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Abstract 1

Background: Chronic syndesmotic injury may cause long-term pain and reduced ankle function. 2

Today, there is no consensus about the best surgical treatment of these injuries. We present the 3

technique and results of revision and fixation with a suture button and a quadricortical screw. 4

Methods: Eleven patients treated for chronic syndesmotic injury were included. The patients 5

completed questionnaires regarding ankle function, and computed tomography (CT) scans were 6

obtained to evaluate tibiofibular distance and osteoarthritis. Complications were registered. 7

Results: At mean 45 months follow-up, the mean American Orthopaedic Foot and Ankle Society 8

(AOFAS) ankle-hindfoot score was 87 points. There were 5 complications, including 3 hardware 9

related pain. The tibiofibular distance was significantly reduced with surgery. Seven patients had 10

progression of osteoarthritis. 11

Conclusions: Even though the majority of the patients had progression of radiological signs of 12

osteoarthritis, the functional outcome after revision and fixation with a suture button and a 13

quadricortical screw in chronic syndesmotic ruptures is good and comparable to the results 14

presented in other studies. 15

2

Key words 16

Chronic syndesmotic injury; Ankle sprain; Ankle fracture; Syndesmotic injury. 17

3

Level of evidence 18

Level 4, case series without control, technical note. 19

4

Text 20

Introduction 21

Injury to the distal tibiofibular syndesmosis is reported in 16-35% of the surgically treated ankle 22

fractures and 1-10% of the ankle sprains 1-4. The syndesmosis stabilizes the ankle joint during 23

weightbearing by maintaining the tibiofibular relationship. Simultaneously, it allows widening of the 24

mortise when ankle dorsiflexion to accommodate the increasing anterior width of the talar dome. 25

Unrecognized syndesmotic injury, malreduction of the fibula, hardware failure, or premature 26

removal of hardware may cause persistent widening of the syndesmosis 5. This may result in long-27

term instability, pain and reduced ankle function 6,7. Operative treatment is necessary to restore 28

stability and a well aligned ankle joint, and prevent the development of osteoarthritis 6,8. 29

Chronic syndesmotic injury has been defined as syndesmotic injury presenting more than 3 months 30

after trauma 9-11. At this time, significant fibrous tissue may be present, and reduction of the 31

syndesmosis necessitates thorough debridement 5,9,12. Several surgical methods for syndesmotic 32

stabilization are described in the literature, including suture button or screw fixation, anatomical 33

ligamentous reconstruction and arthrodesis 13-23. Today, no consensus regarding the best surgical 34

strategy for these injuries exists. 35

The aim of the study was to evaluate the surgical technique and results of revision and 36

transsyndesmotic fixation with a suture button and a quadricortical screw. 37

38

Methods 39

Twelve patients treated for chronic syndesmotic injury between January 2011 and January 2017 40

were identified by searching the surgical procedure according to Nomesco classification of surgical 41

procedures (NOMESCO, NCSP) in the electronic medical record system DIPS (DIPS AS, Bodø, Norway). 42

Chronic syndesmotic injury was defined as syndesmotic injury diagnosed more than 3 months after 43

5

initial trauma. All patients signed an informed consent, but 1 was excluded as he did not meet for 44

follow-up. Eleven patients were included in the study. 45

Preoperative patient characteristics, including initial injury, treatment and radiographic presentation, 46

are presented in Table 1. There were 5 men and 6 women. Six injuries involved the left ankle. Eight 47

patients had sustained an ankle fracture and 3 patients an ankle sprain. The patients presented at 48

the orthopedic outpatient clinic mainly because of persistent pain. The pain was most prominent at 49

weightbearing or during activities. Additionally, some of the patients had recurrent swelling, 50

stiffness, snapping on movement, or a subjective feeling of instability. The clinical examination 51

revealed varying degrees of pain when palpation of the anterior inferior tibiofibular ligament (AITFL), 52

and most of the patients had positive external rotation stress test or anterior impingement test. Plain 53

radiographs, computed tomography (CT) scans and / or magnetic resonance imaging (MRI) confirmed 54

the diagnosis and demonstrated increased distal tibiofibular distance or signs of syndesmotic 55

rupture. 56

The patients were treated with revision of the syndesmosis followed by syndesmotic fixation with a 57

suture button and a quadricortical screw. This was done in general anesthesia, in supine position and 58

