Management of syndesmotic injuries of the ankle ncbi. In conclusion, on mri, syndesmosis injury is associated with anterior talofibular ligament injury, osteochondral lesion, bone bruise acute syndesmosis injury, and tibiofibular joint incongruity. Sep 23, 2010 although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments. Syndesmotic disruption typically occurs at the ankle after external rotation or dorsiflexion injuries. Anatomy of the distal tibiofibular syndesmosis in adults. Ankle syndesmotic injury abstract ankle syndesmotic injury does not necessarily lead to ankle instability. Injury to the tibiofibular syndesmosis can occur with ankle sprain or fracture. Distal tibiofibular syndesmosis reconstruction using a free hamstring autograft. These injuries occur commonly up to 18% of ankle sprains, and the incidence increases in the setting of athletic activity. Acute syndesmosis injuries associated with ankle fractures. Pdf ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey, and soccer, accounting for 1 %18 % of all ankle.
Sd boden, pa labropoulos, p mccowin, wf lestini and sr hurwitz mechanical. Ct scan considered the most valuable technique to evaluate the syndesmosis congruency and fibula position 11. Evaluation and management of injuries of the tibiofibular. Mri findings associated with distal tibiofibular syndesmosis. Open surgical access to the posterolateral talar dome for the treatment of osteochondral lesions is challenging, often requiring a segmental osteotomy of the fibula fibular window and division of the anterior inferior tibiofibular ligament aitfl or a fibular osteotomy with division of the aitfl and the anterior talofibular ligament atfl fibular door. The current benchmark imaging techniques to diagnose syndesmosis injury and diastasis are arthroscopy and high. Differential diagnosis of lesions at the heel and ankle author. A syndesmotic injury of the tibiofibular joint arises from an external rotation force acting on the foot leading to eversion of the talus within the ankle mortise, and increased dorsiflexion or plantar flexion. The in cidence of syndesmotic injury has not been specifically. Anatomy the syndesmosis is a strong ligamentous complex that connects the distal aspect of the fibula and the tibial notch between the anterior and posterior tibial. Ankle fractures include a broad spectrum of injury, including stable patterns as well as severe. Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula.
Injury to the syndesmosis and deltoid ligament is less common than lateral ligament trauma but can lead to significant time away from sport and prolonged rehabilitation. Given the patients age and relative timely diagnosis, an anterior and interosseous ligament reconstruction was planned utilizing a split semitendinosus allograft. The syndesmosis tightrope xp implant system features a unique delivery mechanism that allows surgeons to insert the implant without pulling a needle through the medial skin. Gentle manual resistance exercises, activeassisted exercises, and. Mr imaging typically used to grade ligamentous injuries, as it allows a more thorough assessment of the ligaments, but is also extremely effective for diagnosing avulsion injuries, as it will show fragments of bone adjacent to an irregular lateral or medial malleolus 3.
Sd boden, pa labropoulos, p mccowin, wf lestini and sr hurwitz mechanical considerations for the syndesmosis screw. Ziptight fixation system for ankle syndesmosis surgical. Pdf management of syndesmotic injuries of the ankle. Pdf ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey. Ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey, and soccer, accounting for 1 %18 % of all ankle sprains. Diagnosis of syndesmosis sprain comparing radiography and. This surgical technique shows the ziptight fixation device fixation device used in conjunction with trauma hardware. Medical legal art creates medical demonstrative evidence medical illustrations, drawings, pictures, graphics, charts, medical animations, anatomical models, and interactive presentations for use during legal proceedings, including research, demand letters, client conferences, depositions, arbitrations, mediations. Sprains to the ligaments of the ankle joint are an extremely common injury sustained by both the sedentary and athletic population, with lateral ligament sprains actually rated as the most frequently injured site in the human body 1. Late treatment of syndesmotic injuries foot and ankle clinics. A syndesmosis is a slightly movable fibrous joint in which bones such as the tibia and fibula are joined together by connective tissue. Their relative incidence is between 111% of all softtissue injuries of the ankle. Pain at the syndesmosis with proximal tibia and fibula squeeze or external rotation stress examinations should lead to suspicion for syndesmotic disruption that is not easily observed radiographically. Pdf injuries to the tibioperoneal syndesmosis are more frequent than previously.
Syndesmosis definition of syndesmosis by medical dictionary. Syndesmosis bones connected by a ligament symphysis bone. It is formed between the distal tibia and fibula and it is attached by the interosseous ligament iol, the anteriorinferior tibiofibular ligament aitfl, the posteriorinferior tibiofibular ligament pitfl and the transverse tibiofibular ligament ttfl. Jan 31, 2012 the effect of a syndesmosis screw 52 patients 27 intact screws aofas score 83 15 elective removal aofas score 86 10 broken screws aofas score 92 average 30 1256 month followup 10.
