PROGRESS IN DIAGNOSIS AND TREATMENT OF DISTAL TIBIOFIBULAR SYNDESMOSIS INJURY_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Xiang , YU Guangrong.

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

Corresponding author：

Keywords：

Distal tibiofibular syndesmosis,injury Diagnosis ,Treatment

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Objective To review the progress in the diagnosis and treatment of distal tibiofibular syndesmosis
injury. Methods Different kinds of documents were widely collected, current developments of the diagnosis and treatment
of distal tibiofibular syndesmosis injury were summarized. Results The disease history (damage mechanism), cl inical
examination, and imaging examination (X-ray, CT scan, and MRI) can assist the diagnosis of distal tibiofibular syndesmosis
injury. Patients with unstable distal tibiofibular syndesmosis injury needs active surgery treatment, and the princi ple is
anatomical reduction and fixation so as to avoid the instabil ity of the ankle joint, long-term chronic pain, and traumatic
arthritis. Conclusion The diagnosis of distal tibiofibular syndesmosis injury is still lack of specific quantitative parameters, so
cl inical study for large sample is needed to explicit the effectiveness.

Citation： LIU Xiang,YU Guangrong.. PROGRESS IN DIAGNOSIS AND TREATMENT OF DISTAL TIBIOFIBULAR SYNDESMOSIS INJURY. Chinese Journal of Reparative and Reconstructive Surgery, 2012, 26(5): 612-616. doi: Copy

