The prevalence of syndesmotic injury has been estimated at 23% of all ankles with

fractures, with disruption prevalences as high as 39% to 45% of ankles with

operatively treated lateral malleolar fractures.
Anatomy
The tibiofibular syndesmosis consists of the soft-tissue connections of the distal
aspect of the tibia and fibula. The ligamentous stability of the syndesmosis is
provided by the anterior inferior tibiofibular ligament, the posterior inferior
tibiofibular ligament, the inferior transverse ligament, and the interosseous
ligament.
The anterior inferior tibiofibular ligament originates from the lateral malleolus and
inserts on the anterolateral tibial tubercle.
The interosseous ligament lies deep to the anterior inferior tibiofibular ligament. It
provides the main lateral ligamentous restraint to proximal migration of the talus
and represents the thickened portion of the distal interosseous membrane.
The posterior inferior tibiofibular ligament originates from the posterior tibial
tubercle and inserts on the posterior aspect of the lateral malleolus.
The fibrocartilaginous inferior transverse ligament forms the inferior portion of the
posterior inferior tibiofibular ligament.
The primary vascular supply to the anterior syndesmotic ligaments was the
perforating branch of the peroneal artery, which passed through the interosseous
ligament approximately 3cm proximal to the ankle joint.
Mechanism of Injury
The most common pattern for tibiofibular syndesmotic disruption is external rotation
with hyperdorsiflexion.
Results in a widening of the fibula in relationship to the tibia, disrupting the
syndesmotic ligaments and subsequently destabilizing the talus.
The first structure to be damaged in the externally rotated foot in either pronation
or eversion is the anterior inferior tibiofibular ligament.
Fracture patterns that are associated with syndesmotic injuries include the
supination-external rotation ankle fracture (Weber B). The pronation-external
rotation ankle fracture (Weber C), or a fracture of the proximal aspect of the fibula
(Maisonneuve)
Syndesmotic Stability
Although fibular position and controlled motion are necessary for proper
syndesmotic function and stable ankle motion with talar location within the mortise,
the ligaments around the tibiofibular syndesmosis act to prevent excessive fibular
motion
Diagnosis
History and Physical Examination
The patients history should include prior operations, mechanism of injury, location
of pain, ability to bear weight, and any feelings of instability. Physical examination
may reveal ankle pain and tenderness directly over the anterior syndesmosis.
Reduced passive dorsiflexion may also indicate syndesmotic injury. The external
rotation test has the lowest false-positive results and interobserver variance. It is
important to note that syndesmotic injuries may be missed in clinical diagnosis in
up to 20% of patients
Radiographic Assessment
The initial radiographic evaluation should include two full-length views of the tibia
and fibula (anteroposterior and lateral) and three views of the ankle joint
(anteroposterior, lateral, and mortise).
The radiographic signs that indicate possible syndesmotic disruption include
increased tibiofibular clear space (<6 mm on the AP and mortise views.), decreased
tibiofibular overlap (>6mm in AP and >1mm on mortise), and increased medial
clear space. (Equal to or less than the superior clear space between the dome and
the plafond as measured on the mortise view)
Tibiofibular clear space is considered to be a more reliable measurement as it is not
affected by positioning of the ankle relative to the radiographic beam.
A >4-mm medial clear space was associated with the disruption of the deltoid
ligament and tibiofibular ligaments with relatively high sensitivity but low specificity.
Previous authors have argued that standard radiographic parameters are poor
predictors syndesmotic stability.
If in doubt, stress views should enhance the preoperative diagnosis of syndesmotic
injury. Computed tomography (CT) is a reliable modality capable of detecting
diastasis and/or subluxation of the syndesmosis not otherwise appreciated on
radiographs. The use of MRI has also been shown to be highly sensitive and specific
for detecting syndesmotic disruptions.
Syndesmotic Injuries with Associated Fractures
Syndesmotic injuries are most often associated with LaugeHansen supination-
external rotation (Weber B) and pronation-external rotation (Weber C) injuries.
Intraoperative assessment of the syndesmosis is traditionally done in one of two
ways. The hook test entails distracting the fibula in the coronal plane with a bone
hook and assessing with a fluoroscopic mortise view. Widening by .2 mm suggests
the need for syndesmotic fixation. In the external rotation stress test, the tibia is
stabilized with one hand and an external rotation force is applied to the foot. The
test is positive if the medial clear space is >5 mm.
Candal-Couto et al. found that hook tests performed in the sagittal plane show
greater movement than in the coronal plane and appear to have greater sensitivity.
A fracture of the proximal aspect of the fibula with external rotation, commonly
referred to as a Maisonneuve fracture, should prompt the treating surgeon to
evaluate for syndesmotic injury, but the fracture does not always result in instability.
Treatment
Nonoperative Treatment
In patients with isolated syndesmotic sprains, several grading systems have been
proposed. Mulligan stratified the grade of sprain on the basis of patient symptoms,
syndesmotic stability, and radiographic imaging immobilization and weight-bearing