Syndesmosis preserving osteotomy of the fibula for access. Anatomical reduction of the syndesmosis is important for ankle stability and normal transmission of forces across the tibiotalar joint to minimize the incidence of posttraumatic arthritis. Chronic instability of the anterior tibiofibular syndesmosis. The pdf of the article you requested follows this cover page. Syndesmotic injury may occur in isolation or may be associated with ankle fracture. Syndesmosis preserving osteotomy of the fibula for access to. In the quest to promote normal biomechanics and avoid complications, surgeons continue to debate appropriate fixation, screw size and other components of surgical repair for syndesmotic ankle injuries. Mechanical considerations for the syndesmosis screw. Syndesmosis injuries frequently occur in association with tibial or fibular fractures.
Syndesmotic ligament reconstruction for treatment of. Syndesmoses definition of syndesmoses by medical dictionary. Treatment of syndesmotic injuries california orthopaedic association. The dome of the talus is wider in the anterior than in the posterior, and these movements force apart the medial. Despite the frequency and importance of these injuries, the management of ankle syn. A syndesmotic, or high ankle sprain is one that involves the ligaments binding the distal tibia and fibula at the distal tibiofibular syndesmosis. Management of chronic disruption of the distal tibiofibular. Pdf diagnosis and treatment of tibiofibular syndesmosis. Patients with chronic disruption of the distal tibiofibular syndesmosis generally have persistent pain on weight bearing after their initial injuries of the ankle2123. The fishers exact test and analysis of variance test were used to.
Syndesmosis rupture is a ligamentous injury between the tibia and. A nkle fractures are among the most commonly treated fractures in adults,1 and syndesmosis instability is often associated with fibula fractures above the level of the distal syndesmosis ligaments weber type c. Anatomical reconstruction of the anterior tibiofibular. Ankle syndesmosis injuries are relatively frequent in sports, especially skiing, ice hockey, and soccer, accounting for 1 %18 % of. The tibiofibular syndesmosis, located at the distal articulation of the tibia and the fibula, comprises four fundamental structures to maintain stability and integrity at the ankle joint. Syndesmosis injury with concomitant deltoid disruption in. Syndesmosis injury can occur through different injury mechanisms and is often accompanied by an ankle fracture. Recognition of these injuries is key to preventing longterm morbidity. Isolated syndesmosis injuries are those that are not accompanied by a fracture or other serious ligament injury of the ankle. These patients also complain of instability of the syndesmosis as a. Injuries to the ankle syndesmosis are commonly known as a high ankle sprain.
After syndesmosis injury, chronic ankle pain can occur if the diagnosis is missed and appropriat e treatment is not rendered. High ankle sprains and syndesmotic injuries in athletes. The arthroscopic findings in patients with chronic anterior syndesmotic instability that need reconstructive surgery have never been described extensively. Current concepts in treating syndesmotic ankle injuries.
In an estimated 111% of all ankle sprains, injury of the distal tibiofibular syndesmosis occurs. Syndesmosis bones connected by a ligament symphysis bone separated by fibrocartilage diarthroses freely movable joints bony surfaces enclosed within articular capsule bony surfaces covered by articular cartilage bony surfaces lubricated by synovial fluid structures include menisci fat pads accessory ligaments bursae the structure of a synovial joint. It is estimated that more severe injuries that include the distal tibiofibular syndesmosis make up between 1% and 20% of these ankle injuries 3, 5, 7, 8. Ankle joint injuries are common and are usually related to lateral ligament sprain 16. The term syndesmotic injury is used to describe a lesion of. Forty percent of patients still have complaints of ankle instability 6 months after an ankle sprain. The reduction of the syndesmosis can be guided either arthroscopically or endoscopically. Ankle syndesmosis injuries tend to be overlooked in the context of a sprained lateral ligament complex of the ankle. Pdf syndesmosis injuries of the ankle researchgate. This is a key element in ankle stability and lesions may cause pain or instability and, in the longer term, osteoarthritis. Syndesmosis injury with concomitant deltoid disruption in a.
They consist of an interosseous membrane and ligamentous thickenings. At this time it was determined that a second procedure was necessary. However, it cannot permit the normal range of motion of distal tibiofibular joint, especially the rotation of the fibula. The term syndesmotic injury is used to describe a lesion of the ligaments that connect the distal fibula and the tibial notch surrounded on both.
The tibiofibular syndesmosis is a fibrous joint essential for ankle stability, whence the classical comparison with a mortise. Start scar massage if needed and wound fully healed. Syndesmosis and deltoid ligament injuries in the athlete. Syndesmosis injuries of the ankle pubmed central pmc. Syndesmosis lesions are quite frequent in ankle trauma. Flexible syndesmotic fixation is new gold standard to restore. Many methods to treat a syndesmosis injury are any of. Endoscopic distal tibiofibular syndesmosis arthrodesis.
