Distal Tibiofibular Syndesmosis Dysfunction: A Systematic Literature Review of Dynamic Versus Static Fixation Over the Last 10 Years

Isolated syndesmotic injury: treatment with suture button system-retrospective cohort study

Background

Ankle injuries, often involving the syndesmotic complex, are common and may lead to acute instability. The syndesmosis, comprising several key ligaments, provides critical support for ankle function. This study assesses the efficacy and safety of the suture button system for isolated syndesmotic injuries, a treatment method that is gaining popularity over traditional transsyndesmotic screws.

Methods

A retrospective review was conducted on patients treated surgically with the suture button system for isolated syndesmotic injuries from January 2018 to December 2023. Key outcomes measured included time to full weight-bearing, returning of daily activities, and complications. The study also compared these outcomes with historical data from screw fixation methods.

Results

Thirty-two patients (20 men, 12 women; mean age 41.66 ± 16.57 years [range 16-72 years]) were analyzed over an average follow-up of 9.94 ± 5.49 months (range 3-28 months). Patients achieved full weight-bearing at 1.23 ± 0.31 months postoperatively, resumed daily activities with restrictions at 3 ± 1.09 months, and without restrictions at 6.67 ± 2.55 months. No major complications were reported; minor complications included implant removal due to irritation in two patients (6.25%) and minor wound issues in one patient (3.13%).

Conclusion

The suture button system demonstrated good outcomes in allowing physiological motion, low malreduction rates, and minimizing reoperation needs. The present results indicate a promising safety profile and functional recovery, despite limitations such as small sample size and lack of patient-reported outcome measures.

Post-treatment Functional Outcomes of Distal Tibiofibular Syndesmosis Injuries With Varying Duration and Method of Stabilization

The purpose of this study was to assess whether the type and duration of screw fixation affects ankle joint functional scores and patient activity levels. We evaluated 55 patients who had undergone surgical treatment for ankle fracture with concomitant distal tibiofibular syndesmosis injury. The follow-up period ranged from 2 years to 4 years and 2 months (mean 36 months). Depending on the time of screw removal, patients were divided into 2 groups (the 8-15-week group-19 patients, and the 16-22-week group-36 patients). There were 17 patients with tricortical and 38 patients with quadricortical syndesmosis fixation. The following parameters were assessed: range of motion, rates of complications, level of pain in visual analogue scale (VAS), and function. In the quadricortical fixation group the range of plantar flexion p = .04 and adduction p = .043 were significantly lower in the operated than in the nonoperated limb. In the patients who had their syndesmotic screws removed after 16-22 weeks, the range of plantar flexion in the operated limb was significantly lower than that in the nonoperated limb. We observed no differences between the evaluated groups in terms of ankle joint mobility, VAS pain levels, functional outcomes, or complication rates. All the analyzed subgroups showed poorer ranges of some types of motion in the ankle and worse functional scale and VAS pain scores after treatment in comparison with those before the injury. We suggest removing the syndesmotic screws after 8-15 weeks, due to the possibility of earlier rehabilitation, faster return to work and physical activity and less burden on the health care system. Tricortical or quadricortical syndesmosis fixation is at the surgeon's discretion.

Syndesmosis Injury Contributes a Large Negative Effect on Clinical Outcomes: A Systematic Review

INTRODUCTION

The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. This systematic review aimed to quantify the impact of syndesmosis injury.

METHODS

Published clinical outcomes data were used to compute an effect size reflecting the impact of syndesmosis injury. This was done within the clinical contexts of isolated syndesmosis injury and syndesmosis injury with concomitant ankle fracture. Clinical outcomes data included Olerud-Molander (OM) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale for pain, and days missed from sport competition. Parametric data were compared with Student t tests. Effect size was computed using Cohen's d.

