibiofibular syndesmosis was performed on 30 cadaveric specimens of the ankle in adults. The stability of the tibiofibular mortise is ensured by three ligaments. The interosseous tibiofibular ligament forms a spatial network of fibers of a pyramidal shape filled with fibrofatty tissue. The anterior tibiofibular ligament consists of three parts: the upper one is the shortest, the medial one is the strongest and the lower part is the longest and the thinnest. The posterior tibiofibular ligament is a strong, compact ligament the lower margin of which literally forms the articular labrum for the lateral ridge of the trochlea of the talus. The so-called inferior transverse tibiofibular ligament, as this part of the ligament is sometimes characterized, cannot be considered as a separate ligament. Direct contact between the distal tibia and the fibula was found in 23 cases. Contact facets which were covered with articular cartilage were very small and located in the anterior half of the tibiofibular contact line. In the posterior part of the tibiofibular contact line a vertical V-shaped synovial plica attached by its lateral aspect to the fibula dipped between the two bones. In seven cases where there was no direct contact between the two bones this plica extended anteriorly to the anterior tibiofibular ligament. The findings show that in three quarters of cases the connection of the distal tibia and fibula is not a mere syndesmosis but also a synovial joint. The presented facts change traditional opinions on the structure of the tibiofibular syndesmosis and they should be reflected in the treatment of dislocation-fractures of the ankle as well as in case of so-called anterolateral ankle impingement.

A biomechanical evaluation of the tibiofibular and tibiotalar ligaments of the ankle.

The purpose of this ex vivo biomechanical study was to determine the strength and stiffness of the anterior and posterior syndesmotic tibiofibular ligaments and the posterior tibiotalar component of the deltoid ligament. Injuries to these ligaments are a prevalent clinical problem, yet little is known about their mechanical behavior. Ten fresh-frozen cadaver lower extremities (average age at death, 72 +/- 8 years) were harvested. The anterior and posterior tibiofibular ligaments and the posterior tibiotalar component of the deltoid were isolated and prepared as bone-ligament-bone complexes for tensile testing to determine strength, stiffness, and mode of failure. The posterior tibiofibular ligament exhibited greater strength, but not significantly so (p < .05), than the anterior tibiofibular ligament and the posterior tibiotalar component of the deltoid ligament. There were no significant differences in stiffness between the three ligaments tested. The dominant mode of failure for the anterior tibiofibular ligament was ligament substance rupture, primarily near its fibular insertion, whereas the failure modes of the posterior tibiofibular ligament were evenly split between substance ruptures and fibular avulsions. The posterior tibiotalar component of the deltoid ligament ruptured most often near the talar insertion. The tibiofibular ligaments showed greater strength than the lateral collateral and deltoid ligaments, as mentioned in literature. The greater strength of the tibiofibular ligaments relative to the lateral collateral and deltoid ligaments suggests that these ligaments play an important role in ankle constraint.

A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability.

Displacement transducers were placed across the anterior and posterior tibiofibular ligaments of 17 fresh cadaver (78.4 +/- 6.7 years old at death) lower extremities. Displacements induced by various clinical tests (squeeze, fibula translation, Cotton, external rotation, and anterior drawer) were measured with the ankle ligaments intact and after sequential sectioning of the anterior tibiofibular ligament, anterior deltoid ligament, and posterior tibiofibular ligament. None of the syndesmotic stress tests could distinguish which ligaments were sectioned. Furthermore, the small displacements measured during the stress tests (with the exception of the external rotation test) suggest it is unlikely that the displacement induced in injured syndesmoses can be clinically differentiated from normal syndesmoses. Therefore, pain, rather than increased displacement, should be considered the outcome measure of these tests.

Fracture–dislocation of the ankle with fixed displacement of the fibula behind the tibia—a rare variant

We describe a case of fracture–dislocation of the ankle with fixed displacement of the fibula behind the tibia (Bosworth's fracture). The fracture was irreducible until the anterior tibio-fibular ligament was divided at operation. We believe this to be the first reported case of this fracture in which the ligament was intact. Bosworth first described this fracture in 1947 in a series of five patients and alerted readers to the poor outcome if the injury was missed [ [1] Bosworth D.M. Fracture dislocation of the ankle with fixed displacement of the fibula behind the tibia. J. Bone Jt. Surg. 1947; 29: 130-135 PubMed Google Scholar ].

Anterior tibiofibular ligament avulsion fracture in weber type B lateral malleolar fracture.

The purpose of this study was to determine the incidence, relationship with the ankle diastasis, and effect of treatment of the anterior tibiofibular ligament avulsion fracture (Wagstaffe fracture) combined with the Weber type B lateral malleolar fracture. This study reviewed 94 cases of ankle fractures treated with operative methods. There were 52 cases of Weber type B lateral malleolar fractures and 13 cases of Wagstaffe fractures combined with them (25%). Ankle diastases were diagnosed in 20 cases (38.5%) in all Weber type B fractures and 11 (84.6%) of the 13 Wagstaffe fractures. The Wagstaffe fracture can be a good diagnostic clue of ankle diastasis in Weber type B lateral malleolar fracture. The accurate reduction and fixation of the avulsed fragment is important for restoration of the stable distal tibiofibular joint and to prevent the chronic ankle joint pain caused by impingement of the avulsed fragment.