More than five millimetres of widening of either the. Many methods to treat a syndesmosis injury are any of them. Pdf optimal management of ankle syndesmosis injuries. Fractural line, mostly frontal, passes through the body or the neck of the talus and we classify these fractures according to hawkins in four stages expressing necrosis risk. Michelson and waldman reported no significant change in motion of the talus even. Tensioning handles and a new trocartipped drill bit have been added to the implant system. The distal tibiofibular syndesmosis provides stability to the ankle mortise, and it is composed of the anterior inferior tibiofibular, posterior inferior tibiofibular, interosseous, and inferior. Syndesmotic bolt and tightrope are two of the commonly used methods for the fixation of syndesmotic diastasis. When missed, repeated episodes of ankle instability may predispose to early degenerative changes, and frank osteoarthritis may ensue. The distal syndesmosis was directly visualized and debrided. Those patients sustaining incomplete injuries to the ankle syndesmosis had a recovery time of almost twice o f those patients with severe 3rd degree ankle sprain. Pain is aggravated by a combination of dorsiflexion and external rotation force which enables the distal tibiofibular joint to stretch.
Likewise, disruption of the syndesmosis should be treated operatively to restore mortise stability davidovitch and egol 2010, rudloff 20. Suture button fixation of the syndesmosis at divergent angles offers additional fibula rotational control over singleplane fixation without compromising tibiofibular mobility figure 5. Injuries can occur with any ankle motion, but the most common motions are extreme external rotation or dorsiflexion of the talus. Accordingly, these authors offer pertinent surgical pearls, discuss the intricacies of screw fixation and provide two helpful case studies. The effect of a syndesmosis screw 52 patients 27 intact screws aofas score 83 15 elective removal aofas score 86 10 broken screws aofas score 92 average 30 1256 month followup 10. Continuing navigation will be considered as acceptance of tobill use. Although the syndesmosis is a joint, in the literature the term syndesmotic injury is used to describe injury of the syndesmotic ligaments.
This is performed through the proximal anterolateral and posterolateral portals. Injury to the syndesmosis occurs through rupture or bony. The ziptight fixation system for ankle syndesmosis is indicated to repair ankle syndesmosis disruptions and as an adjunct in connection with trauma hardware for weber b and c ankle fractures. Differential diagnosis of lesions at the heel and ankle. Ziptight fixation device for ankle syndesmosis with ziploop technology 904759 909856 titanium stainless steel ziptight fixation device for ankle syndesmosis with ziploop technology disposable kits 909853 909857 titanium stainless steel sterile kit includes. It is often injured in conjunction with ankle fractures, but rupture may rarely occur in isolation 1. Differential diagnosis of lesions at the heel and ankle disorder diagnosis treatment posterior pain achilles tendinitis pain during rising on tiptoe differentiate 4 types by palpating insertion, localizing sign and passive plantiflexion deep transverse friction alternative. These include the interosseous membrane, transverse ligament and the anterior and posterior inferior tibiofibular ligaments aitfl and pitfl respectively 5. The distal tibiofibular syndesmosis is a syndesmotic joint. Jan 18, 2011 although group ii showed only minimum widening of the syndesmosis 1. Restoration of the deltoid ligament after syndesmosis repair in the appropriate clinical setting can.
In the absence of fracture, physical examination findings. Although the exact mechanism is not certain, previous studies have hypothesized that syndesmosis injuries are due to a forced external rotation of the. Continue arom and start gentle inversioneversion 3. Flexible fixation of syndesmotic diastasis using the. Acute and chronic injuries to the syndesmosis orthovirginia. The scar tissue and bone block are resected to facilitate the subsequent reduction of the syndesmosis. Chronic distal tibiofibular syndesmosis disruption can be managed by endoscopic arthrodesis of the syndesmosis. This is an enhanced pdf from the journal of bone and joint surgery j bone joint surg am.
The distal tibiofibular syndesmosis consists of the interosseous tibiofibular ligament il, the anterior tibiofibular ligament atifl, and the posterior tibiofibular ligament ptifl with the transverse ligament tl. Flexible syndesmotic fixation is new gold standard to. In 1% to 11% of the soft tissue injuries of the ankle, the syndesmosis is reported to be affected 4, 5. A system of orthopaedic medicine, third edition 20 e299e301. Syndesmotic bolt can be used to reduce and maintain the syndesmosis.
357 1592 357 585 69 424 1271 715 1252 488 1607 143 812 143 327 1549 380 18 678 18 344 602 846 444 643 240 1634 1584 1424 1549 1127 1600 276 1640 291 764 560 290 1334 95 743 145 1092