Acute, isolated and unstable syndesmotic injuries are frequently associated with intra-articular pathologies

Ankle Cartilage: Chondral and Osteochondral Lesions: A Further Dive into the Incidence, Terminology, and the Cartilage Cascade

The current concepts thoroughly highlight the ankle cartilage cascade focusing on the different stages and the different etiologic factors that can introduce a patient into the cascade. Moreover, the authors will provide the reader with a comprehensive overview of the types of lesions that may present as symptomatic, asymptomatic, and dangerous for progression into osteoarthritis, and the authors supply the reader with considerations and directions for future clinical implications and scientific endeavors.

Fifteen out of 16 elite athletes showed concomitant low-grade cartilage lesions of the ankle with unstable syndesmotic injuries: concerns from a prospective case series

Objectives

This study aimed to determine the incidence rate and characterise the location and severity of cartilage lesions in the ankle in elite athletes undergoing suture-button stabilisation for unstable distal syndesmotic injuries using needle arthroscopic examination. The feasibility and safety of ad hoc needle arthroscopy and its assisted interventions were also assessed.

Methods

This prospective case series included elite athletes undergoing surgical stabilisation between April 2021 and June 2023. Procedures involved suture button fixation and needle arthroscopy, conducted by a single ankle fellow-trained surgeon. Ankle cartilage lesions were graded using the Cheng and Ferkel classification and located using the nine-zone grid. The study followed the STROBE statement.

Results

This study included 16 elite athletes undergoing surgery for distal syndesmotic injuries, with 75% having acute and 25% chronic injuries. Cartilage lesions were prevalent (n=15/16, 94%), mainly at the talar dome (90%), and primarily scored as grade 1 (33%) or grade 2 (67%). Distal tibia cartilage damage occurred in 13% of cases. All patients were diagnosed with an instability of the syndesmosis confirmed through needle arthroscopy and were treated with a suture button (one or two buttons) fixation.

Conclusion

In 15/16 elite athletes with syndesmotic injuries, concomitant ankle cartilage lesions were identified through needle arthroscopy. In addition, most of the lesions were classified as grade 1 or 2, denoting superficial damage. Needle arthroscopic interventions proved feasible and safe for confirming syndesmotic instability and addressing intra-articular pathologies.

High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment?

Probably one of the most controversial subjects in the orthopedic field is the distal tibiofibular articulation. Even though its most primary knowledge can be a matter of enormous debate, it is in the diagnosis and treatment most of the disagreements reign. Distinguishing between injury and instability remains challenging as well as an optimal clinical decision regarding surgical intervention. The last years presented technology and that was able to bring body to an already well-developed scientifical rationale. In this review article, we aim to demonstrate the current data behind syndesmotic instability in the ligament scenario, whereas using few fracture concepts.

Current status of the management of isolated syndesmotic injuries in Germany

INTRODUCTION

Although non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany.

MATERIALS AND METHODS

An online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS.

RESULTS

Each question of the questionnaire was on average answered by 431 ± 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior-posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices.

CONCLUSIONS

While arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany.

Intraoperative Assessment of Reduction of the Ankle Syndesmosis

PURPOSE OF REVIEW

Postoperative malreduction of the ankle syndesmosis is common, poorly defined, and its assessment is controversial. In the absence of a gold standard method to evaluate the ankle syndesmosis, a variety of techniques have been described. As the knowledgebase expands, data illustrating caveats for such techniques has become available. The purpose of this review is to highlight literature-sourced technical pearls and their related caveats for the intraoperative assessment of the ankle syndesmosis.

RECENT FINDINGS

Although numerical criteria are commonly used to assess syndesmotic reduction, anatomical variation in the healthy population frequently exceeds proposed cutoffs. Patient-specific uninjured anatomy can be defined by comparing to the uninjured contralateral ankle; however, side-to-side variation is present for many anatomical relationships. Advanced imaging (e.g., lateral radiographs, 3-dimensional radiography) can influence intraoperative surgeon decision-making and improve syndesmosis reduction, but minute improvements in syndesmosis reduction may not outweigh increased operating time and costs. Intraoperative imaging is an adjunct, not a replacement for direct visualization or palpation when reducing the syndesmosis. Arthroscopy may benefit younger patients with high physical demands by improving identification of intra-articular pathology absent on MRI. Although anatomical reduction is important to restore pre-injury biomechanics, it is unclear whether differences in reduction quality influence patient-reported outcomes. In the absence of a gold standard, awareness of the options for intraoperative assessment of the syndesmosis and their respective accuracy and limitations reported herein could enhance surgeons' ability to intraoperatively reduce the syndesmosis with the tools currently available.

Incidence of (Osteo)Chondral Lesions of the Ankle in Isolated Syndesmotic Injuries: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine and compare the incidence rate of (osteo)chondral lesions of the ankle in patients with acute and chronic isolated syndesmotic injuries.

DESIGN

A literature search was conducted in the PubMed (MEDLINE) and EMBASE (Ovid) databases from 2000 to September 2021. Two authors independently screened the search results, and risk of bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) criteria. Studies on acute and chronic isolated syndesmotic injuries with pre-operative or intra-operative imaging were included. The primary outcome was the incidence rate with corresponding 95% confidence intervals (CIs) of (osteo)chondral lesions of the ankle in combined and separate groups of acute and chronic syndesmotic injuries. Secondary outcomes were anatomic distribution and mean size of the (osteo)chondral lesions.

RESULTS

Nine articles (402 syndesmotic injuries) were included in the final analysis. Overall (osteo)chondral lesion incidence was 20.7% (95% CI: 13.7%-29.9%). This rate was 22.0% (95% CI: 17.1-27.7) and 24.1% (95% CI: 15.6-35.2) for acute and chronic syndesmotic injuries, respectively. In the combined acute and chronic syndesmotic injury group, 95.4% of the lesions were located on the talar dome and 4.5% of the lesions were located on the distal tibia. (Osteo)chondral lesion size was not reported in any of the studies.

CONCLUSIONS

This meta-analysis shows that (osteo)chondral lesions of the ankle are present in 21% of the patients with isolated syndesmotic injuries. No difference in incidence rate was found between the different syndesmotic injury types and it can be concluded that the majority of lesions are located on the talar dome.

PROSPERO REGISTRATION NUMBER

CRD42020176641.

Ankle and syndesmosis instability: consensus and controversies

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017.

The ankle cartilage cascade: incremental cartilage damage in the ankle joint

Level of evidence Editorial, Level V.