Syndesmotic injuries of the ankle, with or without malleolar ankle fractures, are common. Studies have found that up to 40% of all athletic injuries are ankle sprains and that 5% to 10% of those involve disruption of the tibiofibular syndesmosis. However, despite the frequent occurrence of this injury and related injuries, the best treatment of syndesmotic ankle injuries remains unresolved.
In the October 2015 issue of JBJS Reviews, Jones et al. describe ankle syndesmotic injuries, noting that the normal syndesmosis widening can be up to 1.5 mm, that the syndesmosis helps to prevent excessive fibular motion during locomotion, that clinical examination to diagnose syndesmotic injury is frequently inaccurate, and that initial injury and intraoperative stress radiographs help to confirm the diagnosis. The authors note that effective treatment requires accurate reduction and stable fixation in order to allow the syndesmotic ankle ligament to heal and also to limit syndesmotic motion. This effective treatment provides the best chance for the restoration of stable ankle mechanics. Nonoperative treatment of isolated injuries is appropriate in most cases. However, the timing of weight-bearing remains controversial and the timing of and indications for fixation removal after operative treatment are also unresolved.
After an extensive review and discussion of diagnostic and treatment options, this Critical Analysis Review article provides the following recommendations for ankle syndesmotic injury. There is good evidence that ankle syndesmotic reduction and fixation provides the best results. Similarly, there is good evidence that screw fixation can be achieved with engagement of three or four cortices. There is fair evidence that screw fixation can be metallic or bioabsorbable and that screw fixation and suture button fixation have similar outcomes. There is also fair evidence that syndesmotic injuries with associated malleolar fractures have the worst outcomes. However, there is poor evidence that transsyndesmotic and suprasyndesmotic fixation have similar results. There is also poor evidence that screw removal should be performed after three months.
These recommendations are based on extensive review and analysis and should be helpful in aiding in the treatment of syndesmotic ankle injuries.
Thomas A. Einhorn, Editor