with bloodless surgery. Revision was performed arthroscopically or open. Arthroscopic revision 59

included an anterolateral and anteromedial portal as described by van Dijk et al. 24. The tibiofibular 60

and ankle joint were explored and the extent of syndesmotic injury, fibrous tissue and degenerative 61

changes was identified. A shaver was used to resect all hypertrophic fibrous tissue. Loose bone and 62

cartilage fragments were also resected. Open revision was performed with a lateral approach to the 63

lateral malleolus, exposing the AITFL and the ankle joint (Figure 1). The revision of the syndesmosis 64

allowed for reduction of the distal fibula in the fibular notch. The syndesmosis was reduced manually 65

or with the use of a clamp under visual and / or fluoroscopic guidance (Figure 2a and 2b). 66

Transsyndesmotic fixation was done with a suture button (TightRope; Arthrex, Naples, FL) and a 3.5 67

mm or 4.5 mm quadricortical screw (Synthes, West Chester, PA) (Figure 3). The transsyndesmotic 68

6

fixation was done open in all patients. All patients had postoperative radiographs (Figure 4). The 69

quadricortical screw was removed in local anesthesia 12 weeks postoperatively. Full weightbearing 70

was allowed after 6 weeks. 71

All patients had a minimum of 12 months postoperative follow-up. Primary outcome measure was 72

American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score 25 which devotes 40 73

points to pain, 50 points to function and 10 points to alignment. A total of 100 points is the best 74

result. Other functional outcome measures included the Foot and Ankle Ability Measure (FAAM) 75

Activities of Daily Living (ADL) 26, Manchester-Oxford Foot Questionnaire (MOxFQ) 27, Olerud-76

Molander Ankle (OMA) score 28, and Visual Analogue Scale (VAS) scores for pain during rest, walking, 77

and night. FAAM ADL is reported as a percentage score between 0 and 100 where a higher score 78

represents a higher level of physical function. The MOxFQ comprises the dimensions walking / 79

standing, pain and social interaction, and the total score is reported as a score between 0 and 100 80

where 100 being the most severe. The OMA score is a functional rating scale from 0 to 100 points 81

where 100 points being the best score. Complications were also registered. 82

CT scans were obtained preoperative and at follow-up. The CT scans were examined by a radiologist 83

and 2 orthopedic surgeons. The tibiofibular distance was measured on axial scans, 1 cm proximal to 84

the midpoint of the tibial plafond, at 3 standardized landmarks (Figure 5) 29-31. The measurements 85

were compared to the preoperative CT scans. The extent of ankle osteoarthritis was classified 86

according to the Kellgren and Lawrence grading scale (Table 2) 32. 87

The Statistical Package for Social Science (SPSS) software, version 25 (SPSS Inc, Chicago, IL, USA), was 88

used for statistical analyzes. Normally distributed data are presented as means and standard 89

deviations. Median values with full data range are presented when the data are non-normally 90

distributed. Paired samples T-test was used to analyze changes in means over time. Median values 91

were compared with Mann-Whitney U test. The Spearman’s Rank Order Correlation is a 92

7

nonparametric measure of correlation, and was used to analyze the relationship between continuous 93

data. The level of significance was set at p ≤0.05. 94

95

Results 96

At the time of syndesmotic reconstruction, the mean age was 37±18 years. The mean interval from 97

ankle injury to syndesmotic reconstruction was 28±16 months, and the mean time from syndesmotic 98

reconstruction to follow-up was 45±22 months. Table 3 demonstrates the surgical procedures and 99

postoperative complications. Additional procedures were executed when indicated. In two patients, 100

the plate and screws from the initial surgery were removed to achieve reduction. Malunion of 101

previous fibular fracture required osteotomy with plate and screw fixation in two patients. Deltoid 102

ligament reconstruction was performed in one patient. 103

The level of the transsyndesmotic fixation was measured on postoperative radiographs. The suture 104

buttons were placed median 1.43 (1.02-3.95) cm and the quadricortical screws median 2.77 (1.98-105

4.09) cm proximal to the tibial plafond. In 2 patients the suture button was placed proximal to the 106

screw. 107

The functional results at follow-up are presented in table 4. Eight patients presented with good or 108

excellent AOFAS score, defined as 80 points and more 25. Median VAS pain score was 1.0 (0-5.0) 109

during rest, 1.5 (0-5.0) during walking, and 0 (0-5.0) at night. No significant difference in functional 110

result was found when comparing the patients that had sustained an ankle fracture or an ankle 111

sprain (Table 5). All patients would recommend the surgery to others with the same injury. 112