1.	Grass R, Herzmann K, Biewener A, et al. Injuries of the inferior tibiofibular syndesmosis. Unfallchirurg, 2000, 103(7): 520-532.
2.	Ramsey PL, Hamilton W. Changes in tibilotalar area of contact caused by lateral talar shift. J Bone Joint Surg (Am), 1976, 58(3): 356-357.
3.	Elgafy H, Semaan HB, Blessinger B, et al. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol, 2010, 39(6): 559-564.
4.	Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg, 2007, 15(6): 330-339.
5.	Grass R, Rammelt S, Biewener A, et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int, 2003, 34(5): 392-397.
6.	Stark E, Tornetta P 3rd, Creevy WR. Syndesmotic Instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma, 2007, 21(9): 643-646.
7.	Pankovich AM. Maisonneuve fracture of the ﬁbula. J Bone Joint Surg (Am), 1976, 58(3): 337-342.
8.	Beumer A, Swiertra BA, Mulder PG. Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains. Acta Orthop Scand, 2002, 73(6): 667-669.
9.	Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. J Orthop Sports Phy Ther, 1998, 27(4): 276-284.
10.	Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res, 2004, (423): 227-234.
11.	Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle, 1989, 10(3): 156-160.
12.	Pneumaticos SG, Noble PC, Chatziioannou SN, et al. The effects of rotation on radiographic evaluation of the tibioﬁbular syndesmosis. Foot Ankle Int, 2002, 23(2): 107-111.
13.	Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int, 1995, 16(3): 128-131.
14.	Xenos JS, Hopkinson WJ, Mulligan ME, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of ﬁxation, and radiographic assessment. J Bone Joint Surg (Am), 1995, 77(6): 847-856.
15.	Jenkinson RJ, Sander DW, Macleod MD, et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma, 2005, 19(9): 604-609.
16.	Ebraheim NA, Elgafy H, Panadilam T. Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res, 2003, (409): 260-267.
17.	Ebraheim NA, Lu J, Yang H. et al. Radiographic and CT evaluation of tibioﬁbular syndesmotic diastasis: a cadaver study. Foot Ankle Int, 1997, 18(11): 693-698.
18.	Taser F, Shafiq Q, Ebraheim NA. Three-dimensional volume rendering of tibiofibular joint space and quantitative analysis of change in volume due to tibiofibular syndesmosis diastases. Skeletal Radiol, 2006, 35(12): 935-941.
19.	Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology, 2003, 227(1): 155-161.
20.	Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res, 2005, (436): 216-221.
21.	Takao M, Ochi M, Naito K, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy, 2001, 17(8): 836-843.
22.	Takao M, Ochi M, Oae K, et al. Diagnosis of a tear of the tibiofibular syndesmosis. The role arthroscopy of the ankle. J Bone Joint Surg (Br), 2003, 85(3): 324-329.
23.	Lui TH, Ip K, Chow HT. Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy, 2005, 21(11): 1370.
24.	Candal-Couto JJ, Burrow D, Bromage S, et al. Instability of the tibio-ﬁbular syndesmosis: have we been pulling in the wrong direction? Injury, 2004, 35(8): 814-818.
25.	Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med, 1991, 19(3): 294-298.
26.	Wright RW, Barile RJ, Surprenant DA, et al. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med, 2004, 32(8): 1941-1945.
27.	Chissel 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(3): 435-438.
28.	MyBryde A, Chiasson B, Wilhelm A, et al. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int, 1997, 18(5): 262-266.
29.	Miller RS, Weinhold PS, Dahners LE. Comparison of tricortical screw ﬁxation versus a modiﬁed suture construct for ﬁxation of ankle syndesmosis injury: a biomechanical study. J Orthop Trauma, 1999, 13(1): 39-42.
30.	Kukreti S, Faraj A, Miles JN. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury, 2005, 36(9): 1121-1124.
31.	Stuart K, Panchbhavi VK. The fate of syndesmotic screws. Foot & Ankle International, 2011, 32(5): 519-525.
32.	Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg, 1985, 104(5): 299-302.
33.	Torneeta P 3rd, Spoo JE, Revnolds FA, et al. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg (Am), 2001, 83-A(4): 489-492.
34.	Bragonzoni L, Russo A, Girolami M, et al. The distal tibiofibular syndesmosis during passive foot flexion. RSA-based study on intact, ligament injured and screw fixed cadaver specimens. Arch Orthop Trauma Surg, 2006, 126(5): 304-308.
35.	Nousiainen MT, McConnell AJ, Zdero R, et al. The inﬂuence of the number of cortices of screw purchase and ankle position in Weber C ankle fracture fixation. J Orthop Trauma, 2008, 22(7): 473-478.
36.	Høiness P, Strømsøe K. Tricortical versus quadricortical syndesmosis ﬁxation in ankle fractures: a prospective, randomized study comparing two methods of syndesmotic ﬁxation. J Orthop Trauma, 2004, 18(6): 331-337.
37.	Vander Griend R, Michelson JD, Bone LB. Fractures of the ankle and the distal part of the tibia. Instr Course Lect, 1997, 46: 311-321.
38.	Stufkens SA, van den Bekerom MP, Doornberg JN, et al. Evidence-based treatment of maisonneuve fractures. J Foot Ankle Surg, 2011, 50(1): 62-67.
39.	Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis ﬁxation with 3.5- and 4.5-millimeter stainless steel screws. Foot Ankle Int, 2000, 21(9): 736-741.
40.	Hansen M, Le L, Wertheimer S, et al. Syndesmosis fixation: analysis of shear stress via axial load on 3.5-mm and 4.5-mm quadricortical syndesmotic screws. J Foot Ankle Surg, 2006, 45(2): 65-69.
41.	Heim D, Heim U, Regazzoni P. Malleolar fractures with ankle joint instability—experience with the positioning screw. Unfallchirurgie, 1993, 19(5): 307-312.
42.	Moor JA Jr, Shank JR, Morgan SJ, et al. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int, 2006, 27(8): 567-572.
43.	Beumer A, Campo MM, Niesing R, et al. Screw ﬁxation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical ﬁxation. Injury, 2005, 36(1): 60-64.
44.	Karapinar H, Kalenderer O, Karapinar L, et al. Effects of three- or four-cortex syndesmotic fixation in ankle fractures. J Am Podiatr Med Assoc, 2007, 97(6): 457-459.
45.	Bava E, Charlton T, Thordarson D. Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons. Am J Orthop (Belle Mead NJ), 2010, 39(5): 242-246.
46.	Hovis WD, Kaiser BW, Watson JT, et al. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg (Am), 2002, 84-A(1): 26-31.
47.	Ahmad J, Raikin SM, Pour AE, et al. Bioabsorbable screw fixation of syndesmosis in unstable ankle injuries. Foot Ankle Int, 2009, 30(2): 99-105.
48.	Cox S, Mukherjee DP, Ogden AL, et al. Distal tibioﬁbular syndesmosis fixation: a cadaveric, simulated fracture stabilization study comparing bioabsorbable and metallic single screw fixation. J Foot Ankle Surg, 2005, 44(2): 144-151.
49.	Kaukonen JP, Lamberg T, Korkala O, et al. Fixation of syndesmotic ruptures in 38 patients with a mallleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma, 2005, 19(6): 392-395.
50.	Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg, 1997, 5(3): 172-181.
51.	Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw on ankle motion. Foot Ankle, 1989, 10(1): 17-24.
52.	Bell DP, Wong MK. Syndesmotic screw fixation in Weber C ankle injuriers—should the screw be removed before weight bearing? Injury, 2006, 37(9): 891-898.
53.	Hamid N, Loeffler BJ, Braddy W, et al. Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg (Br), 2009, 91(8): 1069-1073.
54.	Manjoo A, Sanders DW, Tieszer C, et al. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma, 2010: 24(1): 2-6.

