Management Of Syndesmotic Injuries Research Articles

Treatment of Syndesmotic Instability: The Importance of Malleolar Fixation

A significant proportion of syndesmotic injuries often occur simultaneously with malleolar fractures. The existing literature emphasizes that even slight misalignments in the malleolar structures can lead to altered talar motion, ultimately resulting in post-traumatic ankle arthritis. Rotational ankle fractures with syndesmotic injury can manifest with isolated or a combination of lateral, medial, and/or posterior malleolar fractures, and an accurate anatomic restoration of malleolar fractures has been emphasized. One such reason for anatomic reduction is that the fracture fragment may have an important attachment site for ligaments that contributes to the stability of the ankle and syndesmotic joints. While the biomechanical impact of malreduction of the lateral and medial malleolus osteoligamentous complex has been well documented and understood, controversy persists regarding the optimal surgical treatment of posterior malleolar fractures in the context of syndesmosis instability. Advanced imaging and biomechanical studies have shed new light on the role of the posterior malleolus in syndesmosis stability, suggesting that anatomic reduction of the posterior malleolar fragment could decrease the necessity of transfixation of the syndesmosis, lowering the risk of malreduction. As a result, there is growing advocacy for anatomically reducing and fixing the posterior malleolus in ankle fractures with syndesmotic injuries. This review focuses on the critical role of malleolar fixation in the management of syndesmotic injuries. Level of Evidence : Diagnostic Level V—expert opinion. See Instructions for Authors for a complete description of levels of evidence.

Management of Syndesmotic Injuries in Children and Adolescents: Results of a Cross-Sectional Survey of Pediatric Orthopaedic Surgeons

Management of Syndesmotic Injuries in Children and Adolescents: Results of a Cross-Sectional Survey of Pediatric Orthopaedic Surgeons

The role of anatomical repair of the anterior inferior tibiofibular ligament in acute ankle fractures with syndesmotic injury: A systematic review

The management of syndesmotic injury in ankle fractures is still controversial. Anterior inferior tibiofibular ligament (AITFL) primary repair is considered essential to reduce the risk of syndesmotic malreduction. This review examined the available literature on primary AITFL repair in ankle fractures. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Web of Science, Cochrane, and Google Scholar were searched up to July 15, 2021, for articles reporting on the repair of AITFL in acute ankle fractures with syndesmotic injury. The quality of the included studies was assessed using the Newcastle-Ottawa scale. Studies that investigated isolated syndesmotic injury without ankle fracture, reviews, cadaveric studies, case reports, and studies not published in English were excluded from the study. The search yielded 588 articles, of which three studies were included, with a total of 229 AITFL primary repairs. The articles were excluded due to different design, foreign language, irrelevancy, or no syndesmosis injury, including patients with isolated syndesmosis injury or used methods of repair other than anatomical repair. Early functional outcomes were found better after AITFL repair compared to syndesmotic screw fixation alone. Moreover, time to return to play/work was significantly lower in the anatomical repair compared to temporary screw fixation. Anatomical repair of the ankle syndesmosis is an effective and safe method with good functional outcomes and return to activity. However, the future prospective studies are required to assess the efficacy of the anatomical repair of the syndesmosis and its superiority over other treatments.

Current Practices in the Treatment of Syndesmotic Injuries: A Global Perspective

Category:Ankle; SportsIntroduction/Purpose:There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injuries by orthopedic foot and ankle specialists around the world in six athlete scenarios with increasing degrees of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries.Methods:A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis, and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact, and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails distributed two weeks apart. Frequencies and percentages were calculated for all categorical responses.Results:A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to six months post-op. 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured.Conclusion:There is a wide variety of indications and treatment constructs employed by orthopedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although flexible fixation devices are the preferred choice among all respondents, there was considerable variability in device choices. Fellowship training also appears to affect the preferred fixation method. There was no overall difference between device preference between North American and International respondents (Fig1). There also exists substantial variability in expected return to play for every athlete scenario. The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding the management of syndesmotic injuries.

The Evolving Approach to Treating Syndesmotic Injuries in the Elite Athlete: An International Perspective

Objectives:There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopaedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injures by orthopedic foot and ankle specialists around the world in 6 athlete scenarios with increasing degree of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries.Methods:A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails disseminated 2 weeks apart. Frequencies and percentages were calculated for all categorical responses.Results:A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to 6 months post-op (Fig 1). 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured.Conclusion:There is a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although, flexible fixation devices are the preferred among all respondents but there was a considerable variability in device choices. Fellowship training also appears to affect the preferred fixation device choice. There also exists substantial variability in expected return to play for every athlete scenario (Fig 1). The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding management of syndesmotic injuries.

