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Syndesmosis injuries are rare, but very debilitating and frequently misdiagnosed. The purpose of this clinical commentary is to review the mechanisms of syndesmotic injuries, clinical examination methods, diagnosis, and management of the injuries. Cadaveric studies of the syndesmosis and deltoid ligaments are also reviewed for further understanding of stress transmission and the roles of different structures in stabilizing the distal syndesmosis. External rotation and excessive dorsiflexion of the foot on the leg have been reported as the most common mechanisms of injury. The injury is most often incurred by individuals who participate in skiing, football, soccer, and other sport activities played on turf. The external rotation and squeeze tests are reliable tests to detect this injury. The ability of imaging studies to assist in an accurate diagnosis may depend on the severity of the injury. The results of cadaveric studies indicate the importance of the deltoid ligament in maintaining stability of the distal tibiofibular syndesmosis and the congruency of the ankle mortise. Intervention programs with early rigid immobilization and pain relief strategies, followed by strengthening and balance training are recommended. Heel lift and posterior splint intervention can be used to avoid separation of the distal syndesmosis induced by excessive dorsiflexion of the ankle joint. Application of a rigid external device should be used with caution to prevent medial-lateral compression of the leg superior to the ankle mortise, thereby inducing separation of the distal syndesmosis articulation. Surgical intervention is an option when a complete tear of the syndesmotic ligaments is present or when fractures are observed.
Background: Grade III syndesmosis sprains are usually treated with internal fixation. Limited information is available on early weightbearing and early return to activity after operative treatment for grade III syndesmosis sprains.
Hypothesis: Treatment of grade III syndesmosis sprains in intercollegiate athletes with internal fixation, early range of motion, and early weightbearing can lead to rapid return to sport with minimal complications and no ankle problems in midterm follow-up.
Study Design: Case series; Level of evidence, 4.
Methods: We evaluated a consecutive series of intercollegiate athletes treated operatively with 4.5-mm cortical screw fixation for grade III syndesmosis sprains. At 1 week after surgery, patients were allowed to begin range of motion exercises, progressive weightbearing, and gradually return to full activity as tolerated. Outcome measures included time to return to full activity and, at final follow-up, the Sports Ankle Rating System scores.
Results: Six male intercollegiate college athletes met the inclusion criteria for this study. The average time for return to full activity was 41 days (range, 32-48 days). There were no intraoperative complications or complications when resuming in-season sport activities with the screw in place. One screw broke during removal. At an average follow-up of 34.3 months, using the Sports Ankle Rating System, the average clinical rating score was 96.2, the average quality-of-life measure was 96.7, and the average single assessment numeric evaluation was 95.3. Radiographs at final follow-up showed no mortise widening or lateral talar subluxation. Two patients had mild degenerative changes on lateral radiographs with anterior tibial osteophytes.
Conclusions: In selective cases, athletes can return to full activity as early as 6 weeks after internal fixation of grade III syndesmosis sprains.
OBJECTIVE: To present the epidemiology, etiology, diagnostic criteria and therapeutic interventions for an important clinical entity - tibiofibular syndesmosis or "high ankle" sprains.
CLINICAL FEATURES: The most common mechanism of injury is forced external rotation in a dorsiflexed foot. Pain is located anteriorly over the anterior tibiofibular ligament, and is elicited through a variety of tests designed to stress this articulation through diastatic forces. Pain with ambulation is typical, and is usually present during the push-off phase of gait. Radiographs may be useful in determining the extent of this injury, as syndesmotic sprains with malleolar fractures are more common than those without.
INTERVENTION AND OUTCOME: Convalescence is generally protracted compared with a lateral ankle sprain, and care must be taken to avoid stressing the supporting ligaments during the early course of therapy. Initial treatment is aimed at reducing pain and inflammation using modalities such as microcurrent, electroacupuncture and P.R.I.C.E. principles. Treatment over subsequent weeks involves progressive resistance exercises, proprioceptive challenges, plyometric exercises and sport-specific agility drills, while maintaining cardiovascular fitness.
