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Review Article: R. Dattani, S. Patnaik, A. Kantak, B. Srikanth, and T. P. Selvan Injuries to the tibiofibular syndesmosis J Bone Joint Surg Br 2008; 90-B: 405-410 [Abstract] [Full text] [PDF]

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Treatment of Injuries to the Syndesmosis

Julie Kohls-Gatzoulis, Paul J. Halliwell, Anthony Sakellariou, Mathew C. Solan and Alex Wee   (10 July 2008)

Treatment of Injuries to the Syndesmosis 10 July 2008
Julie Kohls-Gatzoulis, Fellow, Foot and Ankle Royal Surrey County and Frimley Hospitals, Paul J. Halliwell, Anthony Sakellariou, Mathew C. Solan and Alex Wee Send letter to journal: Re: Treatment of Injuries to the Syndesmosis juliegatzoulis{at}homechoice.co.uk Julie Kohls-Gatzoulis, et al.	Sir, We congratulate Mr Dattani and his colleagues on their recent article which was a good review of the literature. As tertiary referral units for foot and ankle problems, we have learned how particularly difficult these injuries are to manage. We wish, therefore, to share our experience by emphasising a number of points: A. DIAGNOSIS 1) A high index of suspicion is needed to identify a syndesmotic injury. This applies whether or not there is an associated ankle fracture. 2) In examining those patients who have an acute syndesmotic injury without associated fracture, the Abduction-External Rotation Test and the Squeeze Test1 are useful. In combination, they help to identify those with a ‘high’ ankle sprain. One should suspect a syndesmotic injury and perform these tests in all patients who have sustained a significant ankle sprain. 3) Patients with clinical signs of an isolated syndesmotic injury without associated fracture require either further imaging by way of bilateral fine cut CT2 or an EUA to confirm the injury is only a ‘high’ sprain and not a frank disruption. This is essential, especially where non-operative management is being considered. B. CLASSIFICATION The classification system of Edwards and DeLee3 is a useful guide to management. They describe four types of isolated syndesmotic injuries. Type I is a lateral displacement of the fibula and requires syndesmosis fixation. Type II is a lateral displacement of the fibula with plastic deformation of the fibula and may need a fibular osteotomy in order to restore the ankle anatomy. Type III is a postero-lateral, rotatory subluxation of the fibula and Type IV, has the superiorly dislocated talus between the tibia and fibula. Edwards and DeLee state that types III and IV may be managed with closed reduction and plaster immobilisation. We would have a low threshold for fixing the syndesmosis in type IV injuries. C. MANAGEMENT ACUTE INJURY SOFT TISSUE INJURIES 1. The authors did allude to this point but it is key; those patients who have a high sprain (without frank disruption of the syndesmosis) need a substantial period of immobilisation in a cast. We recommend 8 to 12 weeks. Patients and their physiotherapists need to expect that this injury will take several months to settle. 2. Those patients who have definite syndesmotic instability at the time of EUA, require stabilisation of the syndesmosis. Dattani et al have presented an excellent review of the techniques available. We wish to emphasise that healing of the syndesmosis is a lengthy process. After syndesmotic screw insertion, we prefer two to three months of immobilisation. We do remove the screws, but not until four to six months after the injury. DIFFICULT FRACTURES For those patients who have a syndesmotic injury associated with a multi-fragmentary fibular fracture, it is most important to restore both the length and rotation of the fibula. This may require an open anterior approach to the distal tibio-fibular joint, with care, to avoid injuring the superficial peroneal nerve. Failure to achieve reduction of the ankle mortise makes syndesmotic fixation pointless, as the ankle will be subjected to abnormal loads and likely early degeneration. 4 The goal must be to first restore the ankle mortise and then to fix the syndesmosis (as outlined in the paper). CHRONIC SITUATIONS ISOLATED SYNDESMOTIC INJURIES There is a group of patients who have a chronic, missed, isolated syndesmotic injury (without associated fracture). As always, a good history and examination is essential for successful diagnosis. Supplementary investigation with plain and stress radiographs may afford sufficient confirmation. If further investigation is required, we recommend a fine cut CT scan, with comparison views of the normal ankle, as this demonstrates the diastasis well.2 In chronic cases, arthroscopy5,6 helps to determine whether there is scar tissue in the medial gutter which will need debridement prior to reduction of the diastasis. Debridement of scar tissue from the syndesmosis may also be necessary,7 as might advancement of the anterior inferior tibiofibular ligament on its bony attachment to the tibia.8 Following debridement of the syndesmosis, we would support the use of large AO screw fixation spanning four cortices.7 Occasionally, formal arthrodesis of the tibio-fibular articulation is required. NEW DEVELOPMENTS The tight-rope device is known to cause medial soft tissue irritation and we therefore have reservations about its use as a first line treatment. If there is significant instability, and the tight-rope technique is chosen, then two tight-rope devices may be necessary. J. Kohls-Gatzoulis, BSc MEd FRCS (Tr & Orth), Foot and Ankle Fellow, P.J. Halliwell, FRCS (Tr & Orth), Royal Surrey County Hospital, A. Sakellariou, BSc FRCS (Orth), Frimley Park Hospital, M.C. Solan, FRCS (Tr & Orth), Royal Surrey County Hospital), A. Wee, FRCS (Tr & Orth), Frimley Park Hospital), UK. 1. van den Hoogenband CR, van Moppes FI, Stapert JW, Greep JM. Clinical diagnosis, arthrography, stress examination and surgical findings after inversion trauma of the ankle. Arch Orthop Trauma Surg 1984;103:115-19. 2. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 2006;27:788-92. 3. Edwards GS Jr, DeLee JC. Ankle diastasis without fracture. Foot Ankle 1984;4:305-12. 4. Chissell HR, Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. J Bone Joint Surg [Br] 1995;77-B:435-8. 5. Amendola A, Frost S. The diagnosis and treatment of chronic syndesmosis sprains of the ankle [abstract]. 31st AOFAS, 2001. 6. Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop 2007;455:173-5. 7. Harper MC. Delayed reduction and stabilization of the tibiofibular syndesmosis. Foot Ankle Int 2001;22:15-18. 8. Beumer A, Heijboer RP, Fontijne WP, Swierstra BA. Late reconstruction of the anterior distal tibiofibular syndesmosis: good outcome in 9 patients. Acta Orthop Scand 2000;71:519-21.