Comparative study between syndesmotic and suprasyndesmotic technique in syndesmotic ankle injury

One of the most common injuries treated by orthopedic surgeons is the ankle injuries. Syndesmosis injuries account for 1%–18% of ankle sprains and much more in athletes 32%. The proper classification of syndesmosis injuries and the proper management depends mainly on the clinical and radiological assessment. Objectivesto compare between the suprasyndesmotic and syndesmotic technique in management of syndesmotic injury regarding the functional outcome and time to weight bearing and to assess factors affecting the outcome of syndesmotic injuries management. MethodsThis prospective case series study was conducted on thirty patients attending to Kasr Alainy orthopedic surgery department with ankle fractures, they were divided into two groups each contains fifteen patients: Group 1:underwent and supra-syndesmotic screw fixation. Group 2: underwent syndesmotic screw fixation. Radiological evaluation of fixations using AP, lateral and mortise X-ray. Assessment of post-operative range of motion. Evaluation of functional outcome using FAOS (Foot and ankle outcome score). Patients were followed up for 24 months, with an average of 22 months. ResultsPatients scored 80–100% on the foot & ankle outcome score, with an average of 91.6 ± 5.4; (63.3%) had FAOS of 90% or above. Regaining weight bearing took 6–12 with an average of 8.2 ± 1.8 weeks; in (70%) wt bearing occurred within 6–8 weeks. Only one patient (3.3%) had post-operative infection, while no other patient (96.7%) had any postoperative complications. The mean FAOS score in supra-syndesmotic fixation was 92.5 and in the syndesmotic is 90 with an insignificant difference between the two groups (P = 0.4). The mean time to weight bearing was 8.1 and 8.3 weeks (P = 0.84) in supra-syndesmotic and syndesmotic fixation respectively. Conclusionthere were no significant difference in terms of functional score and time to weight between syndesmotic and suprasyndesmotic techniques however; the functional score was significantly affected by the presence of associated injury and patient age while time to weight bearing was prolonged by the presence of associated injury and comorbidities, patient age as well as operative time.

Role of Arthroscopy in Ankle Fracture Surgery

The ankle arthroscopy is widely used as an essential tool for the various ankle disorders. The use of arthroscopy has also been tried for the treatment of acute ankle fractures, in the hope of improving the postoperative outcome. It was initially thought that the properly reduced ankle fractures had generally acceptable outcomes, with a reported rate of 81% good to excellent results. However further investigation and longer term follow-up has shown more mixed and less encouraging results. Some patients have persistent pain and poor outcomes following open reduction and internal fixation (ORIF), although the cause of poor outcome is not clearly understood. It may be secondary to intra-articular injuries at the time of fracture, which occur in up to 88% of fractures. Ankle arthroscopy at the time of ORIF has been proposed to address these intraarticular injuries. Arthroscopy-assisted reduction and percutaneous screw fixation for syndesmosis injury has been performed as well by some surgeons. However the effectiveness of true arthroscopic reduction and internal fixation compared with ORIF for ankle fractures has yet to be determined, in spite of the advantages such as limited exposure, preservation of blood supply, and improved visualization of the pathology. Postoperative chronic pain and arthrofibrosis after ankle fracture are another good indication for ankle arthroscopy, which can be performed at the time of implant removal. In conclusion, the ankle arthroscopy is a safe adjunctive procedure for the treatment of ankle fractures. It can be performed as well for the evaluation and management of syndesmotic injury, and for persistent pain following the definitive treatment of ankle fractures.