CONCLUSION: The practitioner should also be cognizant of the indolent nature of this injury and possibility for sequelae. Anterior ankle pain and pain with a deep squat or during the push-off phase of gait are typical of this injury. Radiographs to rule out fracture and evaluate the extent of the injury may be warranted. Conservative therapy involving rehabilitation and tissue injury care is appropriate for Grade I and II injuries, while Grade III injuries require a surgical intervention.
Three-Dimensional Analysis of Ankle Instability After Tibiofibular Syndesmosis Injuries: A Biomechanical Experimental Study
Atsushi Teramoto, Hideji Kura, Eiichi Uchiyama, Daisuke Suzuki, Toshihiko Yama****a American Journal of Sports Medicine 2007,
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Background: Rupture of the distal tibiofibular syndesmosis commonly occurs with extreme external rotation. Most studies of syndesmosis injuries have concentrated only on external rotation instability of the ankle joint and have not examined other defects.
Hypothesis: Syndesmosis injuries cause multidirectional ankle instability.
Study Design: Controlled laboratory study.
Methods: Ankle instability caused by distal tibiofibular syndesmosis injuries was examined using 7 normal fresh-frozen cadaveric legs. The anterior tibiofibular ligament, interosseous membrane, and posterior tibiofibular ligament, which compose the distal tibiofibular syndesmosis, were sequentially cut. Anterior, posterior, medial, and lateral traction forces, as well as internal and external rotation torque, were applied to the tibia; the diastasis between the tibia and fibula and the angular motion among the tibia, fibula, and talus were measured using a magnetic tracking system.
Results: A medial traction force with a cut anterior tibiofibular ligament significantly increased the diastasis from 1.1 to 2.0 mm (P =.001) and talar tilt angles from 9.6° to 15.2° (P <.001). External rotation torque significantly increased the diastasis from 0.5 to 1.8 mm (P =.009) with a complete cut; external rotation torque also significantly increased rotational angles from 7.1° to 9.4° (P =.05) with an anterior tibiofibular ligament cut.
Conclusion: Syndesmosis injuries caused ankle instability with medial traction force and external rotation torque to the tibia.
Clinical Relevance: Both physicians and athletes should be aware of inversion instability of the ankle joint caused by tibiofibular syndesmosis injuries.
Treatment of Syndesmotic Disruptions with the Arthrex Tightropetrade mark: A Report of 25 Cases.
Cottom JM, Hyer CF, Philbin TM, Berlet GC. Foot Ankle Int. 2008 Aug;29(8):773-80.
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BACKGROUND: The complexity of syndesmotic injuries, often with both bone and soft tissue injury mandates an expeditious diagnosis and treatment to avoid unfavorable long term outcomes. Various methods of fixation of the syndesmosis have been reported. We present the largest series evaluating the Arthrex Tightropetrade mark for management of syndesmotic injuries.
MATERIALS AND METHODS: Twenty-five patients with disruption of the distal tibiofibular articulation underwent treatment with an Arthrex Tightropetrade mark. In 21 cases, a single tightrope was placed, and in four cases, two tightropes were utilized. Associated ankle fractures were treated using proper AO technique. Those patients with diabetes and/or neuroarthropathic changes foot or ankle were not included in this study. Postoperative evaluation parameters included radiographic measurements, a modified AOFAS scoring system and SF-12.
RESULTS: Average followup was 10.8 months. The mean time to full weightbearing was 5.5 (range, 2 to 8) weeks. Postoperative radiographic analysis of the mean distance from the tibial plafond to the placement of the tightrope(s), medial clear space, average postoperative tibiofibular overlap and the mean tibiofibular clear space demonstrated no evidence of re-displacement of the syndesmotic complex at an average of 10.8 (range, 6 to 12) months. The modified AOFAS hindfoot scoring scale and SF-12 both demonstrated significant improvements; preoperative values were assessed in the office with the first patient visit as they are incorporated into the patient intake form that each patient fills out at the initial visit.