Five patients experienced complications. Three patients had pain related to the hardware after 113

removal of the quadricortical screw, where 1 had removal of all metal, 1 had removal of the suture 114

button, and 1 were planned for removal of the suture button. They had a significant lower functional 115

outcome score at follow-up (Table 5). One patient had a postoperative infection and 1 had an 116

8

infection after removal of the quadricortical screw. After successful treatment, both these patients 117

scored high. 118

The tibiofibular distance was measured on all CT scans at follow-up and compared to the 119

preoperative CT scans. The difference in the anterior and central distances was significantly reduced 120

with surgery, with a mean difference of 2.4±2.1 mm (p=0.004) and 1.5±1.5 mm (p=0.010) 121

respectively. The mean difference in the posterior distance was increased with 0.1±2.3 mm, but this 122

was not significant. 123

Based on the Kellgren and Lawrence grading scale, progression of osteoarthritis on follow-up 124

compared to preoperative CT scans was evident in 7 patients. The grades of osteoarthritis are 125

presented in table 6. Neither the difference in tibiofibular distance nor the grade of osteoarthritis at 126

follow-up was significantly associated to functional outcome (table 7). 127

128

Discussion 129

Diagnosing and treating chronic syndesmotic injuries may be challenging. Undiagnosed injuries may 130

result in delayed treatment and development of degenerative soft tissue and osteoarthritis 5,6,8. The 131

goal of treatment is improvement of ankle function and absence of pain. The patients in the present 132

study reported a high functional outcome. 133

At mean 4 years follow-up, we found a mean AOFAS score of 87±11 points. This is in consistency with 134

previous studies on chronic syndesmotic injuries, reporting an AOFAS score of 83-95 13-16,19,21-23,33. 135

Ryan et al. 23 reported outcomes in 19 patients treated with arthroscopic debridement and 136

stabilization with 2 or 3 suture buttons after a minimum of 24 months follow-up. They found an 137

AOFAS score of 83±26 points. Similarly, Han et al. 33 and Harper et al. 13reported an AOFAS score of 138

87 and 91 points respectively after transcortical screw fixation with or without debridement of the 139

syndesmosis. A mean score of 91.6 in the general population has previously been reported 34. The 140

9

score is not validated and has been criticized for not being important for the patient outcome, but 141

has still been the most frequently used score in foot and ankle injuries 35. The FAAM ADL, MOxFQ and 142

OMA score have to our knowledge not previously been reported in studies addressing chronic 143

syndesmotic injuries. However, the FAAM ADL of 87±15 points in our study was acceptable 144

compared to the normative value of mean 92±12 points in 271 people >18 years old 36. The OMA 145

score demonstrated a high outcome compared to 3 years after surgical treatment for unstable ankle 146

fracture, respectively 79±19 and 76±24 points 37. Contrary to this, the mean MOxFQ for the 147

dimensions walking / standing, pain and social interaction in our study was 30±28, 30±20 and 19±18 148

points. The respective scores reported in 671 patients 9 months after foot and ankle surgery were 149

19±23, 19±19 and 13±18 points 38. 150

In our study, the patients with hardware related pain had the worst functional outcome at follow-up. 151

Totally, 5 of the 11 patients experienced a complication. Compared to previous studies reporting a 152

complication rate between 0% and 20% 13-23,33,39, this rate is high. In the study by Olson et al. 21 153

including 10 patients treated with distal tibiofibular arthrodesis and plate fixation, 2 of the patients 154

had pain from the metal that needed removal, where 1 patient also needed arthroscopic 155

debridement due to persistent pain. After transsyndesmotic screw fixation, Harper et al. 13 reported 156

1 patient with early screw loosening, and Schuberth et al. 14 reported 1 patient with tibiofibular 157

synostosis. In the study by Colcuc et al. 22, there were 2 cases with suture granuloma around the 158

suture button, and also Ryan et al. 23 reported 2 patients with pain from the suture button which 159

required removal. In our study, 3 patients had removal of metal due to pain. The definition of 160

complications varies greatly between studies which could explain the lower rate reported in previous 161

studies. 162

The CT scans at follow-up demonstrated a reduced anterior and central tibiofibular distance 163

compared to the preoperative CT scans. This is consistent with a successful reduction. Other 164

techniques have also presented with better postoperative reduction and good functional outcomes. 165