Subtalar Arthroscopy

The subtalar joint plays an important role in the movement of the ankle and foot. The complex anatomy of the subtalar joint makes it difficult for surgeons to evaluate the entire joint even with extensile approach. The arthroscopy of posterior subtalar joint was first described by Parisien in 1985. The development of good quality small-diameter arthroscopes and refined arthroscopic techniques has contributed to the improvement of the subtalar arthroscopy. The reported advantages of the subtalar arthroscopy include faster postoperative recovery and decreased postoperative pain.The subtalar arthroscopy can be applied as a diagnostic and therapeutic tool. The diagnostic indications are persistent pain, swelling, stiffness, or locking of the subtalar area resistant to conservative treatment. Therapeutic indications include debridement of sinus tarsi syndrome and chondromalacia, excision of subtalar impingement lesions and osteophytes, lysis of adhesions with post-traumatic arthrofibrosis, synovectomy, removal of loose bodies, removal of a symptomatic os trigonum, calcaneal fracture assessment and reduction, and arthroscopic arthrodesis of the subtalar joint.The subtalar arthroscopy can be done in supine position using thigh holder or in lateral decubitus position. The arthroscope generally used is a 2.7-mm 30 degrees short arthroscope. Noninvasive distraction with a strap around the hindfoot can be helpful. Usually anterolateral, middle, and posterolateral portals are utilized for inspection and instrumentation within the subtalar joint. After insertion of the arthroscope, thorough inspection of the joint can be done using 13-point examination techniques. Two-portal posterior subtalar arthroscopy in prone position can be performed as well with 4.0-mm 30 degrees arthroscope, depending on the type and location of the subtalar pathology. The joint capsule and the adjacent fatty tissue should be partially resected for better visualization.The subtalar arthroscopy is a technically demanding procedure, which requires proper instrumentation and careful operative technique. Possible complications after subtalar arthroscopy are nerve damage and persistent wound drainage.In conclusion, the ankle arthroscopy is a safe adjunctive procedure for the treatment of ankle fractures. It can be performed as well for the evaluation and management of syndesmotic injury, and for persistent pain following the definitive treatment of ankle fractures.

Current Strategies in the Management of Syndesmotic Injuries

Failure to adequately reduce and stabilize syndesmotic injuries has been repeatedly linked to poor outcomes in unstable ankle fractures. There remains controversy with regard to the ideal management of these injuries. This article reviews the background of syndesmotic injuries, as well as recent aspects of management that have generated controversy. Particular emphasis is placed on assessment of reduction, syndesmotic stability, and of various methods of fixation. Level of Evidence: Level V—review article, expert opinion. See instructions for authors for a complete description of levels of evidence.

Evolving and Innovative Treatments for Syndesmosis Injuries

Category: Sports Introduction/Purpose: Despite extensive research of syndesmotic fixation techniques, there is little consensus regarding optimal treatment and return to play protocols for isolated syndesmotic injuries. As competing treatment goals may exist, orthopedic clinicians have resorted to a wide variety of treatment strategies, ranging from screw fixation to suture fixation in various constructs. Given the myriad techniques and constructs, it is increasingly important to understand the rationale and intended patient setting for selecting particular implants and constructs. Undoubtedly, a multitude of factors contribute to the range of outcomes following syndesmotic fixation. While there are various theoretical arguments made for selecting one construct over another, this study seeks to assess the distribution of current practice approaches to syndesmotic injuries by foot and ankle orthopaedic surgeons at large. Methods: This cross-sectional study collected data from trained, licensed orthopedic surgeons (i.e. MD, DO, etc.) practicing in North America that treat isolated syndesmotic injuries. A one-time online survey was disseminated to the AOFAS membership. The survey contained questions regarding participant demographics, indications for treating syndesmotic injuries, preferred technique for repairing the syndesmosis and post-operative management, as applied to six athlete scenarios (moderate, high, and very high impact athletes with complete syndesmosis injury, with and without complete deltoid injury), and post-operative return to play protocols. Frequencies and percentages were calculated for all categorical responses using STATA 14.2. Free text responses were analyzed for common themes by fellowship trained, licensed orthopedic surgeons. Results: 273 of 337 responses were complete. Radiographic widening of greater than 2 mm at the syndesmosis was a sole indication for surgery for 83% of respondents, and arthroscopic widening of the syndesmosis was a sole indication for 75%. No clinical exam or MRI finding reached a threshold of 50% as a sole indication. In moderate and high-impact athletes with complete syndesmotic injury, the majority of respondents use one or two flexible fixation devices (61.5% and 50.5%, respectively), 25% use screws only, and 23.7% use a combination. More than 70% do not change their treatment construct choice in the presence of a complete deltoid injury. There was considerable variability in anticipated return to sport amongst respondents for all injury scenarios, ranging from 2 weeks to 6 months. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Despite absent consensus, several trends were evident. Flexible devices were utilized by a majority of respondents in all scenarios, even with ‘very high impact’ scenarios. Hybrid constructs are also common. The presence of a complete deltoid injury impacted fixation constructs for very few respondents. There is substantial variability in expected return to play for all athlete and injury scenarios. The diversity of approaches highlights the need for evidence-based guidelines regarding management of syndesmotic injuries.