CONCLUSION: Utilization of the tightrope in diastasis of the syndesmosis should be considered as a good option. The method of placement is quick, can be minimally invasive, and obviates the need for hardware removal. In this series, it maintained excellent reduction of the syndesmosis.
They are not rare IMO. Mild syndesmosis injuries are not blatantly obvious diagnostically, and are therefore difficult to diagnose.
If you mean a minor diastasis, I agree that they are common. The mechanism I find is during an ankle sprain the peroneal tertius muscle contracts forcefully and damages the superior retinaculum. A subluxation of the distal tibia and fibula results which is a diastasis. I find that there is a weak peroneus tertius that responds to friction of the retinaculum from the edges medially which also corrects the subluxation.
Background
The current study outlines the pathology and treatment of persistent problems following isolated distal tibiofibular syndesmotic injuries.
Methods
A retrospective study was conducted to review patients with isolated chronic syndesmotic disruption who were managed in the authors’ institute during 4 years, from January 2001 to January 2005. Patients with concomitant bony injuries or lateral ankle instability were excluded.
Results
The study included eleven patients with isolated syndesmotic disruption. All were males, with average duration of symptoms 4.7 years. Reconstruction of syndesmosis was achieved by semitendinosus tendon in all patients. The average hospital stay was 3.6 days, and the average follow up period was 3.1 years. According to West Point Ankle Score system, the average score after treatment was 95.4.
Conclusion
Chronic isolated tibiofibular syndesmotic disruption appears amenable to accurate diagnosis and delayed stabilization. Arthroscopic management of the associated intraarticular pathology followed by reconstruction of torn syndesmosis can offer an excellent outcome.
A Dynamic Ultrasound Examination for the Diagnosis of Ankle Syndesmotic Injury in Professional Athletes: A Preliminary Study Am J Sports Med (prepublication)
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Background: Syndesmotic ankle injuries are not easy to recognize when an associated fracture or frank diastasis is not present. There is a need for a simple, fast, inexpensive, and easily reproducible diagnostic tool to assess the integrity of the distal tibiofibular synedesmosis.
Study Design: Cohort study (diagnosis); Level of evidence, 2.
Methods: We evaluated 3 groups: 9 consecutive professional athletes with recent AITFL rupture, a control group of 18 subjects without a history of ankle injury, and 20 patients with lateral ankle sprain. The dynamic US examination was performed in neutral (N), forced internal rotation (IR), and external rotation (ER) of the foot for measuring the tibiofibular clear space on the anterior aspect of the ankle, at the level of the AITFL, 1 cm proximal to the joint line.
Results: The mean age of the study group was 27 years (range, 16-32). Magnetic resonance imaging (MRI) confirmed the diagnosis of AITFL rupture in all cases. Differences between the injured and control group were statistically significant for the N, IR, and ER positions (P < .001) and for the measured Δ between the AITFL in the ER and N positions (P < .01). The difference in the tibiofibular clear space between the 2 ankles of the injured athletes was significantly different compared with the control athletes for all 3 positions (P < .001). The measured difference between the ER and N positions for both sides of the study group showed a specificity and sensitivity of 100% (P < .001; cutoff point of 0.9 mm and 0.7 mm, respectively). The Δ (Δ = ER – N) of the injured side showed a specificity and sensitivity of only 89% (P < .001; cutoff point of 0.4 mm). Additionally, the third group with the history of lateral ankle sprain showed, as expected, that this type of injury does not correlate with AITFL injury on dynamic US examination.
Conclusion: We conclude that dynamic US examination can be used to accurately diagnose an AITFL rupture. This preliminary study has found the described method to be a simple, inexpensive, and easily reproducible examination
Dynamic Gait Analysis of Blocked Distal Tibiofibular Joint Following Syndesmotic Complex Lesions.