10

Schuberth et al. 14 compared pre- and postoperative plain radiographs after debridement and 2 or 3 166

transsyndesmotic screws in 6 patients. The mean change in total clear space was 4.4 mm, in total 167

fibular overlapping was 4.4 mm, and in medial clear space was 3.2 mm, indicating improvement in 168

ankle reduction. They also reported a significant increase in AOFAS score of 32 points at minimum 24 169

months follow-up. Similarly, Grass et al. 17 found improved reduction on plain radiographs after 170

peroneus longus ligamentoplasty and decreased tibiofibular distance measured centrally on axial CT 171

scan. The Karlsson score, where 100 points is the best, was 88 points at mean 16 months follow -up. 172

Previous studies addressing acute syndesmotic injuries have reported a significant effect of 173

tibiofibular distance on functional outcome 1,40-42. The small numbers in the present study prevents 174

any significant correlation between the tibiofibular distance and functional outcome. Still, a better 175

reduction suggests a high level of ankle function. 176

The correlation between the adequacy of the syndesmotic reduction and osteoarthritis after 4 years 177

was presented already in 1984 by Leeds and Ehrlich 6. Olson et al. 21 found no progression of 178

osteoarthritis after distal tibiofibular arthrodesis in 10 patients at mean 41 months follow-up. The 179

mean interval between the initial injury and the salvage procedure in their study was 9 (2-20) 180

months. Based on the Kellgren and Lawrence grading scale, progression of osteoarthritis was evident 181

in 7 patients after syndesmotic reconstruction in our study. Even though minor, the progression 182

might be related to latency of revision surgery, as the mean interval from injury to reconstruction 183

was 28±16 months. Also, the grade of osteoarthritis at follow-up was not correlated to functional 184

outcome. As the Kellgren and Lawrence grading scale is widely used, it was utilized despite being 185

based on radiographic assessment and not being ankle specific 32,43. 186

In previous studies, chronic syndesmotic injuries have been treated using different surgical methods, 187

and promising results are reported. A systematic review by Parlamas et al. 44 did not find support for 188

recommending one surgical method in the literature. They reported a pooled success rate of 87.9% 189

after screw fixation, 79.4% after arthrodesis and 78.7% after arthroscopic debridement. Lubberts et 190

11

al. 11 presented a systematic review including isolated syndesmotic injuries only. Also, they report 191

satisfactory results in all included studies, independent of surgical method used. The total 192

complication rate in their study was 10%. Transsyndesmotic fixation is the most frequent method, 193

but there is no consensus about type or number of devices today. 194

To our knowledge, no previous study has reported the surgical technique or results of revision and 195

fixation with a suture button and a quadricortical screw. Initial revision of the syndesmosis with 196

resection of interposed fibrous tissue is necessary to allow for reduction of the distal fibula in the 197

fibular notch 5,12. An arthroscopic approach is thought to be preferable because of less extensive 198

dissection and reduced risk of injury to the vascular supply of the bones 14,45. In the present study, all 199

patients were finally treated with open fixation of the syndesmosis and the advantages of an 200

arthroscopic approach on the soft tissues is not investigated. Additionally, arthroscopy allows for 201

revision of the medial clear space and removal of osteochondral defects and synovitis in the ankle 202

joint 9,10,14,46. Directly positioning of the fibula in the fibular notch necessitates an open approach. The 203

“self-centering effect” of the dynamic suture button allows for anatomic reduction of the fibula, and 204

a quadricortical screw adds additional securing of the fixation. A knotless suture button should be 205

preferred because of the otherwise risk of pain from the suture knot. 206

There are several limitations in our study. Firstly, there is a huge heterogenicity in our patient 207

material, including all patients with chronic syndesmotic injury regardless of type of injury. Secondly, 208

the type of treatment was not standardized, utilizing both arthroscopic and open revision and 3.5 209

mm and 4.5 mm screw. Also, some patients had concomitant procedures. Thirdly, our sample size is 210

small, and the low incidence of this injury prevents high quality studies. Multicenter studies should 211

be preferred in the future. 212

Strengths of the study are the long-term follow-up and the use of CT scans. CT scans taken both 213

preoperative and at follow-up were available for analyses. Additionally, bilateral CT scans should be 214