1. Grass R, Herzmann K, Biewener A, et al. Injuries of the inferior tibiofibular syndesmosis. Unfallchirurg, 2000, 103(7): 520-532.
2. Ramsey PL, Hamilton W. Changes in tibilotalar area of contact caused by lateral talar shift. J Bone Joint Surg (Am), 1976, 58(3): 356-357.
3. Elgafy H, Semaan HB, Blessinger B, et al. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol, 2010, 39(6): 559-564.
4. Zalavras C, Thordarson D. Ankle syndesmotic injury. J Am Acad Orthop Surg, 2007, 15(6): 330-339.
5. Grass R, Rammelt S, Biewener A, et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int, 2003, 34(5): 392-397.
6. Stark E, Tornetta P 3rd, Creevy WR. Syndesmotic Instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma, 2007, 21(9): 643-646.
7. Pankovich AM. Maisonneuve fracture of the ﬁbula. J Bone Joint Surg (Am), 1976, 58(3): 337-342.
8. Beumer A, Swiertra BA, Mulder PG. Clinical diagnosis of syndesmotic ankle instability: evaluation of stress tests behind the curtains. Acta Orthop Scand, 2002, 73(6): 667-669.
9. Alonso A, Khoury L, Adams R. Clinical tests for ankle syndesmosis injury: reliability and prediction of return to function. J Orthop Sports Phy Ther, 1998, 27(4): 276-284.
10. Beumer A, van Hemert WL, Niesing R, et al. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res, 2004, (423): 227-234.
11. Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle, 1989, 10(3): 156-160.
12. Pneumaticos SG, Noble PC, Chatziioannou SN, et al. The effects of rotation on radiographic evaluation of the tibioﬁbular syndesmosis. Foot Ankle Int, 2002, 23(2): 107-111.
13. Ostrum RF, De Meo P, Subramanian R. A critical analysis of the anterior-posterior radiographic anatomy of the ankle syndesmosis. Foot Ankle Int, 1995, 16(3): 128-131.
14. Xenos JS, Hopkinson WJ, Mulligan ME, et al. The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of ﬁxation, and radiographic assessment. J Bone Joint Surg (Am), 1995, 77(6): 847-856.
15. Jenkinson RJ, Sander DW, Macleod MD, et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma, 2005, 19(9): 604-609.
16. Ebraheim NA, Elgafy H, Panadilam T. Syndesmotic disruption in low fibular fractures associated with deltoid ligament injury. Clin Orthop Relat Res, 2003, (409): 260-267.
17. Ebraheim NA, Lu J, Yang H. et al. Radiographic and CT evaluation of tibioﬁbular syndesmotic diastasis: a cadaver study. Foot Ankle Int, 1997, 18(11): 693-698.
18. Taser F, Shafiq Q, Ebraheim NA. Three-dimensional volume rendering of tibiofibular joint space and quantitative analysis of change in volume due to tibiofibular syndesmosis diastases. Skeletal Radiol, 2006, 35(12): 935-941.
19. Oae K, Takao M, Naito K, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology, 2003, 227(1): 155-161.
20. Nielson JH, Gardner MJ, Peterson MG, et al. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res, 2005, (436): 216-221.
21. Takao M, Ochi M, Naito K, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy, 2001, 17(8): 836-843.
22. Takao M, Ochi M, Oae K, et al. Diagnosis of a tear of the tibiofibular syndesmosis. The role arthroscopy of the ankle. J Bone Joint Surg (Br), 2003, 85(3): 324-329.
23. Lui TH, Ip K, Chow HT. Comparison of radiologic and arthroscopic diagnoses of distal tibiofibular syndesmosis disruption in acute ankle fracture. Arthroscopy, 2005, 21(11): 1370.
24. Candal-Couto JJ, Burrow D, Bromage S, et al. Instability of the tibio-ﬁbular syndesmosis: have we been pulling in the wrong direction? Injury, 2004, 35(8): 814-818.
25. Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med, 1991, 19(3): 294-298.
26. Wright RW, Barile RJ, Surprenant DA, et al. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med, 2004, 32(8): 1941-1945.
27. Chissel 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(3): 435-438.
28. MyBryde A, Chiasson B, Wilhelm A, et al. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int, 1997, 18(5): 262-266.
29. Miller RS, Weinhold PS, Dahners LE. Comparison of tricortical screw ﬁxation versus a modiﬁed suture construct for ﬁxation of ankle syndesmosis injury: a biomechanical study. J Orthop Trauma, 1999, 13(1): 39-42.
