Optimal management of ankle syndesmosis injuries

Abstract

Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

Caso Clínico: Fractura de Tobillo Weber B, Tratamiento Quirúrgico con Doble Sistema Tightrope®

“…En un estudio conducido por Thornes y colaboradores en comparación con la fijación mediante tornillo (93 versus 83), se obtuvo un mejor resultado al año de seguimiento y un regreso más rápido al trabajo (2.8 meses frente a 4.6 meses); sin embargo, el 75 % de los pacientes con fijación de tornillo necesitó remoción de los dispositivos de fijación mientras que ninguno de los pacientes que fue tratado con TightRope® requirió una segunda cirugía [2]. Coetzee y colaboradores realizaron un estudio prospectivo que comparó el uso de TightRope® y tratamiento con tornillos en el cual se reportó un mejor rango de movimiento, menor rigidez y disconfort en respecto de la primera técnica [16].…”

“…Dentro de la población atlética, la incidencia se incrementa entre 12 y 32 %, sobre todo en deportes que involucran fuerzas externas sobre el tobillo [2]. Estas fracturas configuran una causa importante de incapacidad laboral y funcional; su origen por lo general se debe a un traumatismo indirecto de baja energía, durante actividades de vida diaria o la práctica deportiva [3].…”

“…La técnica Tightrope® ha surgido como alternativa al ofrecer ventajas como el retorno temprano a las actividades diarias y el no requerir la remoción de tornillos con lo que se evita una segunda cirugía [2].…”

Current trends in the diagnosis and management of syndesmotic injury

“…The four most important considerations when treating syndesmosis injuries can be summarized as follows: (1) early recognition of the injury and its severity, (2) accurate assessment of the degree of (in)stability and any other associated pathology, (3) prompt reduction and stabilization of all unstable injuries along with treatment of any associated pathology as indicated, and (4) progressive rehabilitation focusing on full range of motion and return of normal strength [2].…”

“…In the setting of Weber B or C fractures, it is paramount that the fibula be anatomically reduced to obtain appropriate length; however, because in the absence of doing this, there will often end up being progressive lateral translation of the talus even when the syndesmosis is stable and/or properly stabilized surgically [2]. However, even though it is not as common, it needs to be noted that non-isolated syndesmotic injuries can also happen in Maisonneuve fibula fractures and isolated posterior malleolus factures [2,[78][79][80].…”