12

obtained at follow-up for comparison between the injured and non-injured ankle as significant 215

anatomic variations of the syndesmosis are reported 47,48. 216

217

Conclusion 218

The patients in this study were treated with revision and transsyndesmotic fixation with a suture 219

button and a quadricortical screw. We found a high functional outcome score which is comparable 220

with previous studies, even though the radiological signs of osteoarthritis increased in the majority of 221

the patients. Hardware related pain was the most frequently observed complication. We suggest that 222

the presented surgical method is a good alternative for treating chronic syndesmotic injuries. 223

224

Author Contribution Statement 225

All authors were fully involved in the study and preparation of the manuscript. 226

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335

Tables 336

18

Table 1. Patient characteristics including initial injury, treatment and radiographic presentation.

Patient

Initial ankle

fracture Primary treatment

Syndesmotic

screw removal

Secondary

treatment

Plain

radiographs CT scan MRI

1

No fracture Arthroscopic revision x4 . . Partial syndesmotic rupture

2 Unimalleolar Cast . . Malunion with syndesmotic

incongruence

3

Unimalleolar Cast . . Calcification of the syndesmosis Syndesmotic rupture

4 Trimalleolar ORIF, syndesmotic screw fixation Yes . Increased distal tibiofibular

distance

5 Unimalleolar ORIF, syndesmotic screw fixation Yes . Increased MCS Increased distal tibiofibular

distance

6 Unimalleolar ORIF, syndesmotic screw fixation Yes . Increased MCS

7 Trimalleolar ORIF (no syndesmotic screw fixation) . . Increased distal tibiofibular

distance

8 Unimalleolar ORIF, syndesmotic screw fixation Yes Arthroscopic

revision x2

Increased distal tibiofibular

distance

9 No fracture Walker . . Partial rupture of AITFL

10 Trimalleolar External fixation . . Increased distal tibiofibular

distance

11 No fracture Arthroscopic revision . . Partial rupture of AITFL

The initial ankle injury with primary and secondary treatment, before the diagnosis of chronic syndesmotic injury. Radiographic presentation, including plain radiographs, CT scan and MRI,

which confirmed the diagnosis of chronic syndesmotic injury.

Abbreviations: CT = Computed tomography. MRI = Magnetic resonance imaging. ORIF = Open Reduction Internal Fixation. MCS = Medial clear space. AITFL = Anterior inferior tibiofibular

ligament.

337

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338

Table 2. The Kellgren and Lawrence grading scale for osteoarthritis.

Grade Description

None No features

Doubtful Doubtful joint space narrowing, possible osteophytic lipping

Minimal Definite osteophytes, possible narrowing of joint space

Moderate Moderate multiple osteophytes, definite narrowing of joint

space, some sclerosis, possible deformity of bone ends

Severe Large osteophytes, marked narrowing of joint space, severe

sclerosis and definite deformity of bone ends

The grading of osteoarthritis as classifies according to Kellgren and Lawrence [32].

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Table 3: Surgical procedures and postoperative complications.

Patient Syndesmotic reconstruction

Additional

procedures

Syndesmotic

screw removal Complications

Treatment of

complications

1 Open revision and fixation,

4.5 mm screw and suture button Yes


4.5 mm screw and suture button Fibulaosteotomy Yes Pain from metal

Removal of

metal



Postoperative

infection

Revision, VAC

and antibiotics

4 Arthroscopic revision, open fixation,



4.5 mm screw and suture button

Removal of plate

and screws Yes Pain from metal

Removal of

suture knot



Removal of plate

and screws Yes



Deltoid ligament

reconstruction Yes




3.5 mm screw and suture button Yes Pain from metal

Planned

removal of

suture button


4.5 mm screw and suture button Fibulaosteotomy Yes

Infection after

syndesmotic

screw removal

Antibiotics



The surgical procedures including syndesmotic reconstruction, additional procedures, and syndesmotic screw removal.

Postoperative complications and treatment.

Abbreviations: VAC = Vacuum assisted closure.

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Table 4: Functional results at follow-up.

Mean SD Min. Max.

