Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Abstract

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

Isolated injuries to the lateral ankle ligaments have no direct effect on syndesmotic stability

“…First, this study evaluated the translation of the fibula in the coronal and sagittal directions as the laxity of syndesmosis, but not in fibula rotation. Markus et al demonstrated that an unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula [22]. Given those ligament injuries of the ankle generally occur from the anterolateral side in clinical situation, fibula laxity in the external rotation can occur in the early stages of ligament injury, compared to the appearance of coronal and sagittal laxity.…”

“…First, this study evaluated the translation of the ibula in the coronal and sagitdirections as the laxity of syndesmosis, but not in ibula rotation. Markus et al demonstrated that an unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal ibula [22].…”

Intramedullary osteosynthesis for ankle fractures and distal tibiofibular syndesmotic disruption

“…J. Litrenta et al в своем рандомизированном контролируемом исследовании также подтвердили негативное влияние повреждения дистального синдесмоза на результаты хирургического лечения переломов лодыжек [21]. Во многих случаях для устранения повреждений и восстановления функции пораженного сустава необходимо хирургическое вмешательство, что в настоящее время является приоритетным методом лечения данной патологии [7,[22][23][24]. Проведено множество исследований, сравнивающих различные варианты хирургических вмешательств, например, мета-анализ A. Grassi et al на тему динамического и статического методов фиксации дистального синдесмоза, доказавший преимущество динамических видов фиксации над статическими [22].…”

Determining the Tightrope Tightening Force for Effective Fixation of the Tibiofibular Syndesmosis during Osteomeatal Synthesis of Fibula Injuries

“…At the same time, concomitant repair of unstable syndesmosis injuries does not have a unified approach. Here, the most common divergence of views on surgical treatment is associated with the use of two conceptually different methods-screw fixation of the syndesmosis and elastic (dynamic) fixation [11]. Injuries of the tibiofibular syndesmosis are among the most difficult in surgical treatment.…”