Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HUANG Hui ,  YANG Yunfeng

Department of Orthopaedics, Tongji Hospital, Tongji University, Shanghai, 200065, P.R.China;

Corresponding author：

YANG Yunfeng, Email: yyfscn@163.com

Keywords：

Distal tibiofibular syndesmosis injury; reduction; internal fixation; elastic fixation

DOI：

10.7507/1002-1892.201911090

Video：

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Objective To review the research progress in the diagnosis and treatment of distal tibiofibular syndesmosis injury.Methods The recent literature about distal tibiofibular syndesmosis injury was reviewed and analyzed.Results Distal tibiofibular syndesmosis injury is commonly seen in ankle joint injury, the anatomical complexities make diagnosis and treatment difficult. Preoperative physical examination, radiologic evaluation, and intraoperative stress-testing are important for the diagnosis. Aggressive treatment is also recommended for these injuries to prevent long-term chronic instability. Internal fixation is the main treatment, including metal screw, degradable screw, elastic fixation, and hybrid techniques. Metal screw fixation is still the current mainstream, but elastic fixation represented by Suture-button is more in line with the physiological characteristics of ankle joint, and the rate of secondary operation is low while the clinical outcome is satisfactory. The application prospect of elastic fixation is worthy of expectation.Conclusion It’s crucial for patient with ankle fracture to repair the distal tibiofibular syndesmosis injury. How to diagnose the injury more accurately and simply, how to increase the success rate of reduction, and how to reduce the complications of surgery are still worthy for further exploration.

Citation： HUANG Hui, YANG Yunfeng. Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(10): 1346-1351. doi: 10.7507/1002-1892.201911090 Copy