Vasarhelyi A, Lubitz J, Zeh A, Wohlrab D, Hein W, Mittlmeier T. Z Orthop Unfall 2009; 147: 439-444
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AIM: Dynamic gait analysis of blocked distal tibiofibular joint (TFJ) has not performed yet. This prospective study investigated patients treated for ankle fractures with combined syndesmotic complex lesions after surgery including tibiofibular positioning screw using CT data detecting fibular maltorsion and dynamic gait analysis.
METHOD: Prepublished data of 61 patients after surgical block of TFJ were analysed for torsional deformity of the distal fibula with an especially developed novel CT method. 10 of these patients were selected for dynamic pedography (emed-SF4, Novel GmbH, Munich). The measurements were accomplished one and six weeks (with blocked TFJ) and four months (with deblocked TFJ) postoperatively.
RESULTS: The gait pattern of 10 pedographically investigated patients showed increased loads of the hindfoot as well as a load shift to the lateral midfoot. Four months postoperative significant differences of the plantar pressure pattern concerning the parameters force, pressure, impulse and contact time were not observed. The analysis of the foot progression angle (fpa) of the non operated feet demonstrated external rotation of 9,5 degrees in average. In comparison to the healthy side with tibiofibular positioning screw the operated feet were significantly internal rotated during the first two measurements. Patients with fibular torsional differences > 15 degrees showed not only with tibiofibular positioning screw but also after its removal a persistant difference of fpa in average of 5,6 degrees without external rotating retraction.
CONCLUSIONS: The temporary blockage of TFJ results into an altered pattern of dynamic plantar pressure distrubution. A constant foot progression angle in relative internal rotation is registered. After removal of the positioning screw the recovered ligamentous structures allow retraction to the anatomic position. But, concerning fibular torsional differences > 15 degrees osseous fixation leads to alterated fpa presented as diminished external rotation of the foot of the formerly fractured ankle with consecutive dysfunction of the physiologic kinematic of movement and eventual provocation of posttraumatic arthritis. AIM: Dynamic gait analysis of a blocked distal tibiofibular joint (TFJ) has not been performed yet. This prospective study investigated patients treated for ankle fractures with combined syndesmotic complex lesions after surgery including a tibiofibular positioning screw using CT data for detecting fibular maltorsion and dynamic gait analysis. METHOD: Prepublished data of 61 patients after surgical block of TFJ were analysed for torsional deformity of the distal fibula with an especially developed novel CT method. Ten of these patients were selected for dynamic pedography (emed-SF4, Novel GmbH, Munich). The measurements were accomplished one and six weeks (with blocked TFJ) and four months (with deblocked TFJ) postoperatively. RESULTS: The gait patterns of 10 pedographically investigated patients showed increased loads of the hindfoot as well as a load shift to the lateral midfoot. Four months postoperative significant differences of the plantar pressure pattern concerning the parameters force, pressure, impulse and contact time were not observed. The analysis of the foot progression angle (fpa) of the non-operated feet demonstrated external rotation of 9,5 degrees in average. In comparison to the healthy side the operated feet with tibiofibular positioning screw were significantly internally rotated during the first two measurements. Patients with fibular torsional differences > 15 degrees showed not only with the tibiofibular positioning screw but also after its removal a persistant difference of fpa in average of 5.6 degrees without external rotating retraction. CONCLUSIONS: The temporary blockage of the TFJ results into an altered pattern of dynamic plantar pressure distrubution. A constant foot progression angle in relative internal rotation is registered. After removal of the positioning screw the recovered ligamentous structures allow retraction to the anatomic position. But, concerning fibular torsional differences > 15 degrees osseous fixation leads to alterated fpa presented as diminished external rotation of the foot of the formerly fractured ankle with consecutive dysfunction of the physiologic kinematic of movement and eventual provocation of posttraumatic arthritis
Ankle syndesmosis injuries
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