TREATMENT OF NEGLECTED SYNDESMOTIC INJURIESStephen Schmid DPM

Chief of Surgery, Lake Region Hospital

CONFLICTS OF INTEREST

• None

ANATOMY

• Syndesmotic ligament complex

• Anterior inferior tibiofibular ligament (AITFL) – 35%

• Posterior inferior tibiofibular ligament (PITFL) – 42%

• Interosseous ligament (IL) – 22%

• Inferior transverse tibiofibular ligament *

Hsu, et al. Syndesmotic injuries in athletes. Op Tech Sports Med. 2014; 22 (4): 270-281.

Ogilvie-Harris Dj, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy .1994 Oct;10(5):558-60.

DIAGNOSIS

• Signs and Symptoms:

• Persistent ankle pain

• Difficulty with uneven surfaces

• Sensation of ankle giving way

• Stiffness

• Limited dorsiflexion

DIAGNOSIS

• Radiographic Exam:

• Tibiofibular clear space < 6 mm on AP and Mortise

• Tibiofibular overlap

• AP: >6 mm or >42% width of fibula

• Mortise: >1 mm

• Medial clear space ≤ superior clear space

• Advanced Imaging

• MRI

• CT

http://www.cmcedmasters.com/ortho-blog/the-adult-ankle

DIAGNOSIS

• Exam

• External rotation stress test

• Squeeze test

• Cotton test

• Fibula translation test

• Arthroscopic evaluation

Johnson ZA, et al. Arthroscopic Stabilization for Chronic Latent Syndesmotic Instability. Arthroscopy Techniques, Vol. 5, No 2 (April), 2016: e262-e268

SURGICAL TECHNIQUES

LIGAMENTOPLASTY

Morris, Matthew William John et al. “Distal tibiofibular syndesmosis reconstruction using a free hamstring autograft.” Foot & ankle international 30 6 (2009): 506-11.

TRANSLATIONAL OSTEOTOMY

Beaumer, et al. Late reconstruction of the anterior distal tibiofibular syndesmosis. Acta Orthop Scand 2000; 71 (5): 519-521

SURGICAL TECHNIQUES

SYNDESMOTIC FUSION

• Injuries > 6 months

• Begin 1 cm proximal to ankle joint

• 2-3 cm fusion site

• Bone graft

Penã FA, Coetzee JC. Ankle Syndesmosis Injuries. Foot Ankle Clin N Am. 11 (2006); 35-50.

CASE EXAMPLE

• 44 y/o male

• Severe ankle sprain 3 years prior

• Complains of stiffness, pain with running and cutting

• Pain at anterolateral ankle/syndesmosis

• Positive external rotation stress test

• Abnormal CT scan

CASE EXAMPLE

CASE EXAMPLE

SUMMARY AND PEARLS

• 6 weeks to 6 months – consider repair/reconstruction

• >6 months – Syndesmotic fusion

• When performing syndesmotic fusion

• Be aggressive in bone resection

• Grafting- size matters

• Avoid malreduction

THANK YOU