Ultrasound examination of ankle injuries in children.

Fourteen children with ankle injuries, an open tibia and fibula physis, and negative radiographs had ultrasonography of their injured ankles. Five had an anterior talofibular ligament injury and five had an anterior tibiofibular ligament injury. Four had normal ultrasound examinations. Only two had a physeal injury, both of which were associated with a ligament injury. Eleven children had only lateral ankle tenderness. Ultrasound of these 11 revealed ligamentous injuries, normal examinations, and the two physeal injuries. Ligamentous injury was not associated with other tenderness patterns.

Prospective Evaluation of Syndesmotic Ankle Sprains without Diastasis

Sixty consecutive collegiate athletes with "high" ankle symptoms were prospectively evaluated over a 3-year period in an effort to better define this debilitating ankle injury. All athletes included in this study had tenderness over the distal anterior tibiofibular ligament, tenderness proximally along the interosseous membrane, and functional disability. No study subject had a fracture or frank tibia-fibula diastasis. The severity of the sprain was quantified using the interosseous "tenderness length." A standard rehabilitation protocol was followed by all patients. Athletes returned to competition when they could perform all functional testing without difficulty. Time to return to full competitive activity averaged 13.4 days. The number of days missed from competition was statistically related to the interosseous tenderness length (P = 0.0001) and to positive results on the squeeze test (P = 0.03). Fifty-three of the 60 injured athletes were evaluated at least 6 months after injury. Patients rated their outcomes as good or excellent. Six of the patients experienced occasional ankle pain and stiffness, four patients reported recurrent ankle sprains, and one patient had heterotopic ossification formation.

A sample of Chinese literature MRI diagnosis of interosseous membrane injury in Maisonneuve fractures of the fibula

Objective: In Maisonneuve fractures of the fibula (MFF) it remains controversial whether there is an injury of the interosseous membrane (IOM) and how severely it ruptures. The author studied injuries to the IOM in MFF by MRI to elucidate this question. Method: Twelve patients were examined with MRI before operation. MRI examination to the leg was performed with knee coil in 2 steps to obtain a complete image of the IOM. Using axial scan, we took T1 (TR500/TE40 msec), T1STIR and T2 sequence. The asymptote side was also examined in three patients as a comparison. Result: IOM was ruptured in a range of 32–112 mm, on average 79 mm proximal to the talar dome in all 12 patients. No IOM rupture was found at the level of high fibular fractures. IOM usually orients at the site 30 mm proximal to the talar dome. Anatomy and rupture of IOM are clearly visualized with T1 (TR500/TE40 msec) STIR sequence; haemorrhage and oedema would be seen better on a T2 image. Conclusion: The injury level of IOM in MFF is only at the distal 1 3 part of the leg; it is not consistent with high fibular fractures. MFF is a special type of pronation-external rotation type, there are four stages in the classification of MFF: 1. injury of medial structures, including medial malleolar fracture or rupture of the deltoid ligament 2. rupture of the anterior tibiofibular ligament or avulsion fracture of one of its bone insertions, or one associated with interosseous ligament rupture and partial rupture of IOM in the distal 1 3 of the leg 3. fracture of the proximal part of the fibula 4. avulsion fracture of the posterior tibial tubercle

Verletzungen der unteren tibiofibularen Syndesmose

The incidence of isolated distal tibiofibular syndesmotic ruptures in acute ankle sprains lies between 1% and 11%. These injuries are frequently overseen or misdiagnosed as anterolateral rotational instability of the ankle and often become apparent through protracted courses. Although the pathomechanics and extent of syndesmotic injuries have been systematically described by Lauge-Hansen and Weber, no generally accepted guidelines exist as to when these complex injuries are to be treated surgically to ensure sufficient and stable healing of the syndesmosis besides correct alignment of the distal fibula. So far, systematic follow-up regarding syndesmotic injuries in ankle fractures is missing, although it has long been recognized that tibiofibular diastasis secondary to chronic syndesmotic instability leads to external rotation of the talus. In combination with a valgus position of the talus, this instability leads to a decrease in the contact area which results in posttraumatic arthritic changes. This paper reviews the standard diagnostic and therapeutic procedures for acute syndesmotic ruptures in fracture dislocations of the ankle. Among the few corrective procedures advocated for chronic syndesmotic insufficiency are tibiofibular arthrodesis, synthetic ligament substitutes, and tenodesis with the peroneus brevis tendon. A sufficient reconstruction must restore the stability of the ankle mortise and alignment of the fibula in the tibiofibular incisura to ensure limitation of talar rotation. Therefore, a tenodesis was developed which substitutes the three important ligaments of the syndesmotic complex. The Casting procedure for chronic syndesmotic insufficiency was modified with reconstruction of the interosseous tibiofibular ligament in addition to the anterior and posterior tibiofibular ligaments. The resulting three-point fixation of the distal fibula appears more anatomically, physiologically, and biomechanically advantageous. The operative procedure is given in detail. Distal tibiofibular syndesmosis. Persistent instability of the distal syndesmosis. Ankle fractures. Syndesmotic screw.