What is the treatment approach for ankle syndesmosis injury repair?

Ankle Syndesmosis Injury Repair

The treatment of ankle syndesmosis injuries should be based on injury grade, with grade 1 managed conservatively, grade 2 often requiring surgical fixation, and grade 3 always requiring surgical reconstruction to ensure optimal outcomes in terms of morbidity and mortality. 1

Diagnosis and Assessment

Clinical Evaluation

• Look for specific physical examination findings:
  • Swelling and pain over the anterior tibiofibular ligament
  • Positive external rotation test (pain with external rotation of the foot)
  • Positive squeeze test (pain with compression of tibia and fibula at mid-calf level)
  • Crossed-leg test (pain in syndesmosis area when pressure is applied to medial side of knee) 2

Imaging

• Initial radiographs if Ottawa Ankle Rules are positive:
  • Look for widening of the tibiofibular clear space
  • Decreased tibiofibular overlap
  • Increased medial clear space 2
• MRI is the gold standard for soft tissue evaluation of syndesmotic injuries 2
• CT can help detect syndesmotic injuries and is useful for preoperative planning 2

Treatment Algorithm

Grade 1 Syndesmosis Injury (Sprain without instability)

• Conservative management:
  • PRICE protocol (Protection, Rest, Ice, Compression, Elevation) for 72 hours 2
  • NSAIDs to reduce pain, swelling, and improve function 2
  • Immobilization for 1-3 weeks followed by gradual return to activity 1
  • Functional rehabilitation with semirigid or lace-up ankle supports 2

Grade 2 Syndesmosis Injury (Partial tear with some instability)

• If stable enough: Conservative management as above
• Most cases: Surgical fixation is strongly favored 1
  • Options include:
    1. Syndesmosis screws (metallic or bioabsorbable)
    2. Dynamic fixation systems (TightRope, ZipTight) 1

Grade 3 Syndesmosis Injury (Complete tear with instability)

• Surgical reconstruction is required 1
• Anatomic reduction is critical to prevent long-term ankle dysfunction 3
• Fixation options:

  1. Traditional syndesmosis screws

     • Requires second surgery for removal
     • Risk of screw breakage during rehabilitation 4

  2. Dynamic fixation (TightRope)

     • Allows for physiologic micromotion
     • No need for hardware removal
     • Faster return to weight-bearing (average 7.7 weeks) 5
     • Better patient-reported outcomes 4

Surgical Considerations

Fixation Method Selection

• TightRope fixation shows advantages over traditional screw fixation:
  • Similar clinical outcomes
  • Shorter recovery time
  • Earlier return to activities
  • No need for second surgery for hardware removal 4, 5
  • Modified technique can reduce soft-tissue complications 5

Post-operative Management

• Non-weight bearing for 6-8 weeks (average 7.7 weeks with TightRope) 5
• Return to normal activities around 11-12 weeks 5
• Functional rehabilitation with:
  • Range of motion exercises
  • Strengthening
  • Proprioceptive training 2, 6

Pitfalls and Caveats

1. Misdiagnosis is common - syndesmosis injuries are frequently overlooked or misdiagnosed as simple ankle sprains 6

2. Inadequate treatment leads to chronic problems:

   • Decreased range of motion
   • Persistent pain
   • Joint instability
   • Premature osteoarthritis 2, 6

3. Excessive dorsiflexion during early rehabilitation can disrupt healing - consider heel lift or posterior splint to avoid separation of the distal syndesmosis 6

4. Avoid medial-lateral compression of the leg superior to the ankle mortise during immobilization as this can induce separation of the distal syndesmosis 6

5. Anatomic reduction is critical - even small malreductions (1-2mm) can lead to significant ankle dysfunction 3