Elite Athletes Successfully Return to the Preinjury Level of Sport Following Ankle Syndesmosis Injuries: A Systematic Review and Meta-Analysis

Abstract

Objective:To comprehensively review and report the outcomes of ankle syndesmotic injury management in elite athletes.Data sources:Three databases were searched for articles reporting the rate of return to sport following treatment of ankle syndesmotic injuries in elite athletes (collegiate or professional level). Ten articles and 440 athletes were included. Articles reporting the rate of return to sport following high ankle sprain injury in elite athletes. Data collected included demographics, type of treatment received, and return to sport (RTS) information. A random effects model was used.Main results:The estimated overall rate of RTS was 99% (95% CI, 95.5-99.9). The mean time to RTS was 38 ± 18 (range, 14-137) days. Of the 440 athletes, 269 (269/440%, 61%) were treated nonoperatively (nonoperative group); the rate of RTS was 99.6%, and the athletes returned at a mean time of 29 ± 14 (range, 13-45) days. A total of 171 athletes (171 of 440%, 39%) underwent surgical treatment (operative group). All (171 of 171%, 100%) athletes returned at a mean time of 50.3 ± 13 (range, 41-137) days. Almost all athletes who underwent surgery had suture button fixation (164 of 171 athletes, 96%), and the mean time to RTS was 7 weeks with 9.1% complication rate.Conclusions:Elite athletes with ankle syndesmosis injury return to sport at an extremely high rates, following operative or nonoperative treatment. Return to the preinjury level of competition should be expected at 4 weeks and 7 weeks in high-level athletes who undergo nonoperative and operative management, respectively. Suture button fixation was used by the majority of studies reporting surgical management of ankle syndesmosis injuries in athletes.

Postoperative Return to Play and the Role of Imaging

“…50,52,58 Nonoperative management is generally considered an appropriate treatment strategy for patients with a stable syndesmosis. 53,55,59 However, multiple degrees of variation exist within nonoperative management of such injuries, including the weight-bearing regimen and immobilization options, with reported lengths of immobilization ranging from 1 to 6 weeks. 53 A survey of orthopaedic surgeons in 2022 identified common surgical indications for syndesmotic fixation to include radiographic evidence of syndesmotic widening > 2 mm, findings of an AITFL injury with a concomitant PITFL or deltoid ligament injury on MRI, or diastasis of the distal tibiofibular joint at arthroscopy.…”

“…55,60,61 Suture button constructs have also been reported to have lower rates of complications and obviate the need for routine removal. 55,59,60 Among a survey of orthopaedic surgeons, dynamic fixation with suture button constructs was the preferred fixation approach for syndesmotic injuries. 52 Previous studies demonstrated high rates of American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, a validated instrument evaluating patient outcomes following an ankle or hindfoot injury.…”

“…52 Previous studies demonstrated high rates of American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores, a validated instrument evaluating patient outcomes following an ankle or hindfoot injury. 59 Additionally, in a recent meta-analysis of 440 athletes sustaining syndesmotic injuries, among the 39% undergoing surgical fixation, most patients were treated with suture button constructs by a margin of 96%. 59 In considering RTP following syndesmotic fixation, the sports medicine physician has multiple clinical scores and exam findings available, such as the AOFAS Ankle-Hindfoot score, the Olerud-Molander Ankle Score (OMAS), and the Foot and Ankle Disability Index Score (FADI Score).…”

“…59 Additionally, in a recent meta-analysis of 440 athletes sustaining syndesmotic injuries, among the 39% undergoing surgical fixation, most patients were treated with suture button constructs by a margin of 96%. 59 In considering RTP following syndesmotic fixation, the sports medicine physician has multiple clinical scores and exam findings available, such as the AOFAS Ankle-Hindfoot score, the Olerud-Molander Ankle Score (OMAS), and the Foot and Ankle Disability Index Score (FADI Score). 62 Additionally, the "tenderness length" appreciated on physical exam was previously shown to correlate with RTP time course.…”

“…50 52 58 Nonoperative management is generally considered an appropriate treatment strategy for patients with a stable syndesmosis. 53 55 59 However, multiple degrees of variation exist within nonoperative management of such injuries, including the weight-bearing regimen and immobilization options, with reported lengths of immobilization ranging from 1 to 6 weeks. 53…”