Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective

Postoperative Return to Play and the Role of Imaging

“…The ligaments of the distal tibiofibular syndesmosis include the anterior inferior tibiofibular ligament (AITFL), the posterior inferior tibiofibular ligament (PITFL), the inferior transverse ligament (ITL), and the interosseous ligament. 52 The AITFL traverses the anterior tubercle of the distal tibia to the anterior surface of the distal fibula; the PITFL extends from the posterior malleolus to the posterior aspect of the lateral malleolus. 53 The ITL, a fibrocartilaginous structure that helps stabilize the posteroinferior distal tibiofibular articulation, has a small attachment on the fibula immediately distal to the PITFL and a variable attachment site on the distal tibia.…”

“…53 Lateral ankle sprains represent the most common ligamentous injury of the ankle, but syndesmotic involvement was reported in 1 to 25% of all ankle sprains. 52 Although less frequent than lateral ankle sprains, syndesmotic injuries, often referred to as "high-ankle sprains" given their proximal relationship to other ligamentous structures of the ankle, portend a longer recovery time. 53 Syndesmotic injuries can be isolated to the syndesmotic ligaments or in a complex injury pattern with involvement of other ligamentous or osseous structures.…”

“…55 Because syndesmotic injuries represent a heterogeneous group with varying grades of syndesmotic ligament injury, possible concomitant osseous and/or other ligamentous injuries, and potential syndesmotic instability, it is not surprising that optimal treatment is controversial. 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. 52 Options for syndesmotic fixation include syndesmotic screw placement or stabilization with a suture button construct.…”

“…55 Stabilization with a syndesmotic screw leads to a rigid fixation, with cadaveric studies demonstrating decreased residual diastasis when compared with suture button constructs. 52 This factor is potentially problematic in the athlete because normal physiologic motion at the syndesmosis can lead to implant failure. In the athletic population, screws are often removed between 6 and 12 weeks to avoid the risk of implant loosening or fracture.…”