Syndesmosis Injury From Diagnosis to Repair

Physical Examination, Diagnosis, and Arthroscopic-Assisted Reduction

Jeffrey Wake, DO; Kevin D. Martin, DO, FAAOS


J Am Acad Orthop Surg. 2020;28(13):517-527. 

In This Article

Author Preferred Method of Treatment

In our practice, we use a standardized preoperative examination and radiographic workup including a gravity stress view and MRI. Based on these findings, we formulate an appropriate surgical approach. Owing to the high prevalence of intra-articular pathology as described by Ferkel et al, we conduct an arthroscopic examination before and in conjunction with all repairs.[63] For isolated AITFL injuries, we perform an isolated anatomic repair augmented with a suture-tape construct from the anterolateral tibia (Chaput tubercle) to Wagstaffe tubercle on the fibula. If deltoid injury is noted or a medial tilt remains, a deltoid repair is performed. If the PITFL, IOL, and AITFL are all involved or sagittal and coronal plane instabilities are noted, we reduce the fibula in the incisura with a clamp under arthroscopic visualization. We then place a suture-button construct, thus providing coronal plan stability in conjunction with an AIFTL repair using suture-tape augmentation. This dual fixation construct is also used if the MRI demonstrates a flattened insufficient incisura with sagittal instability. If a posterior malleolus fracture is noted with an intact PITFL, we address this first by placing the patient prone and performing a posterior arthroscopic fixation and internal fixation with 3.5 mm cannulated screws. We then reassess stability with stress maneuvers and arthroscopic visualization, if instability is appreciated, we then proceed down our aforementioned algorithm of repairs.

Immediately after surgery, a nonweight-bearing splint is applied for 10 to 14 days. At 2 weeks, partial weight-bearing is initiated in a postoperative CAM boot, allowing for range-of-motion exercises and recumbent bike. Formal physical therapy is also initiated at this point because proprioception and strengthening are paramount. At 4 weeks, patients may transition into an ankle lace-up brace if they can maintain a nonantalgic gait, this progression is variable. The patient may begin a walk to run program and return to early sport if they can do a single leg hop and heel raise at 6 weeks.