Validation of a new method for evaluation of syndesmotic injuries of the ankle



To define a new parameter in CT that could make imaging of the contralateral ankle dispensable evaluating the position of the fibula after syndesmotic injury.


Thirty bilateral CTs of 30 patients were included. Five parameters were defined in axial CT for the injured (_inju) and uninjured (_unin) ankle. Reproducibility was examined for inter-observer and intra-observer reliability. Comparisons for all parameters were performed between the CT scans of both ankles.


All measurements had a high agreement for the inter-observer and intra-observer correlation coefficients. A large interindividual variance could be found between all parameters. If the difference of the anterior tibiofibular distance antTFD_unin and antTFD_inju was less than 2 mm, there was a strong significant pairwise correlation between all parameters between both sides.


Bilateral CT is still to be recommended, as it is the only way to exactly assess anterior posterior reduction of the fibula.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    Tornetta P, Axelrad TW, Sibai TA, Creevy WR (2012) Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making. J Orthop Trauma 26:659–661.

    Article  PubMed  Google Scholar 

  2. 2.

    Jensen SL, Andresen BK, Mencke S, Nielsen PT (1998) Epidemiology of ankle fractures. A prospective population-based study of 212 cases in Aalborg, Denmark. Acta Orthop Scand 69:48–50

    CAS  Article  Google Scholar 

  3. 3.

    Rammelt S, Zwipp H, Grass R (2008) Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin 13:611–633, vii–viii.

    Article  PubMed  Google Scholar 

  4. 4.

    Sagi HC, Shah AR, Sanders RW (2012) The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma 26:439–443.

    Article  PubMed  Google Scholar 

  5. 5.

    Vasarhelyi A, Lubitz J, Gierer P et al (2006) Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int 27:1115–1121.

    Article  PubMed  Google Scholar 

  6. 6.

    Weening B, Bhandari M (2005) Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma 19:102–108

    Article  Google Scholar 

  7. 7.

    Gardner MJ, Demetrakopoulos D, Briggs SM et al (2006) Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int 27:788–792.

    Article  PubMed  Google Scholar 

  8. 8.

    Marmor M, Hansen E, Han HK et al (2011) Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot Ankle Int 32:616–622.

    Article  PubMed  Google Scholar 

  9. 9.

    Miller AN, Carroll EA, Parker RJ et al (2009) Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int 30:419–426.

    Article  PubMed  Google Scholar 

  10. 10.

    Rammelt S, Obruba P (2015) An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 41:601–614.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Franke J, von Recum J, Suda AJ et al (2012) Intraoperative three-dimensional imaging in the treatment of acute unstable syndesmotic injuries. J Bone Joint Surg Am 94:1386–1390.

    Article  PubMed  Google Scholar 

  12. 12.

    Franke J, von Recum J, Suda AJ et al (2014) Predictors of a persistent dislocation after reduction of syndesmotic injuries detected with intraoperative three-dimensional imaging. Foot Ankle Int 35:1323–1328.

    Article  PubMed  Google Scholar 

  13. 13.

    Davidovitch RI, Weil Y, Karia R et al (2013) Intraoperative syndesmotic reduction: three-dimensional versus standard fluoroscopic imaging. J Bone Joint Surg Am 95:1838–1843.

    Article  PubMed  Google Scholar 

  14. 14.

    Summers HD, Sinclair MK, Stover MD (2013) A reliable method for intraoperative evaluation of syndesmotic reduction. J Orthop Trauma 27:196–200.

    Article  PubMed  Google Scholar 

  15. 15.

    Dikos GD, Heisler J, Choplin RH, Weber TG (2012) Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma 26:433–438.

    Article  PubMed  Google Scholar 

  16. 16.

    Cotton F (1910) Fractures and joint dislocations. WB Saunders, Philadelphia

    Google Scholar 

  17. 17.

    Stoffel K, Wysocki D, Baddour E et al (2009) Comparison of two intraoperative assessment methods for injuries to the ankle syndesmosis. A cadaveric study. J Bone Joint Surg Am 91:2646–2652.

    Article  PubMed  Google Scholar 

  18. 18.

    Beumer A, Swierstra BA (2003) The influence of ankle positioning on the radiography of the distal tibial tubercles. Surg Radiol Anat 25:446–450.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174

    CAS  Article  Google Scholar 

  20. 20.

    Phisitkul P, Ebinger T, Goetz J et al (2012) Forceps reduction of the syndesmosis in rotational ankle fractures: a cadaveric study. J Bone Joint Surg Am 94:2256–2261.

    Article  PubMed  Google Scholar 

  21. 21.

    Kocadal O, Yucel M, Pepe M et al (2016) Evaluation of reduction accuracy of suture-button and screw fixation techniques for syndesmotic injuries. Foot Ankle Int 37:1317–1325.

    Article  PubMed  Google Scholar 

  22. 22.

    Thordarson DB, Motamed S, Hedman T et al (1997) The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am 79:1809–1815

    CAS  Article  Google Scholar 

  23. 23.

    Mukhopadhyay S, Metcalfe A, Guha AR et al (2011) Malreduction of syndesmosis--are we considering the anatomical variation? Injury 42:1073–1076.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Boszczyk A, Kwapisz S, Krümmel M et al (2018) Correlation of Incisura anatomy with syndesmotic malreduction. Foot Ankle Int 39:369–375.

    Article  PubMed  Google Scholar 

  25. 25.

    Bartoníček J, Rammelt S, Tuček M (2017) Posterior malleolar fractures: changing concepts and recent developments. Foot Ankle Clin 22:125–145.

    Article  PubMed  Google Scholar 

Download references

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Code availability

Not applicable

Author information




All authors contributed to the study conception and design. Data collection and analysis were performed by Annette B. Ahrberg and Ulrich J. Spiegl. The first draft of the manuscript was written by Annette B. Ahrberg, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Annette B. Ahrberg.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

Approval of the local institutional review board for study had been given (Ethical Committee at the Medical Faculty, Leipzig University, AZ 131/18-ek) in view of the retrospective nature of the study, and all the procedures being performed were part of the routine care.

Consent to participate

All individuals have given general consent in the use of their data, including imaging, for analysis and publication. This has been approved by the Ethical Committee.

Consent for publication

All individuals have given general consent in the use of their data, including imaging, for analysis and publication. This has been approved by the Ethical Committee.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ahrberg, A.B., Hennings, R., von Dercks, N. et al. Validation of a new method for evaluation of syndesmotic injuries of the ankle. International Orthopaedics (SICOT) 44, 2095–2100 (2020).

Download citation


  • Syndesmosis
  • Ankle
  • Screw
  • Suture-button
  • Computed tomography