When should the syndesmosis be fixed?

From the Guidelines

The syndesmosis should be fixed when there is evidence of instability or widening of the distal tibiofibular joint, typically following ankle injuries, to reduce morbidity and mortality. This includes cases with frank diastasis (separation greater than 2mm on standard radiographs), positive stress tests showing abnormal tibiofibular clear space, or MRI/CT evidence of disrupted syndesmotic ligaments 1. Surgical fixation is generally indicated for all unstable syndesmotic injuries, as they can lead to chronic ankle instability, pain, and premature arthritis if left untreated. The standard approach involves anatomic reduction of the syndesmosis followed by fixation using either syndesmotic screws (typically 3.5mm or 4.5mm, placed 2-4cm above the ankle joint) or suture button devices like TightRope. Key considerations in the management of syndesmotic injuries include:

• Early definitive osteosynthesis of diaphyseal fractures is recommended within the first 24 hours to reduce the incidence of local and systemic complications, in the absence of severe visceral injury, circulatory shock, or respiratory failure 1
• A delayed definitive osteosynthesis of diaphyseal fractures is probably recommended within the first 24h to reduce the incidence of systemic complications related to surgical hit, perioperative blood loss, coagulopathy or fat embolism syndrome, in the presence of one or several severe visceral injuries, circulatory shock, or respiratory failure 1 Post-operative management usually involves 6 weeks of non-weight bearing in a cast or boot, followed by progressive weight bearing and physical therapy focusing on ankle range of motion, proprioception, and strengthening. Proper fixation is crucial as both under-reduction and over-compression of the syndesmosis can lead to poor outcomes, with malreduction being the most common cause of persistent symptoms after syndesmotic repair. It is essential to note that the management of syndesmotic injuries should be individualized based on the patient's clinical status, physiological stability, and injury assessment.

From the Research

Syndesmosis Injury Treatment

The treatment of syndesmosis injuries depends on the grade of the injury and associated injuries around the ankle.

• Grade 1 syndesmosis injuries should be treated conservatively, with immobilization for one to three weeks followed by gradual return to activity 2.
• For grade 2 syndesmosis injuries, if stable, patients can be managed with conservative therapies, but most favor surgical treatment 2, 3.
• Grade 3 syndesmosis injuries should be treated with surgical reconstruction 2.
• If syndesmosis injury is associated with ankle fractures, surgical reduction, fixation, and reconstruction are usually required 2, 4.

Surgical Treatment Methods

Common surgical treatment methods for syndesmosis injuries include:

• Syndesmosis screws, composed of either metallic or bioabsorbable material
• Fibula intramedullary nails
• Dynamic button-suture fixation, TightRope or ZipTight 2 Each method has advantages and disadvantages, which must be considered when determining the best treatment for the patient's needs.

Timing of Syndesmosis Fixation

The timing of syndesmosis fixation is crucial to prevent long-term dysfunction and morbidity.

• Athletes may return to training and play sooner if the syndesmosis is surgically stabilized 3.
• Obtaining and maintaining an anatomic reduction is the key to long-term success when treating syndesmotic injuries 4.