1.	Porter DA, Jaggers RR, Barnes AF, et al. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med, 2014, 5: 173-182.
2.	Liu GT, Ryan E, Gustafson E, et al. Three-dimensional computed tomographic characterization of normal anatomic morphology and variations of the distal tibiofibular syndesmosis. J Foot Ankle Surg, 2018, 57(6): 1130-1136.
3.	Hermans JJ, Beumer A, de Jong TA, et al. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat, 2010, 217(6): 633-645.
4.	Lilyquist M, Shaw A, Latz K, et al. Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int, 2016, 37(8): 882-890.
5.	Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat, 2003, 25(5-6): 379-386.
6.	Yuen CP, Lui TH. Distal tibiofibular syndesmosis: anatomy, biomechanics, injury and management. Open Orthop J, 2017, 11: 670-677.
7.	Hu WK, Chen DW, Li B, et al. Motion of the distal tibiofibular syndesmosis under different loading patterns: A biomechanical study. J Orthop Surg (Hong Kong), 2019, 27(2): 2309499019842879.
8.	Xu D, Wang Y, Jiang C, et al. Strain distribution in the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous membrane using digital image correlation. Foot Ankle Int, 2018, 39(5): 618-628.
9.	Clanton TO, Williams BT, Backus JD, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int, 2017, 38(1): 66-75.
10.	Van Heest TJ, Lafferty PM. Injuries to the ankle syndesmosis. J Bone Joint Surg (Am), 2014, 96(7): 603-613.
11.	Miller TL, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med, 2014, 44(2): 179-188.
12.	Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med, 2013, 47(10): 620-628.
13.	Chun DI, Cho JH, Min TH, et al. Diagnostic accuracy of radiologic methods for ankle syndesmosis injury: A systematic review and meta-analysis. J Clin Med, 2019, 8(7): E968.
14.	Kortekangas TH, Pakarinen HJ, Savola O, et al. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int, 2014, 35(10): 988-995.
15.	Pakarinen H, Flinkkilä T, Ohtonen P, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg (Am), 2011, 93(22): 2057-2061.
16.	Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin, 2009, 14(2): 277-298.
17.	Gardner MJ, Graves ML, Higgins TF, et al. Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg, 2015, 23(8): 510-518.
18.	Yang Y, Zhou J, Li B, et al. Operative exploration and reduction of syndesmosis in Weber type C ankle injury. Acta Ortop Bras, 2013, 21(2): 103-108.
19.	Shaner AC, Sirisreetreerux N, Shafiq B, et al. Open versus minimally invasive fixation of a simulated syndesmotic injury in a cadaver model. J Orthop Surg Res, 2017, 12(1): 160.
20.	Carrozzo M, Vicenti G, Pesce V, et al. Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis’ injuries in Weber B and C type fractures. Injury, 2018, 49(Suppl 3): S54-S60.
21.	Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
22.	Boszczyk A, Kordasiewicz B, Kiciński M, et al. Operative setup to improve sagittal syndesmotic reduction: technical tip. J Orthop Trauma, 2019, 33(1): e27-e30.
23.	van den Heuvel SB, Dingemans SA, Gardenbroek TJ, et al. Assessing quality of syndesmotic reduction in surgically treated acute syndesmotic injuries: A systematic review. J Foot Ankle Surg, 2019, 58(1): 144-150.
24.	Park YH, Choi WS, Choi GW, et al. Ideal angle of syndesmotic screw fixation: A CT-based cross-sectional image analysis study. Injury, 2017, 48(11): 2602-2605.
25.	van Vlijmen N, Denk K, van Kampen A, et al. Long-term results after ankle syndesmosis injuries. Orthopedics, 2015, 38(11): e1001-e1006.
26.	Markolf KL, Jackson SR, McAllister DR. Syndesmosis fixation using dual 3.5 mm and 4.5 mm screws with tricortical and quadricortical purchase: a biomechanical study. Foot Ankle Int, 2013, 34(5): 734-739.
27.	Verim O, Er MS, Altinel L, et al. Biomechanical evaluation of syndesmotic screw position: a finite-element analysis. J Orthop Trauma, 2014, 28(4): 210-215.
28.	Tucker A, Street J, Kealey D, et al. Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal—Is it really necessary? Injury, 2013, 44(12): 1880-1884.
29.	Boyle MJ, Gao R, Frampton CM, et al. Removal of the syndesmotic screw after the surgical treatment of a fracture of the ankle in adult patients does not affect one-year outcomes: a randomised controlled trial. Bone Joint J, 2014, 96-B(12): 1699-1705.
30.	Kaftandziev I, Spasov M, Trpeski S, et al. Fate of the syndesmotic screw—Search for a prudent solution. Injury, 2015, 46(Suppl 6): S125-S129.
31.	Sun H, Luo CF, Zhong B, et al. A prospective, randomised trial comparing the use of absorbable and metallic screws in the fixation of distal tibiofibular syndesmosis injuries: mid-term follow-up. Bone Joint J, 2014, 96-B(4): 548-554.
32.	Cho SY, Chae SW, Choi KW, et al. Biocompatibility and strength retention of biodegradable Mg-Ca-Zn alloy bone implants. J Biomed Mater Res B Appl Biomater, 2013, 101(2): 201-212.
33.	Kose O, Turan A, Unal M, et al. Fixation of medial malleolar fractures with magnesium bioabsorbable headless compression screws: short-term clinical and radiological outcomes in eleven patients. Arch Orthop Trauma Surg, 2018, 138(8): 1069-1075.
34.	Teramoto A, Suzuki D, Kamiya T, et al. Comparison of different fixation methods of the suture-button implant for tibiofibular syndesmosis injuries. Am J Sports Med, 2011, 39(10): 2226-2232.
35.	Seyhan M, Donmez F, Mahirogullari M, et al. Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures. Injury, 2015, 46(Suppl 2): S19-S23.
36.	Laflamme M, Belzile EL, Bédard L, et al. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma, 2015, 29(5): 216-223.
37.	Andersen MR, Frihagen F, Hellund JC, et al. Randomized trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg (Am), 2018, 100(1): 2-12.
38.	Grassi A, Samuelsson K, D’Hooghe P, et al. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: A meta-analysis of randomized controlled trials. Am J Sports Med, 2020, 48(4): 1000-1013.
39.	Westermann RW, Rungprai C, Goetz JE, et al. The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. J Bone Joint Surg (Am), 2014, 96(20): 1732-1738.
40.	Xie L, Xie H, Wang J, et al. Comparison of suture button fixation and syndesmotic screw fixation in the treatment of distal tibiofibular syndesmosis injury: A systematic review and meta-analysis. Int J Surg, 2018, 60: 120-131.
41.	Chen B, Chen C, Yang Z, et al. To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: A meta-analysis. Foot Ankle Surg, 2019, 25(1): 63-70.
42.	Neary KC, Mormino MA, Wang H. Suture button fixation versus syndesmotic screws in supination-external rotation type 4 injuries: A cost-effectiveness analysis. Am J Sports Med, 2017, 45(1): 210-217.
43.	Teramoto A, Shoji H, Sakakibara Y, et al. Suture-button fixation and mini-open anterior inferior tibiofibular ligament augmentation using suture tape for tibiofibular syndesmosis injuries. J Foot Ankle Surg, 2018, 57(1): 159-161.