Stable versus Unstable Grade 2 High Ankle Sprains in Athletes: A Noninvasive Tool to Predict the Need for Surgical Fixation

There are no standardized criteria for the diagnosis and management of syndesmotic injuries, creating great ambiguity regarding optimal treatment. Traditionally, individuals with clinical and/or radiological suspicion of syndesmotic instability warrant an examination under anaesthesia and/or diagnostic arthroscopy to confirm and treat. Our purpose was to identify clinical syndesmotic instability without the need of invasive arthroscopic procedures. However, the invasive process of this has inherent risks to the patient. We developed a device to dynamically evaluate the distal tibiofibular stability during external rotation of the ankle as an extension to the available clinical tests. We compared the results of this device with intra-operative arthroscopic findings in 15 athlete cases with isolated grade 2 syndesmotic instability and found very good correlation, especially when tested in dorsiflexion. We consider this syndhoo device very helpful as part of the available options in the clinical diagnosis of syndesmotic instability.

Current trends in the diagnosis and management of syndesmotic injury

Ideal management of the various presentations of syndesmotic injury remains controversial to this day. High quality evidentiary science on this topic is rare, and numerous existing studies continue to contradict one another. The primary reasons for these discrepancies are that previous studies have failed to (1) properly distinguish between isolated (non-fractured) and non-isolated injuries, (2) accurately define stable from unstable injuries, and (3) sufficiently differentiate between acute and chronic injuries. The purpose of this review is to summarize today's body of literature regarding diagnosis and management of syndesmotic injury and discuss current trends and important future directions to optimize care of this very heterogeneous population.

Syndesmosis and deltoid ligament injuries in the athlete

Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. This literature review will discuss both syndesmotic and deltoid ligament injuries without fracture in the professional athlete. A narrative review was performed using PUBMED, OVID, MEDLINE and EMBASE using the key words syndesmosis, injury, deltoid, ankle ligaments, and athlete. Articles related to the topic were included and reviewed. The incidence of syndesmotic injury ranges from 1 to 18 % of ankle sprains. This may be underreported and is an often missed injury as clinical examination is generally not specific. Both MRI and ultrasonography have high sensitivities and specificities in diagnosing injury. Arthroscopy may confirm the diagnosis, and associated intra-articular pathology can be treated at the same time as surgical stabilization. Significant deltoid ligament injury in isolation is rare, there is usually associated trauma. Major disruption of both deep and superficial parts can lead to ankle dysfunction. Repair of the ligament following ankle fracture is not necessary, but there is little literature to guide the management of deltoid ruptures in isolation or in association with syndesmotic and lateral ligament injuries in the professional athlete. Management of syndesmotic injury is determined by the grade and associated injury around the ankle. Grade I injuries are treated non-surgically in a boot with a period of non-weight bearing. Treatment of Grade II and III injuries is controversial with little literature to guide management. Athletes may return to training and play sooner if the syndesmosis is surgically stabilized. For deltoid ligament injury, grade I and II sprains should be treated non-operatively. Unstable grade III injuries with associated injury to the lateral ligaments or the syndesmosis may benefit from operative repair.

The management of acute distal tibio-fibular syndesmotic injuries: Results of a nationwide survey

IntroductionAnkle fractures are one of the most frequently encountered musculoskeletal injuries, and 10% of patients have a concomitant distal tibiofibular syndesmotic disruption necessitating surgical repair. A national survey was conducted to gain more insight into the current approaches in the management of syndesmotic injuries in the Netherlands. Materials and methodsA postal survey was sent to one or two staff members of the trauma and orthopaedic surgery departments in each of the 86 hospitals in the Netherlands. Questions concerned the pre-, per- and postoperative strategies and the different ideas on the type, number and placement of the syndesmotic screw. ResultsA total of 85.2% of the trauma surgeons and 61.9% of the orthopaedic surgeons responded (representing 87% of all hospitals). Syndesmotic injury was judged mainly using the ‘Hook test’. Syndesmotic injuries in a Weber-B ankle fracture were treated with one screw in 81.2% of cases and in Maisonneuve injuries mainly with two screws. The 3.5-mm screw was used most frequently over three cortices at 2.1–4.0cm above the tibial plafond. Removal of the syndesmotic screw was routinely done by 87.0% of surgeons, mostly between 6 and 8 weeks. Of all respondents, 62.3% showed interest in participating in a randomised controlled trial comparing standard removal with removal on indication. ConclusionCompared with previous surveys our survey is more complete, has the highest response rate and has almost national coverage. Most individual items reviewed compare well with current literature, except for the routine removal of the syndesmotic screw, which might not be encouraged from a literature point of view. For this reason, the results of the current survey will be used in the development of a multicentre randomised controlled trial comparing the functional outcome in routine removal of the syndesmotic screw compared with removal on indication.