Abstract
In recent years, there has been increasing emphasis on the diagnosis and treatment of syndesmotic injuries. Injury recognition is crucial, especially in athletes where it has been shown to be associated with long-term ankle dysfunction, missed time from sports, and the need for operative stabilization. However, the physical and radiographic examinations can be deceiving, and accurate diagnosis can be difficult despite improved diagnostic modalities. Additionally, there is controversy regarding criteria for operative intervention and, when indicated, which implants are optimal. This chapter’s objective is to present an evidence-based review of the current best practice of syndesmosis injuries in sports.
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References
Mei Dan O, Kots E, Barchilon V, Massarwe S, Nyska M, et al. A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: a preliminary study. Am J Sports Med. 2009;37:1009–16.
Kofotolis ND, Kellis E, Vlachopoulos SP. Ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. Am J Sports Med. 2007;35:458–66.
Roemer FW, Jomaah N, Niu J, Almusa E, Roger B, et al. Ligamentous injuries and the risk of associated tissue damage in acute ankle sprains in athletes: a cross-sectional MRI study. Am J Sports Med. 2014;42:1549–57.
Woods C, Hawkins R, Hulse M, Hodson A. The football association medical research programme: an audit of injuries in professional football: an analysis of ankle sprains. Br J Sports Med. 2003;37:233–8.
Van den Bekerom MP. Diagnosing syndesmotic instability in ankle fractures. World J Orthop. 2011;2:51–6.
Wright RW, Barlie J, Suprent DA, Matave MJ. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32:1941–5.
Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle. 1998;19:653–60.
Waldén M, Hagglund M, Ekstrand J. Time-trends and circumstances surrounding ankle injuries in men’s professional football: an 11-year follow-up of the UEFA champions league injury study. Br J Sports Med. 2013;47:748–53.
Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007;35:1197–207.
Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA. The tibiofibular syndesmosis: evaluation of the ligamentous structures, methods of fixation, and radiographic assessment. J Bone Joint Surg Am. 1995;77:847–56.
Waterman BR, Belmont PJ, Cameron KL, Svoboda SJ, Alitz CJ, et al. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39:992–8.
Williams GN, Allen EJ. Rehabilitation of syndesmotic (high) ankle sprains. Sports Health. 2010;2:460–70.
Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, et al. Effects of ligament sectioning on the kinematics of the distal tibiofibular syndesmosis. Acta Orthop. 2006;77:531–40.
Zalavras C, Thordarson D. Ankle syndesmosis injury. J Am Acad Orthop Surg. 2007;15:330–9.
Calder JD, Bamford R, Petrie A, McCollum GA. Stable versus unstable grade ii high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy. 2016;32:634–42.
van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1217–27.
Thormeyer JR, Leonard JP, Hutchinson M. Syndesmotic injuries in athletes. In: Zaslav KR, editor. An international perspective on topics in sports medicine and sports injury: InTech; 2012. isbn:978-953-51-0005-8. Available from http://www.intechopen.com/books/an-international-perspectiveon-topics-in-sports-medicine-and-sports-injury/syndesmotic-injuries-in-athletes.
Hermans JJ, et al. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633–45.
Kelikian H, Kelikian AS. Disorders of the ankle. Philadelphia: Saunders; 1985. p. 893.
Elgafy H, et al. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol. 2010;39(6):559–64.
Hocker K, Pachucki A. [The fibular incisure of the tibia. The cross-sectional position of the fibula in distal syndesmosis]. Unfallchirurg. 1989;92(8):401–406.
Sora MC, et al. Evaluation of the ankle syndesmosis: a plastination slices study. Clin Anat. 2004;17(6):513–7.
Grass R. [Injuries of the inferior tibiofibular syndesmosis]. Unfallchirurg, 2000;103(7):519.
Yildirim H, et al. Evaluation of the fibular incisura of the tibia with magnetic resonance imaging. Foot Ankle Int. 2003;24(5):387–91.
Bassett FH 3rd, et al. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am. 1990;72(1):55–9.
Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin. 2008;13(4):611–33.. vii-viii
D’Hooghe P, Alkhelaifi K, Abdelatif N, Kaux JF. From “low” to “high” athletic ankle sprains: a comprehensive review. Oper Tech Orthop. 2018;28(2):54–60. https://doi.org/10.1053/j.oto.2018.01.002.
Lubberts B, D’Hooghe P, Bengtsson H, DiGiovanni CW, Calder J, Ekstrand J. Epidemiology and return to play following isolated syndesmotic injuries of the ankle: a prospective cohort study of 3677 male professional footballers in the UEFA Elite Club Injury Study. Br J Sports Med. 2017;21:bjsports-2017-097710. https://doi.org/10.1136/bjsports-2017-097710.
Fritschy D. An unusual ankle injury in top skiers. Am J Sports Med. 1989;17(2):282–5; discussion 85–6.
Flik K, Lyman S, Marx RG. American collegiate men’s ice hockey: an analysis of injuries. Am J Sports Med. 2005;33(2):183–7.
Wright RW, Barile RJ, Surprenant DA, et al. Ankle syndesmosis sprains in national hockey league players. Am J Sports Med. 2004;32(8):1941–5.
Kaplan LD, Jost PW, Honkamp N, et al. Incidence and variance of foot and ankle injuries in elite college football players. Am J Orthop. 2011;40(1):40–4.
Hunt KJ, George E, Harris AH, et al. Epidemiology of syndesmosis injuries in intercollegiate football: incidence and risk factors from National Collegiate Athletic Association injury surveillance system data from 2004-2005 to 2008-2009. Clin J Sport Med. 2013;23(4):278–82.
Boytim MJ, Fischer DA, Neumann L. Syndesmotic ankle sprains. Am J Sports Med. 1991;19(3):294–8.
Osbahr DC, Drakos MC, O’Loughlin PF, et al. Syndesmosis and lateral ankle sprains in the National Football League. Orthopedics. 2013;36(11):1378–84.
Purvis GD. Displaced, unstable ankle fractures: classification, incidence, and management of a consecutive series. Clin Orthop Relat Res. 1982;165:91–8.
Hopkinson St WJ, Pierre P, Ryan JB, et al. Syndesmosis sprains of the ankle. Foot Ankle. 1990;10:325–30.
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;77:847–56.
Beumer A, Valstar ER, Garling EH, et al. Effects of ligament sectioning on the kinematics of the distal tibio-fibular syndesmosis. Acta Orthop. 2006;77:531–40.
D’Hooghe P, et al. Fixation techniques in lower extremity syndesmotic injuries. Foot Ankle Int. 2017;38(11):1278–88.
D’Hooghe P, Bouhdida S, Whiteley R, Rosenbaum A, AlKhelaifi K, Kaux JF. Stable versus unstable grade 2 high ankle sprains in athletes: a noninvasive tool to predict the need for surgical fixation. Clin Res Foot Ankle. 2018;6(1):252–9. https://doi.org/10.4172/2329-910X.1000252.
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;47:620–8.
Harper MC. An anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 1993;14:455–8.
Sikka RS, Fetzer GB, Sugarman E, et al. Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot Ankle Int. 2012;33(5):371–8.
van den Bekerom MPJ, Lamme B, Hogervorst M, Bolhuis HW. Which ankle fractures require syndesmotic stabilization? J Foot Ankle Surg. 2007;46(6):456–63.
Schnetzke M, Vetter SY, Beisemann N, Swartman B, Grützner PA, Franke J. Management of syndesmotic injuries: what is the evidence? World J Orthop. 2016;7(11):718.
Femino JE, Vaseenon T, Phistkul P, et al. Varus external rotation stress test for radiographic detection of deep deltoid ligament disruption with and without syndesmotic disruption. Foot Ankle Int. 2013;34(2):251–60.
Dikos GD, Heisler J, Choplin RH, Weber TG. Normal tibiofibular relationships at the syndesmosis on axial CT imaging. J Orthop Trauma. 2012;26(7):433–8.
Hermans J, Wentink N, Beumer A, et al. Correlation between radiological assessment of acute ankle fractures and syndesmotic injury on MRI. Skeletal Radiol. 2012;41:787–801.