1. Porter DA, Jaggers RR, Barnes AF, et al. Optimal management of ankle syndesmosis injuries. Open Access J Sports Med, 2014, 5: 173-182.
2. Liu GT, Ryan E, Gustafson E, et al. Three-dimensional computed tomographic characterization of normal anatomic morphology and variations of the distal tibiofibular syndesmosis. J Foot Ankle Surg, 2018, 57(6): 1130-1136.
3. Hermans JJ, Beumer A, de Jong TA, et al. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat, 2010, 217(6): 633-645.
4. Lilyquist M, Shaw A, Latz K, et al. Cadaveric analysis of the distal tibiofibular syndesmosis. Foot Ankle Int, 2016, 37(8): 882-890.
5. Bartonícek J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat, 2003, 25(5-6): 379-386.
6. Yuen CP, Lui TH. Distal tibiofibular syndesmosis: anatomy, biomechanics, injury and management. Open Orthop J, 2017, 11: 670-677.
7. Hu WK, Chen DW, Li B, et al. Motion of the distal tibiofibular syndesmosis under different loading patterns: A biomechanical study. J Orthop Surg (Hong Kong), 2019, 27(2): 2309499019842879.
8. Xu D, Wang Y, Jiang C, et al. Strain distribution in the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, and interosseous membrane using digital image correlation. Foot Ankle Int, 2018, 39(5): 618-628.
9. Clanton TO, Williams BT, Backus JD, et al. Biomechanical analysis of the individual ligament contributions to syndesmotic stability. Foot Ankle Int, 2017, 38(1): 66-75.
10. Van Heest TJ, Lafferty PM. Injuries to the ankle syndesmosis. J Bone Joint Surg (Am), 2014, 96(7): 603-613.
11. Miller TL, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med, 2014, 44(2): 179-188.
12. Sman AD, Hiller CE, Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. Br J Sports Med, 2013, 47(10): 620-628.
13. Chun DI, Cho JH, Min TH, et al. Diagnostic accuracy of radiologic methods for ankle syndesmosis injury: A systematic review and meta-analysis. J Clin Med, 2019, 8(7): E968.
14. Kortekangas TH, Pakarinen HJ, Savola O, et al. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int, 2014, 35(10): 988-995.
15. Pakarinen H, Flinkkilä T, Ohtonen P, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg (Am), 2011, 93(22): 2057-2061.
16. Jelinek JA, Porter DA. Management of unstable ankle fractures and syndesmosis injuries in athletes. Foot Ankle Clin, 2009, 14(2): 277-298.
17. Gardner MJ, Graves ML, Higgins TF, et al. Technical considerations in the treatment of syndesmotic injuries associated with ankle fractures. J Am Acad Orthop Surg, 2015, 23(8): 510-518.
18. Yang Y, Zhou J, Li B, et al. Operative exploration and reduction of syndesmosis in Weber type C ankle injury. Acta Ortop Bras, 2013, 21(2): 103-108.
19. Shaner AC, Sirisreetreerux N, Shafiq B, et al. Open versus minimally invasive fixation of a simulated syndesmotic injury in a cadaver model. J Orthop Surg Res, 2017, 12(1): 160.
20. Carrozzo M, Vicenti G, Pesce V, et al. Beyond the pillars of the ankle: A prospective randomized CT analysis of syndesmosis’ injuries in Weber B and C type fractures. Injury, 2018, 49(Suppl 3): S54-S60.
21. Futamura K, Baba T, Mogami A, et al. Malreduction of syndesmosis injury associated with malleolar ankle fracture can be avoided using Weber’s three indexes in the mortise view. Injury, 2017, 48(4): 954-959.
22. Boszczyk A, Kordasiewicz B, Kiciński M, et al. Operative setup to improve sagittal syndesmotic reduction: technical tip. J Orthop Trauma, 2019, 33(1): e27-e30.
23. van den Heuvel SB, Dingemans SA, Gardenbroek TJ, et al. Assessing quality of syndesmotic reduction in surgically treated acute syndesmotic injuries: A systematic review. J Foot Ankle Surg, 2019, 58(1): 144-150.
24. Park YH, Choi WS, Choi GW, et al. Ideal angle of syndesmotic screw fixation: A CT-based cross-sectional image analysis study. Injury, 2017, 48(11): 2602-2605.