status are then guided by symptom severity, amount of instability, and functional
ability. For grade I, sprains without diastasis, patients may bear weight as tolerated
and may be immobilized for zero to three days. For grade II, sprains with latent
diastasis, patients may require three to seven days of immobilization, with full
weight bearing after one to two weeks. For grade III, sprains with frank diastasis,
patients require more than seven days of immobilization, with a minimum of two to
three weeks of non weight-bearing.
The first phase is governed by joint protection, reduction of inflammation, and pain-
free walking.
Second phase, the return of strength, mobility, and a normal gait are the main
goals.
These following stages of all programs are directed at advanced motions with the
goals of returning to athletic activity or pain-free activities of strenuous daily living.
Nonoperative treatment has been recommended in Weber-B or low Weber-C ankle
fractures when the deltoid ligament and the posterior aspect of the syndesmosis are
intact.
Operative Fixation
Indications
syndesmotic sprains refractory to nonoperative treatment, for persistent
syndesmotic instability despite definitive fixation, and in many Weber-C fractures.
Reduction
The importance of an accurate ankle and syndesmotic reduction (Fig. 4, A) cannot
be overstated to improve functional outcomes and to prevent posttraumatic
arthritis. Malreduction of the tibiofibular joint may be caused by improper reduction
of the fibula, the syndesmotic injury, or even the syndesmotic screw.
When the reduction clamp is placed 1 cm proximal to the mortise and in the neutral
anatomic axis, it reduces the fracture more accurately but may produce slight over
compression.
Eccentrically applied clamps anterior to the plane of the distal tibiofibular joint can
translate the fibula anterior to the tibia. Direct visualization of the reduction has
been proven to reduce the number of malalignments.
Fixation
Even though syndesmotic screw fixation was once considered the gold standard, a
variety of constructs are available; these include one or two screws, 3.5 or 4.5 mm
in diameter, placed suprasyndesmotically or transsyndesmotically, with tricortical or
quadricortical purchase, and metallic or bioabsorbable in composition.
Outcomes
Nonoperative Treatment
Several studies have demonstrated that substantially greater recovery time is
required for the nonoperative treatment of syndesmotic sprains compared with
lateral ankle sprains.
Nussbaum et al. reported that, at a six-month followup, thirty-five cases had
excellent outcomes and eighteen cases had good outcomes utilizing that same
system; however, of the fifty-three patients, six had occasional ankle pain or
stiffness and four reported recurrent sprains.
Nonoperative management research did not employ consistent methods of
diagnosing or grading syndesmotic sprains; thus, injury severity may be variable
among the studies.
Operative Fixation
Syndesmotic Screw
A number of studies have found no major differences with regard to functional
outcomes among several screw parameters and characteristics. A study comparing
one 4.5-mm quadricortical screw with two 3.5-mm tricortical screws did find a
significant difference in functional outcome(p=0.025) and pain. (p = 0.017) at three
months favoring the tricortical group, but these differences were not seen at the
one-year followup.
To our knowledge, there have been no major differences in functional outcomes with
regard to 3.5-mm and 4.5-mm screws, tricortical and quadricortical screws,
transsyndesmotic and suprasyndesmotic screws, stainless steel and titanium
screws, or metal and bioabsorbable screws.
Suture Button
A systematic review by Schepers109 compared suture buttons with syndesmotic
screws. It was found that the American Orthopaedic Foot & Ankle Society (AOFAS)
scores in patients treated with suture buttons was 89.1 points, with a mean follow-
up of nineteen months. The AOFAS score in patients treated with syndesmotic
screws was 86.3 points with a mean follow-up
of forty-two months. Implant removal was required in 10% of patients treated with
suture-button screws compared with 51.9% of patients treated with screws or bolts.
Posterior Malleolar Fixation
Posterior malleolar fractures of varying sizes are commonly associated with ankle
fractures. Posterior malleolar fixation yielded better stabilization of the syndemosis
in this cadaveric study, with restoration of 70% of normal syndesmotic stiffness
after posterior malleolar fixation compared with 40% after syndesmotic fixation
alone114. Posterior malleolar fixation may also improve the accuracy of ankle
fracture reduction

Complications
Implant Failure and Screw Removal
Fixation of the syndesmosis results in alterations to normal biomechanics and fibular
motion116,117; thus, the added shear stress when weight-bearing may cause
syndesmotic screws to fatigue and break. Previous studies have shown 7% to 91%
of screws loosening or breaking. 3.5-mm screws were more likely to break than 4 or
4.5-mm screws.
Authors have argued against screw removal due to added cost, risk of infection,
recurrent diastasis, and questionable improvement in outcomes. Recurrent diastasis
may occur following screw removal, as studies have shown such recurrence in 6.6%
to 15.8% of cases in which screws had to be removed at six to eight weeks because
of breakage or loosening.
Egol et al. found that greater age, male sex, absence of diabetes, and a lower
American Society of Anesthesiologists (ASA) class all predicted better functional
outcomes at a one-year follow-up. A recent study also identified age, body mass
index, and duration of plaster immobilization as negative indicators