RESULTS

In ankle fracture patients, syndesmosis injury demonstrated a large effect size for OM (d = 0.96) and AOFAS (d = 0.83) scores. In athletic populations without concomitant ankle fracture, syndesmosis injury demonstrated a large effect size on days missed from competition (d = 2.32).

DISCUSSION

These findings confirm the magnitude of the negative impact of syndesmosis injury in athletic populations with isolated injury and in ankle fracture patients. In ankle fracture patients, this large negative effect remains despite surgery. Thus, syndesmosis repair may not fully mitigate the impact of the injury.

LEVELS OF EVIDENCE

Level III: Systematic review.

Comparison of Suture Button and Syndesmotic Screw for Ankle Syndesmotic Injuries: A Meta-analysis of Randomized Controlled Trials

Background

The syndesmotic screw (SS) and suture button (SB) fixation methods are both widely used for the reduction of ankle syndesmotic injury, with varying outcomes.

Purpose

To review recently published randomized controlled trials (RCTs) to assess the outcomes between SS and SB fixation for ankle syndesmotic injury.

Study Design

Systematic review; Level of evidence, 1.

Methods

The PubMed, Embase, ClinicalTrials.gov, and Cochrane databases were searched for relevant RCTs published between 1966 and 2021 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies were RCTs comparing SS and SB fixation for ankle syndesmotic injury. The risk of bias was evaluated using the Cochrane Risk of Bias tool. Primary outcomes included complications, malreduction, and unplanned reoperation, and secondary outcomes were the American Orthopaedic Foot & Ankle Society (AOFAS) score, Olerud-Molander ankle score (OMAS), and EuroQol-5 Domain (EQ-5D) score. The mean difference (MD) and risk ratio (RR) were calculated for continuous and dichotomous outcomes, respectively. Random- or fixed-effects model was applied according to heterogeneity.

Results

Of 389 studies, 8 RCTs involving 512 patients were included. Overall, 257 patients received SS fixation and 255 patients received SB fixation. The 2 groups did not differ significantly in malreduction (RR, -0.06; 95% CI, -0.18 to 0.07) or EQ-5D (MD, 0.01; 95% CI, -0.01 to 0.03). However, the SB group showed significant advantages over the SS group in complications (RR, 0.42; 95% CI, 0.26 to 0.66), unplanned reoperation (RR, 0.62; 95% CI, 0.43 to 0.89), AOFAS score (MD, 3.04; 95% CI, 1.77 to 4.31), and OMAS (MD, 4.51; 95% CI, 1.54 to 7.48). The risk of bias of the included studies was acceptable.

Conclusion

The results showed that there were no significant differences between the SS and SB groups in malreduction and EQ-5D scores. However, the SB group had significantly better local irritation rates, unplanned reoperation rates, AOFAS scores, and OMASs.

Management of Syndesmosis Injury: A Narrative Review

The syndesmosis is an important fibrous joint that plays a crucial role in normal ankle weight-bearing and movements. Syndesmosis injuries include disruption of one or more of the ligaments comprising the distal tibiofibular syndesmosis and are commonly associated with ankle fractures. The treatment of grade 1 syndesmosis injury should be conservative, such as immobilization for one to three weeks followed by gradual return to activity. For the treatment of grade 2 syndesmosis injury, if it was stable enough, the patients still could be managed with conservative therapies. But majority of them strongly favor surgical treatment. For the treatment of grade 3 syndesmosis injury, it should treat with surgical reconstruction. If syndesmosis injury is associated with ankle fractures, surgical reduction, fixation, and reconstruction are usually required. Common surgical treatment methods include syndesmosis screws, composed of either metallic or bioabsorbable material; fibula intramedullary nails; and dynamic button-suture fixation, TightRope or ZipTight. Each method has advantages and disadvantages which must be considered while determining which treatment will provide the best outcomes depending on the patient's needs. Continued exploration of new materials, devices, and methods for surgical fixation is necessary for advancement in this field.