Williams BT, Ahrberg a B, Goldsmith MT, et al. Ankle syndesmosis: a qualitative and quantitative anatomic analysis. Am J Sports Med. 2015;43(1):88–97.
van den Bekerom MPJ, Mutsaerts ELAR, Dijk CN. Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature. Arch Orthop Trauma Surg. 2009;129(2):227–35.
Gennis E, Koenig S, Rodericks D, Otlans P, Tornetta P. The fate of the fixed syndesmosis over time. Foot Ankle Int. 2015;36(10):1202–8.
Drijfhout van Hooff CC, Verhage SM, Hoogendoorn JM. Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. Foot Ankle Int. 2015;36(6):673–8.
Gerber J, Williams G, Scoville C, Arciero R, Taylor D. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle Int. 1998;19(10):653–60.
Hansen M, Le L, Wertheimer S, Meyer E, Haut R. 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):65–9.
Taylor DC, Englehardt DL, Bassett FH 3rd. Syndesmosis sprains of the ankle. The influence of heterotopic ossification. Am J Sports Med. 1992;20(2):146–50.
Heim D, Schmidlin V, Ziviello O. Do type B malleolar fractures need a positioning screw? Injury. 2002;33(8):729–34.
Amendola A, Williams G, Foster D. Evidence-based approach to treatment of acute traumatic syndesmosis (high ankle) sprains. Sports Med Arthrosc. 2006;14(4):232–6.
Mc Collum GA, van den Bekerom MP, Kerkhoffs GM, Calder JD, van Dijk CN. Syndesmosis and deltoid ligament injuries in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013;21:1328–37.
Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High ankle sprains and syndesmotic injuries in athletes. J Am Acad Orthop Surg. 2015;23:661–73.
Kerkhoffs GMMJ, de Leeuw PAJ, Tennant JN, Amendola A. Ankle ligament lesions. In: The ankle in football. Paris: Springer; 2014. p. 81–96.
Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop. 2012;36:1199–206.
van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24:1217–27.
Nussbaum ED, Hosea TM, Sieler SD, Incremona BR, Kessler DE. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29:31–5.
Miller TL, Skalak T. Evaluation and treatment recommendations for acute injuries to the ankle syndesmosis without associated fracture. Sports Med. 2014;44(2):179–88.
van Dijk CN, Longo UG, Loppini M, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1217–27.
Nussbaum ED, et al. Prospective evaluation of syndesmotic ankle sprains without diastasis. Am J Sports Med. 2001;29(1):31–5.
Zhan Y, Yan X, Xia R, Cheng T, Luo C. Anterior-inferior tibiofibular ligament anatomical repair and augmentation versus trans-syndesmosis screw fixation for the syndesmotic instability in external-rotation type ankle fracture with posterior malleolus involvement: a prospective and comparative study. Injury. 2016;47(7):1574–80.
Samra DJ, Sman AD, Rae K, Linklater J, Refshauge KM, Hiller CE. Effectiveness of a single platelet-rich plasma injection to promote recovery in rugby players with ankle syndesmosis injury. BMJ Open Sport Exerc Med. 2015;1(1):e000033.
Amendola A, Williams G, Foster D. Evidence-based approach to treatment of acute traumatic syndesmosis (high ankle) sprains. Sports Med Arthrosc Rev. 2006;14(4):232–6.
Taylor DC, Tenuta JJ, Uhorchak JM, Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2007;35(11):1833–8.
Carr JBI, Werner BC, Yarboro SR. An update on management of syndesmosis injury: a National US Database Study. Am J Orthop (Belle Mead NJ). 2016;45(7):E472–7.
Matson AP, Hamid KS, Adams SB. Predictors of time to union after operative fixation of closed ankle fractures. Foot Ankle Spec. 2017;10(4):308–14.
Tornetta P. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation. J Bone Joint Surg Am. 2000;82(6):843–8.
Thompson M, Gesink D. Biomechanical comparison of syndesmosis fixation with 3.5- and 4.5-millimeter stainless steel screws. Foot Ankle Int. 2000;21(9):736–41.
Beumer A, Campo MM, Niesing R, Day J, Kleinrensink GJ, Swierstra BA. Screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. Injury. 2005;36(1):60–4.
McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P. Syndesmotic screw placement: a biomechanical analysis. Foot Ankle Int. 1997;18(5):262–6.
Darwish HH, Glisson RR, DeOrio JK. Compression screw fixation of the syndesmosis. Foot Ankle Int. 2012;33(10):893–9.
van den Bekerom MPJ, Hogervorst M, Bolhuis HW, van Dijk CN. Operative aspects of the syndesmotic screw: review of current concepts. Injury. 2008;39(4):491–8.
Høiness P, Strømsøe K. Tricortical versus quadricortical syndesmosis fixation in ankle fractures: a prospective, randomized study comparing two methods of syndesmosis fixation. J Orthop Trauma. 2004;18(6):331–7.
Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg. 2011;131(7):879–83.
Bell DP, Wong MK. Syndesmotic screw fixation in Weber C ankle injuries—should the screw be removed before weight bearing? Injury. 2006;37(9):891–8.
Moore JA Jr, Shank JR, Morgan SJ, Smith WR. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Foot Ankle Int. 2006;27(8):567–72.
Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19(2):102–8.
Dingemans SA, Rammelt S, White TO, Goslings JC, Schepers T. Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? A systematic review. Bone Joint J. 2016;98(11):1497–504.
Naqvi GA, Shafqat A, Awan N. Tightrope fixation of ankle syndesmosis injuries: clinical outcome, complications and technique modification. Injury. 2012;43(6):838–42.
Teramoto A, Suzuki D, Kamiya T, Chikenji T, Watanabe K, Yamashita T. Comparison of different fixation methods of the suture-button implant for tibiofibular syndesmosis injuries. Am J Sports Med. 2011;39(10):2226–32.
Kortekangas T, Savola O, Flinkkilä T, et al. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015;46(6):1119–26.
Ebramzadeh E, Knutsen AR, Sangiorgio SN, Brambila M, Harris TG. Biomechanical comparison of syndesmotic injury fixation methods using a cadaveric model. Foot Ankle Int. 2013;34(12):1710–7.
Phisitkul P, Ebinger T, Goetz J, Vaseenon T, Marsh JL. Forceps reduction of the syndesmosis in rotational ankle fractures. J Bone Joint Surg Am. 2012;94:2256–61.
Schon J, Mikula J, Backus J, et al. 3D model analysis of ankle flexion on anatomic reduction of a syndesmotic injury. Foot Ankle Int. 2017;38(4):436–42.
Tornetta P, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg Am. 2001;83(4):489–92.
de César PC, Avila EM, de Abreu MR. Comparison of magnetic resonance imaging to physical examination for syndesmotic injury after lateral ankle sprain. Foot Ankle Int. 2011;32(12):1110–4.
Clanton TO, Whitlow SR, Williams BT, et al. Biomechanical comparison of 3 current ankle syndesmosis repair techniques. Foot Ankle Int. 2017;38(2):200–7.
Schottel PC, Baxter J, Gilbert S, Garner MR, Lorich DG. Anatomic ligament repair restores ankle and syndesmotic rotational stability as much as syndesmotic screw fixation. J Orthop Trauma. 2016;30(2):e36–40.
Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165–71.
Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res. 2010;468(4):1129–35.
Verhage SM, Boot F, Schipper IB, Hoogendoorn JM. Open reduction and internal fixation of posterior malleolar fractures using the posterolateral approach. Bone Joint J. 2016;98(6):812–7.
Calder JD, Bamford R, Petrie A, et al. Stable versus unstable grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy. 2016;32:634–42.
Hunt KJ, Phisitkul P, Pirolo J, et al. High ankle sprains and syndesmotic injuries in athletes. J Am Acad Orthop Surg. 2015;23:661–73.
Taylor DC, Tenuta JJ, Uhorchak JM, et al. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. Am J Sports Med. 2017;35:1833–8.
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D’Hooghe, P. (2019). Syndesmosis Injuries. In: Canata, G., d'Hooghe, P., Hunt, K., Kerkhoffs, G., Longo, U. (eds) Sports Injuries of the Foot and Ankle. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-58704-1_6
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