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Background: Documenting the healthy articulation of the syndesmosis and talocrural joints, and measurement of 3D medial and lateral clear spaces may improve diagnostic and treatment guidelines for patients suffering from severe syndesmotic injury or chronic instability. This study aimed to define the range of motion (ROM) and displacement of the fibula and talus during static and dynamic activities, and measure the 3D movement in the tibiofibular (syndesmosis) and medial clear space. Methods: Six healthy volunteers performed dynamic weightbearing motions on a single-leg: heel-rise, squat, torso twist, and box jump. Participants posed in a nonweightbearing neutral stance as well as weightbearing neutral standing, plantarflexion, and dorsiflexion. High-speed stereoradiography measured 3D rotation and translation of the fibula and talus throughout each task. Medial clear space and tibiofibular gap distances were measured under each condition. Results: Total ROM for the fibula was greatest in internal-external rotation (9.3 ± 3.5 degrees), and anteroposterior (3.3 ± 2.2 mm) and superior-inferior (2.5 ± 0.9 mm) translation, rather than lateral widening (1.7 ± 1.0 mm). The total rotational ROM of the talus was greatest in dorsiflexion-plantarflexion (34.7 ± 12.9 degrees) and internal-external rotation (15.0 ± 3.4 degrees). Single-leg squatting increased the lateral clear space ( P = .045) and widened the medial tibiofibular joint, whereas single-leg heel-rises decreased the lateral clear space ( P = .001) and widened the tibiotalar space. Gap spaces in the tibiofibular and medial clear spaces did not exceed 2.3 ± 0.9 mm and 2.7 ± 1.2 mm, respectively. Conclusion: These data support a potential shift in the clinical understanding of fibula displacements during dynamic activities and how implant device constructs might be developed to restore physiologic mechanics. Clinical Relevance: Syndesmosis stabilization and rehabilitation should consider restoration of normal physiologic rotation and translation of the fibula and ankle mortise rather than focusing solely on the restriction of lateral translation.

Objectives: Fractures of the proximal metaphysis of the fifth metatarsal (i.e., Jones fractures) are common in the athletic population and frequently require surgical fixation to optimize healing rates and return to sport. Subtle hindfoot varus alignment, which likely results in greater forces at the fifth metatarsal, has been associated with increased risk of Jones fractures due to presumed increase in forces on the lateral foot. The goal of the present study was to dynamically assess plantar pressure loads at the fifth metatarsal in elite athletes with a history of Jones fracture. We hypothesize that athletes who have suffered Jones fractures will apply significantly higher loads at the fifth metatarsal base during athletic activities compared to matched uninjured athletes. Methods: Sixteen elite, competitive athletes were recruited to participate. Eight athletes had a history of Jones fracture and eight age, gender and position-matched athletes without a history of foot injury were recruited as controls. While wearing calibrated, wireless pressure mapping insoles, all athletes performed a standardized series of athletic movements including walking, running and cutting. Tests were repeated with the patient's standard corrective insole. Peak pressure, mean pressure, maximum force, and force-time integral (i.e., impulse) were recorded for each activity. Comparison between groups was performed using a paired Wilcoxon Sign Rank test. Results: Athletes with a history of Jones fracture showed a significantly increased peak pressure (183 ±23 kPA vs. 138±7 kPA), mean pressure (124±14 kPA vs. 95±4 kPA), and maximum force (15±1.2%BW vs. 12±1.2%BW) at the fifth metatarsal base during walking and running compared to uninjured matched controls (all P<0.05). Use of the corrective orthotic insole did not significantly reduce peak or mean pressure, maximum force, or impulse at the fifth metatarsal base during running or cutting. Conclusion:Athletes with a history of Jones fracture exert significantly increased peak and mean forces at the base of the fifth metatarsal during common athletic activities. Standard corrective orthoses do not appear to offload this region in all cases. These increased loads may contribute to the development of stress injury to the fifth metatarsal during repetitive loading, and ultimately fracture of the bone. Identifying patients at risk for Jones fracture using dynamic loading assessment may facilitate an injury prevention program. Further study of orthotic devices, training programs, shoe wear, and devices designed to offload the fifth metatarsal is necessary.

Objectives: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopaedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injures by orthopedic foot and ankle specialists around the world in 6 athlete scenarios with increasing degree of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails disseminated 2 weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to 6 months post-op (Fig 1). 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although, flexible fixation devices are the preferred among all respondents but there was a considerable variability in device choices. Fellowship training also appears to affect the preferred fixation device choice. There also exists substantial variability in expected return to play for every athlete scenario (Fig 1). The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding management of syndesmotic injuries.