Radiographic Assessment of Tibiofibular Syndesmosis Injury with Different Durations and Types of Fixation

Introduction: There is no consensus among orthopedic surgeons on the number of cortical layers (tricortical or quadricortical fixation) involved or the duration of syndesmotic fixation after a tibiofibular syndesmosis (TFSD)-injury treatment. The purpose of this study was to assess radiographic parameters following the treatment of TFSD injuries, with various time-windows of syndesmotic screw removal and numbers of cortical layers involved. Materials and Methods: Fifty-five patients, aged from 25 to 75 years, were included in the study. The follow-up period ranged from 2 years to 4 years and 2 months. The patients were subdivided into groups based on the duration of the syndesmotic fixation (8–15 weeks—19 patients or 16–22 weeks—36 patients) and the number of cortices involved (tricortical—17 patients or quadricortical fixation—38 patients). Results: The quadricortical fixation group showed a significant development of ankle joint arthritis and subtalar joint arthritis at the final follow-up. The mean medial clear space was 2.84 mm in the tricortical fixation group and 3.5 mm in the quadricortical fixation group (p = 0.005). Both groups, with different screw removal times showed significant development of posttraumatic arthritis. A comparison of the two groups (with different time-windows of the screw removal) revealed a significant difference only in terms of the postoperative tibiofibular (TF) overlap and the observed rates of talonavicular arthritis at the final follow-up. Discussion: We found that the duration of the screw fixation had no effect on most of the evaluated radiographic parameters. Only the postoperative TF overlap was lower in the 8–15-week fixation group, and the proportion of patients with talonavicular joint arthritis at the final follow-up was higher in the 16–22-week fixation group. In addition, the number of cortices involved in the screw fixation had no effect on the radiographic outcomes in our patients, apart from the differences in one parameter—the medial clear space—at the final follow-up. Conclusion: We achieved similar radiographic results irrespective of the duration of the screw fixation and the number of cortices involved. All study subgroups showed the development of adjacent-joint arthritis following treatment. Considering the results of our study, the economic and medical aspects of treatment, and the possibility of a faster recovery, the most optimal solution seems to be the use of a tricortical fixation, with the screws being removed after 8–15 weeks.

The Effect of Stabilization Procedures on Sports Discipline and Performance Level in Non-Elite Athletes after Acute Syndesmotic Injury: A Prospective Randomized Trial

BACKGROUND

Suture button devices for tibiofibular syndesmosis injuries provide semirigid dynamic stabilization. The effect of stabilization procedures on sports discipline and performance level in non-elite athletes after acute syndesmotic injury has not been clarified in sports medicine research to date.

METHODS

A total of 47 of 56 eligible patients were analyzed and completed the 1-year follow-up. The average age was 35.5 years (range, 18-60 years). The screw fixation and knotless suture button groups comprised 26 and 21 patients, respectively. Nine patients were lost to follow-up. Patients underwent clinical and radiological evaluations preoperatively and twice during the 1-year postoperative follow-up. Function was measured using the FADI sports scale, the FAAM sports module, and a visual analogue scale for pain and function in sports. Questionnaires were completed to assess preoperative and postoperative sports levels and to evaluate the sports discipline.

RESULTS

All scores increased during the follow-up, but no significant differences were found in the FADI score, the FAAM sports module score and or the VAS score for pain and function during sport (p ≤ 0.05). Using Spearman's rank correlation coefficient, we found no significant correlation between the groups for age, injury mechanism, or body mass index. Differences were identified in sports discipline and performance level between the groups during the follow-up period.

CONCLUSION

No statistically significant differences could be demonstrated between the two stabilization methods in terms of return to previous sport level and return to the original sport discipline, so both procedures can be regarded as equivalent at present.