30. Kukreti S, Faraj A, Miles JN. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury, 2005, 36(9): 1121-1124.
31. Stuart K, Panchbhavi VK. The fate of syndesmotic screws. Foot & Ankle International, 2011, 32(5): 519-525.
32. Olerud C. The effect of the syndesmotic screw on the extension capacity of the ankle joint. Arch Orthop Trauma Surg, 1985, 104(5): 299-302.
33. Torneeta P 3rd, Spoo JE, Revnolds FA, et al. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg (Am), 2001, 83-A(4): 489-492.
34. Bragonzoni L, Russo A, Girolami M, et al. The distal tibiofibular syndesmosis during passive foot flexion. RSA-based study on intact, ligament injured and screw fixed cadaver specimens. Arch Orthop Trauma Surg, 2006, 126(5): 304-308.
35. Nousiainen MT, McConnell AJ, Zdero R, et al. The inﬂuence of the number of cortices of screw purchase and ankle position in Weber C ankle fracture fixation. J Orthop Trauma, 2008, 22(7): 473-478.
36. Høiness P, Strømsøe K. Tricortical versus quadricortical syndesmosis ﬁxation in ankle fractures: a prospective, randomized study comparing two methods of syndesmotic ﬁxation. J Orthop Trauma, 2004, 18(6): 331-337.
37. Vander Griend R, Michelson JD, Bone LB. Fractures of the ankle and the distal part of the tibia. Instr Course Lect, 1997, 46: 311-321.
38. Stufkens SA, van den Bekerom MP, Doornberg JN, et al. Evidence-based treatment of maisonneuve fractures. J Foot Ankle Surg, 2011, 50(1): 62-67.
39. Thompson MC, Gesink DS. Biomechanical comparison of syndesmosis ﬁxation with 3.5- and 4.5-millimeter stainless steel screws. Foot Ankle Int, 2000, 21(9): 736-741.
40. Hansen M, Le L, Wertheimer S, et al. Syndesmosis fixation: analysis of shear stress via axial load on 3.5-mm and 4.5-mm quadricortical syndesmotic screws. J Foot Ankle Surg, 2006, 45(2): 65-69.
41. Heim D, Heim U, Regazzoni P. Malleolar fractures with ankle joint instability—experience with the positioning screw. Unfallchirurgie, 1993, 19(5): 307-312.
42. Moor JA Jr, Shank JR, Morgan SJ, et al. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int, 2006, 27(8): 567-572.
43. Beumer A, Campo MM, Niesing R, et al. Screw ﬁxation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical ﬁxation. Injury, 2005, 36(1): 60-64.
44. Karapinar H, Kalenderer O, Karapinar L, et al. Effects of three- or four-cortex syndesmotic fixation in ankle fractures. J Am Podiatr Med Assoc, 2007, 97(6): 457-459.
45. Bava E, Charlton T, Thordarson D. Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons. Am J Orthop (Belle Mead NJ), 2010, 39(5): 242-246.
46. Hovis WD, Kaiser BW, Watson JT, et al. Treatment of syndesmotic disruptions of the ankle with bioabsorbable screw fixation. J Bone Joint Surg (Am), 2002, 84-A(1): 26-31.
47. Ahmad J, Raikin SM, Pour AE, et al. Bioabsorbable screw fixation of syndesmosis in unstable ankle injuries. Foot Ankle Int, 2009, 30(2): 99-105.
48. Cox S, Mukherjee DP, Ogden AL, et al. Distal tibioﬁbular syndesmosis fixation: a cadaveric, simulated fracture stabilization study comparing bioabsorbable and metallic single screw fixation. J Foot Ankle Surg, 2005, 44(2): 144-151.
49. Kaukonen JP, Lamberg T, Korkala O, et al. Fixation of syndesmotic ruptures in 38 patients with a mallleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw. J Orthop Trauma, 2005, 19(6): 392-395.
50. Wuest TK. Injuries to the Distal Lower Extremity Syndesmosis. J Am Acad Orthop Surg, 1997, 5(3): 172-181.
51. Needleman RL, Skrade DA, Stiehl JB. Effect of the syndesmotic screw on ankle motion. Foot Ankle, 1989, 10(1): 17-24.
52. Bell DP, Wong MK. Syndesmotic screw fixation in Weber C ankle injuriers—should the screw be removed before weight bearing? Injury, 2006, 37(9): 891-898.
53. Hamid N, Loeffler BJ, Braddy W, et al. Outcome after fixation of ankle fractures with an injury to the syndesmosis: the effect of the syndesmosis screw. J Bone Joint Surg (Br), 2009, 91(8): 1069-1073.
54. Manjoo A, Sanders DW, Tieszer C, et al. Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal. J Orthop Trauma, 2010: 24(1): 2-6.

Chinese Journal of Reparative and Reconstructive Surgery

PROGRESS IN DIAGNOSIS AND TREATMENT OF DISTAL TIBIOFIBULAR SYNDESMOSIS INJURY

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