Respondents

(total n = 11)

AOFAS score 87 11 63 100 11

- Pain score 31 7 20 40

- Function score 46 4 38 50

- Alignment score 10 2 5 10

FAAM ADL 87 15 57 100 9

MOxFQ 27 22 0 67 10

- Walking / standing domain 30 28 0 82

- Pain domain 30 20 0 60

- Social interaction domain 19 18 0 50

OMA score 79 19 35 100 10

Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living. MOxFQ = Manchester-Oxford

Foot Questionnaire. OMA score = Olerud-Molander Ankle score. SD = Standard deviation.

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Table 5: Left: Functional outcome for patients that had sustained an ankle fracture or an

ankle sprain. Right: Functional outcome for patients that experienced pain related to

the hardware and not.

Injury

P-value

Pain from hardware

P-value Fracture Sprain Yes No

AOFAS score 87 87 0.757 78 88 0.013

FAAM ADL 92 87 0.362 63 93 0.039

MOxFQ 25 30 0.819 55 13 0.029

OMA score 85 75 0.491 58 85 0.189

The scores are presented as median values. Mann-Whitney U test was used to test

differences between the groups. P-value ≤ 0.05 is significant.

Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-

hindfoot score. FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living.

MOxFQ = Manchester-Oxford Foot Questionnaire. OMA score = Olerud-Molander Ankle

score.

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Table 6: Grades of osteoarthritis preoperative and at follow-up.

Preoperative Follow-up

Patient 1 None None

Patient 2 Doubtful Doubtful

Patient 3 Minimal Minimal

Patient 4 Doubtful Moderate

Patient 5 Minimal Moderate

Patient 6 Doubtful Minimal

Patient 7 Doubtful Minimal

Patient 8 None Doubtful

Patient 9 None None

Patient 10 Moderate Severe

Patient 11 None Minimal

Osteoarthritis is graded according to the Kellgren and Lawrence

grading scale (33).

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Table 7: Left: Correlation between reduction in anterior, central and posterior tibiofibular distance

and outcome. Right: Correlation between grade of osteoarthritis at follow-up and outcome.

Difference in tibiofibular distance Osteoarthritis at

follow-up Anterior Central Posterior

rs p-value rs p-value rs p-value rs p-value

AOFAS 0.234 0.488 0.326 0.327 0.120 0.726 -0.071 0.835

FAAM ADL -0.076 0.847 0.151 0.698 -0.034 0.932 0.150 0.700

MOxFQ 0.043 0.907 0.018 0.960 0.195 0.589 -0.047 0.896

OMAS 0.207 0.565 0.000 1.000 -0.098 0.789 0.478 0.162

Spearmans’s Rank-Order Correlation was used for the analyses. The numbers demonstrate the

correlation coefficients (rs) and the subsequent p-values. P-value ≤ 0.05 is significant.

Abbreviations: AOFAS score = American Orthopaedic Foot and Ankle Society ankle-hindfoot score.

FAAM ADL = Foot and Ankle Ability Measure Activities of Daily Living. MOxFQ = Manchester-Oxford

Foot Questionnaire. OMA score = Olerud-Molander Ankle score.

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Figures 345

Figure 1 346

347

348

Figure 2a 349

350

26

351

Figure 2b 352

353

354

Figure 3 355

356

357

27

Figure 4 358

359

360

Figure 5 361

362

363

28

Legends 364

Figure 1. A direct lateral approach was used to access the AITFL and the ankle joint for open revision. 365

The figure demonstrates a normal right ankle with intact AITFL. 366

Figure 2a and 2b. After revision, the syndesmosis was reduced manually or with a clamp. The figures 367

demonstrate the joint after arthroscopically revision and the tibiofibular distance before (a) and after 368

reduction (b) syndesmotic reduction. 369

Figure 3. The peroperative fluoroscopy demonstrates the fixation of the syndesmosis in a reduced 370

position with a suture button and a 4.5 mm quadricortical screw. 371

Figure 4. The postoperative radiograph displays the surgical technique including syndesmotic fixation 372

with a suture button and a quadricortical screw. 373

Figure 5. The bilateral axial CT scan demonstrates the postoperative measurement of the tibiofibular 374

distance of the right ankle (left). The distance was measured on axial scans, 1 cm proximal to the 375

midpoint of the tibial plafond, at 3 standardized landmarks; representing anterior, central and 376

posterior distances. 377

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