Biomechanical comparison of screw, tightrope and novel double endobutton in the treatment of tibiofibular syndesmotic injuries

BACKGROUND

Adequate reduction and stabilization of the syndesmosis are significant to prevent early degeneration of the ankle joint and get better clinical outcomes. However, the routine surgical methods have diffierent limitations. The purpose of this study was to develop a novel double Endobutton fixation to treat the distal tibiofibular syndesmotic injuries, and determine whether the novel double Endobutton fixation demonstrates a better biomechanical property compare with the intact syndesmosis, the screw fixation and the Tightrope fixation.

METHODS

Twenty-four normal fresh-frozen ankle specimens with a mean age of 42 ± 8 (range, 28-62) years were randomly divided equally into four groups: (1) the intact group, (2) the screw group, (3) the Tightrope group, (4) the Endobutton group. 3D printer technology was used to establish the personalized distal tibiofibular syndesmotic navigation modules to determine the accurate bone tunnel. Axial loading was applied in five ankle positions: neutral position, dorsiflexion, plantar flexion, varus and valgus. Rotation torque was applied in two ankle rotation of the neutral position: internal and external.

RESULTS

In most situations, the displacements of the intact group were larger than the screw group, the Tightrope group and the Endobutton group (P < .05), and the displacements of the screw group were smaller than other three groups (P < .05). The displacements of the double Endobutton group were slightly larger than the Tightrope group but no significant differences were found between these two groups except in the dorsiflexion position of axial loading experiments (P < .05). The novel double Endobutton fixation was steadier than intact syndesmosis and more micromotional than screw fixation.

CONCLUSION

Our study demonstrated that the novel double Endobutton can be considered as the better fixation in treatment of distal tibiofibular syndesmotic injuries.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison between cotton test and tap test for the assessment of coronal syndesmotic instability: A cadaveric study

INTRODUCTION

In surgically treated rotational malleolar fractures, residual syndesmotic instability is typically assessed following fixation with the widely used intraoperative Cotton test. However, due to its dynamic nature, there are inconsistencies of the magnitude and direction of the distraction force when attempting to pull the fibula away from the tibia using a bone hook. The novel Tap test advances a cortical tap through a drilled hole in the fibula with a stable, unidirectional distraction force applied to the tibia. The objective of this cadaveric study was to compare the Cotton and Tap tests as diagnostic tools for coronal plane syndesmotic instability.

METHODS

Tibiofibular Clear Space (TFCS) of 10 cadaveric specimens was measured for: intact, non-stressed; intact, stressed; injured, non-stressed; and injured, stressed (Tap and Cotton tests). In injured conditions, the syndesmotic ligamentous complex was sectioned using an anterolateral longitudinal approach. Perfect fluoroscopic Mortise images were acquired for all conditions. Two independent and blinded Orthopaedic Foot and Ankle Surgeons measured TFCS 1 cm proximal to the ankle joint line. Intra and interobserver reliabilities were assessed by Intraclass Correlation Coefficient. Syndesmotic TFCS values for all conditions were compared by paired Wilcoxon. Diagnostic performance of the Cotton and Tap tests was assessed using a relative increase of TFCS > 2 mm when comparing intact stressed and injured stressed conditions. P-values <0.05 were considered significant.

RESULTS

The intraclass correlation coefficient for intraobserver and interobserver reliability was respectively 0.96 and 0.79. TFCS measurements were similar in intact non-stressed, intact stressed (both Cotton and Tap tests) and injured non-stressed conditions, with mean values and 95% Confidence Intervals of: intact non-stressed, 3.5 mm; intact stressed, 3.6 mm (Cotton test) and 4.0 mm (Tap test); injured non-stressed, 3.8 mm. The Cotton test and Tap test had, respectively, 73.3% and 70% sensitivity, 100% and 90% specificity, 86.7% and 80% diagnostic accuracy.

CONCLUSIONS

Our cadaveric study compared the Cotton and Tap tests for detection of coronal plane syndesmotic instability. Both tests demonstrated similar increases in the TFCS measurements in stressed injured conditions when compared to intact non-stressed and stressed conditions, as well as injured non-stressed conditions.