25. van Vlijmen N, Denk K, van Kampen A, et al. Long-term results after ankle syndesmosis injuries. Orthopedics, 2015, 38(11): e1001-e1006.
26. Markolf KL, Jackson SR, McAllister DR. Syndesmosis fixation using dual 3.5 mm and 4.5 mm screws with tricortical and quadricortical purchase: a biomechanical study. Foot Ankle Int, 2013, 34(5): 734-739.
27. Verim O, Er MS, Altinel L, et al. Biomechanical evaluation of syndesmotic screw position: a finite-element analysis. J Orthop Trauma, 2014, 28(4): 210-215.
28. Tucker A, Street J, Kealey D, et al. Functional outcomes following syndesmotic fixation: A comparison of screws retained in situ versus routine removal—Is it really necessary? Injury, 2013, 44(12): 1880-1884.
29. Boyle MJ, Gao R, Frampton CM, et al. Removal of the syndesmotic screw after the surgical treatment of a fracture of the ankle in adult patients does not affect one-year outcomes: a randomised controlled trial. Bone Joint J, 2014, 96-B(12): 1699-1705.
30. Kaftandziev I, Spasov M, Trpeski S, et al. Fate of the syndesmotic screw—Search for a prudent solution. Injury, 2015, 46(Suppl 6): S125-S129.
31. Sun H, Luo CF, Zhong B, et al. A prospective, randomised trial comparing the use of absorbable and metallic screws in the fixation of distal tibiofibular syndesmosis injuries: mid-term follow-up. Bone Joint J, 2014, 96-B(4): 548-554.
32. Cho SY, Chae SW, Choi KW, et al. Biocompatibility and strength retention of biodegradable Mg-Ca-Zn alloy bone implants. J Biomed Mater Res B Appl Biomater, 2013, 101(2): 201-212.
33. Kose O, Turan A, Unal M, et al. Fixation of medial malleolar fractures with magnesium bioabsorbable headless compression screws: short-term clinical and radiological outcomes in eleven patients. Arch Orthop Trauma Surg, 2018, 138(8): 1069-1075.
34. Teramoto A, Suzuki D, Kamiya T, et al. Comparison of different fixation methods of the suture-button implant for tibiofibular syndesmosis injuries. Am J Sports Med, 2011, 39(10): 2226-2232.
35. Seyhan M, Donmez F, Mahirogullari M, et al. Comparison of screw fixation with elastic fixation methods in the treatment of syndesmosis injuries in ankle fractures. Injury, 2015, 46(Suppl 2): S19-S23.
36. Laflamme M, Belzile EL, Bédard L, et al. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma, 2015, 29(5): 216-223.
37. Andersen MR, Frihagen F, Hellund JC, et al. Randomized trial comparing suture button with single syndesmotic screw for syndesmosis injury. J Bone Joint Surg (Am), 2018, 100(1): 2-12.
38. Grassi A, Samuelsson K, D’Hooghe P, et al. Dynamic stabilization of syndesmosis injuries reduces complications and reoperations as compared with screw fixation: A meta-analysis of randomized controlled trials. Am J Sports Med, 2020, 48(4): 1000-1013.
39. Westermann RW, Rungprai C, Goetz JE, et al. The effect of suture-button fixation on simulated syndesmotic malreduction: a cadaveric study. J Bone Joint Surg (Am), 2014, 96(20): 1732-1738.
40. Xie L, Xie H, Wang J, et al. Comparison of suture button fixation and syndesmotic screw fixation in the treatment of distal tibiofibular syndesmosis injury: A systematic review and meta-analysis. Int J Surg, 2018, 60: 120-131.
41. Chen B, Chen C, Yang Z, et al. To compare the efficacy between fixation with tightrope and screw in the treatment of syndesmotic injuries: A meta-analysis. Foot Ankle Surg, 2019, 25(1): 63-70.
42. Neary KC, Mormino MA, Wang H. Suture button fixation versus syndesmotic screws in supination-external rotation type 4 injuries: A cost-effectiveness analysis. Am J Sports Med, 2017, 45(1): 210-217.
43. Teramoto A, Shoji H, Sakakibara Y, et al. Suture-button fixation and mini-open anterior inferior tibiofibular ligament augmentation using suture tape for tibiofibular syndesmosis injuries. J Foot Ankle Surg, 2018, 57(1): 159-161.

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