Comparison of Suture-Button Versus Syndesmotic Screw in the Treatment of Distal Tibiofibular Syndesmosis Injury: A Meta-analysis

Traditionally screw fixation is an effective surgical procedure for the treatment of unstable syndesmosis injuries. However, it is still a controversy whether suture-button (SB) device can achieve better clinical outcomes and decrease the risk of complications compared with syndesmotic screw (SS). The present meta-analysis was conducted to figure out whether SB fixation was superior to traditionally screw fixation. Twelve clinical studies were identified, involving 320 patients in the SB group and 334 patients in the SS group. Among patients treated with SB, the American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher at 3-month follow-up (p = .01) and 2-year follow-up (p = .02), and the Olerud-Molander Ankle (OMA) score at 1-year follow-up (p = .002). In addition, the SB group had significantly better results in the malreduction (p = .0008), implant failure (p < .01), implant removal (p < .01), and local irritation (p = .004). No statistical differences were found in the AOFAS at 6 months follow-up (p = .33) and 1-year follow-up (p = .33), OMA at 3 months follow-up (p = .09), 6 months follow-up (p = .14) and 2 years follow-up (p = .36), the Foot and Ankle Disability Index (p = .73), Euro Qol 5-dimension questionnaire (p = .33), dorsiflexion (DF; p = .91), plantarflexion (p = .23), medial clear space (p = .42), tibiofibular clear space (p = .60), tibiofibular overlap (p = .84), and other complications (p = .95). Based on this meta-analysis, there was no significant difference in postoperative radiological measurements, and no sufficient evidence was found to support the improved clinical outcomes compared with SS fixation group. However, SB technique could improve functional outcomes, reduce the rate of implant removal, implant failure, local irritation, and malreduction without increasing risk of other complications. Therefore, the SB technique should be recommended in the treatment of syndesmosis injuries.

APKASS Consensus Statement on Chronic Syndesmosis Injury, Part 3: Fusion Techniques, Comorbidity Treatments, Postoperative Rehabilitation, and Return-to-Sport Indications

Background:

Questions regarding surgical fusion techniques, postoperative treatment, and indications for return to sport after chronic syndesmosis injury or its comorbidities remain unanswered.

Purpose:

An international group of experts representing the field of injuries in the foot and ankle area was invited to collaboratively advance toward consensus opinions based on the best available evidence regarding chronic syndesmosis injury. All were members of the Asia-Pacific Knee, Arthroscopy and Sports Medicine Society (APKASS).

Study Design:

Consensus statement.

Methods:

From November to December 2020, a total of 111 international experts on sports medicine or ankle surgery participated in a 2-stage Delphi process that included an anonymous online survey and an online meeting. A total of 13 items with 38 statements were drafted by 13 core authors. Of these, 4 items with 6 clinical questions and statements were related to surgical fusion techniques, comorbidity treatments, postoperative rehabilitation, and return-to-sports indications and are presented here. Each statement was individually presented and discussed, followed by a general vote. The strength of consensus was characterized as follows: consensus, 51% to 74%; strong consensus, 75% to 99%; and unanimous, 100%.

Results:

Of the 6 questions and statements, 5 achieved unanimous support and 1 reached strong consensus.

Conclusion:

This APKASS consensus statement, developed by international experts in the field, will assist surgeons and physical therapists with surgical and postoperative treatment strategies for chronic syndesmosis injury.

Implications of the Overlapping Degree Between Proximal Fibula and Tibia for Placing the Optimal Syndesmotic Screw: A Virtual Cadaveric Study

BACKGROUND

To determine the optimal direction of the syndesmotic screw and to introduce a consistent landmark for practical application by analyzing three-dimensional (3D) modeling and virtual implantation.

METHODS

A total of 105 cadaveric lower legs (50 males and 55 females; average height, 160.6 ± 7.1 cm) were used to reconstruct a 3D model by using the Mimics® software and the joint morphology was evaluated. Syndesmotic cylinders (Ø3.5 mm/Length 100 mm) were transversely placed in the proximal end of the incisura fibularis for simulating screw fixation. The tibial proximal cylinder, which was tangent to the posterior tibial condyles, was traced and the angle between the two cylinders was measured as the tibial torsion angle (TTA). After rotating the syndesmotic cylinder parallel to the ground, the overlapping degree between the proximal fibula and tibia was assessed as a radiologic indicator.

RESULTS

Concerning tibial torsion, the TTA was an average of 36.7° (range, 17.2°-54.4°; SD, 8.78) When the syndesmotic cylinder was rotated to be parallel to the ground, the proximal fibula had nonlinear or linear overlap with the lateral border of the tibia, regardless of the joint morphology. In this non-overlapping view, three Weber's indices for normal fibular length could be better visualized than the mortise view.

CONCLUSION

The syndesmotic cylinder in the proximal end of the incisura fibularis could be consistently placed parallel to the ground by internally rotating the tibia until there was a nonlinear or linear overlap between the proximal fibula and the tibia, regardless of the joint morphology.

Anatomical Study of the Interosseous Ligament of the Tibiofibular Syndesmosis: An Analysis of Osseous Morphology and Attaching Interposing Structures

BACKGROUND

The morphological features of the interosseous tibiofibular area in relation to the tensile stress of the interosseous ligament (IOL) have rarely been discussed. The purpose of the present study was to investigate the IOL on the basis of osseous surface morphology and macroscopic and histological anatomy. We hypothesized that the osseous surface of the interosseous tibiofibular area has a specific feature corresponding to the fibrous structure in the IOL.

METHODS

Eighteen ankles from 15 cadavers were analyzed. Micro-computed tomography (micro-CT) images were obtained for all specimens to observe the osseous surface in the syndesmosis and to visualize the distribution of cortical bone thickness. Fifteen ankles were macroscopically analyzed, and the other 3 ankles were histologically analyzed.

RESULTS

Micro-CT imaging revealed the osseous prominence on the medial side of the fibula. Cortical thickness mapping showed that the thickness of the cortical bone on the medial side of the fibula proximal to the prominence (mean and standard deviation, 1.4 ± 0.5 mm; p < 0.001) was greater in comparison with the other quadrants, namely, the proximal part of the tibia (0.8 ± 0.2), distal part of the fibula (0.7 ± 0.2), and distal part of the tibia (0.5 ± 0.1). Macroscopic analysis indicated that the perforating branch of the fibular artery ran through the proximal top of the IOL, which formed a thickened fiber and was attached to the fibular prominence. Histological analysis revealed that the thickened fibrous part of the IOL attached to the fibula via the fibrocartilaginous insertion. At the middle of the IOL, thin and fatty-like tissue was interposed between the tibia and the fibula.

CONCLUSIONS

We observed that the osseous prominence of the fibula corresponded to the proximal thickened part of the IOL via the fibrocartilaginous attachment. The thickened proximal part of the IOL was consistently found in this location; we believe that this finding was related to the fact that the fibular artery perforated the adjacent distal part of the interosseous membrane (IOM).

CLINICAL RELEVANCE

The location of the prominence on the medial aspect of the fibula could be a helpful clue as to the ideal location of syndesmotic fixation.

A meta-analysis comparing the outcomes of syndesmotic injury treated with metal screw, dynamic fixation, and bioabsorbable screw

Background

Currently there is significant controversy regarding which fixation method is most effective for the treatment of syndesmotic ankle injuries.

Objective

This meta-analysis was designed to compare the metal screw, dynamic, and bioabsorbable screw fixation methods for treatment of syndesmotic ankle injuries.

Methods

An online search for RCT and prospective/retrospective clinical comparison studies between January 1998 and December 2018 on syndesmotic fixation was conducted. The main parameters collected include functional scores, mean time to full weightbearing, postoperative tibiofibular clear spaces, tibiofibular overlap, medial clear spaces, and complication rates. Statistical analysis was conducted using One Way ANOVAs and Chi-Squared tests using Review Manager and Excel.

Results

A total of 18 comparison studies, with 509 patients in the metal screw fixation group, 275 in the dynamic fixation group, and 226 in the bioabsorbable screw fixation group, were included in this meta-analysis. For the metal screw group, dynamic fixation group, and bioabsorbable screw group, the mean AOFAS score were 83.8, 87.2, and 84.3 (p < 0.05), the mean time to full weightbearing were 9.0 weeks, 7.2 weeks, and 7.7 weeks (p < 0.05), and the complication rates were 0.19, 0.09, and 0.19, respectively (p < 0.05). Similarly, the mean postoperative TFCS were 4.85, 3.87, and 5.70 for the metal screw group, dynamic fixation group, and bioabsorbable screw fixation group, respectively (p < 0.05).

Conclusion

The dynamic fixation group was found to have significantly improved functional scores, lower complication rates, and lower mean time to full weight-bearing than the metal screw and bioabsorbable screw fixation methods.

Level of evidence

Meta-analysis of all relevant Level 1-3 Evidence Comparative Studies.

Screw versus suture button in treatment of syndesmosis instability: Comparison using weightbearing CT scan

BACKGROUND

The superiority of screw or suture button fixation for syndesmotic instability remains debatable. Our aim is to compare radiographic outcomes of screw and suture button fixation of syndesmotic instability using weight bearing CT scan (WBCT).

METHODS

Twenty patients with fixation of unilateral syndesmotic instability were recruited and divided among two groups (screw = 10, suture button = 10). All patients had WBCT of both ankles ≥12 months postoperatively.

RESULTS

In suture button group, injured side measurements were significantly different from normal side for syndesmotic area (P = 0.003), fibular rotation (P = 0.004), anterior difference (P = 0.025) and direct anterior difference (P = 0.035). In screw group, syndesmotic area was the only significantly different measurement (P = 0.006).

CONCLUSION

While both screw and suture button didn't completely restore the syndesmotic area as compared to the contralateral uninjured ankle, external malrotation of the fibula was uniquely associated with suture button fixation.

LEVEL OF EVIDENCE

III Retrospective Cohort Study.

Is there any change in surgeon's attitude to the management of ankle fractures accompanying syndesmotic injury? A nationwide survey

Objectives

This study aims to investigate the attitudes of orthopedic surgeons to the management of ankle fractures accompanied by syndesmotic injury with a nationwide survey.

Patients and methods

In the first step of this descriptive study, an electronic survey was prepared in Google drive and a survey link was sent to the Turk-Ortopedi e-mail group between 09 and 19 January 2019. The orthopedic surgeons and residents were requested to complete the questionnaire. A total of 320 orthopedic surgeons (77%) and residents (23%) participated in the survey. The responses were analyzed statistically. To evaluate the changing attitudes, our results were compared with the surgeon survey studies key worded “syndesmotic injury” in PubMed.

Results

The majority of the participants stated that they used the hook test, external rotation stress test, and fluoroscopy together (47.2%) for the diagnosis of syndesmotic injury during the operation. Of the participants, the majority (93%) reported to use metallic syndesmotic screws, and 59% reported to remove the syndesmotic screw routinely. Young surgeons with five to 10 years of experience preferred intraoperative diagnosis methods compared to surgeons with more than 20 years of experience. Foot and ankle surgeons and sports surgeons reported to allow weight bearing before removal of the screw much more than other unspecified branches.

Conclusion

The preferences of the surgeon vary in syndesmotic injuries and there is still no consensus regarding diagnosis and rehabilitation. Compared to the past decade, fewer surgeons prefer to remove the screws today.