Syndesmosis Injuries and Surgical Intervention by Bill Kelly APA Physiotherapist

Understanding Syndesmotic Injuries

Syndesmosis injuries—commonly referred to as high ankle sprains—involve damage to the ligaments connecting the distal tibia and fibula. These ligaments, including the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), and the interosseous membrane, are critical for ankle stability. Injury usually occurs through external rotation or hyper-dorsiflexion mechanisms, particularly in pivoting sports. Such injuries are clinically significant because they often lead to prolonged disability and delayed return to play compared to lateral ankle sprains (Hunt & Wallace, 2022). Early diagnosis is crucial, as untreated injuries may progress to chronic instability, altered biomechanics, and even degenerative joint disease.

Indications for Surgical Intervention

Conservative management is typically appropriate for stable, low-grade (Grade I) injuries. However, unstable injuries, especially Grade III or unstable Grade II, usually require surgical stabilization. The presence of an associated ankle fracture—such as in Maisonneuve injuries—also represents a strong indication for surgery (Parlamas et al., 2013; Shen et al., 2024). Imaging tools such as MRI and weight-bearing CT have improved the ability to accurately identify syndesmotic instability and guide decision-making (Hunt & Wallace, 2022).

Surgical Techniques and Fixation Methods

Static fixation using screws has been the traditional gold standard. Screws provide rigid stabilisation but can limit physiologic motion of the syndesmosis and frequently require later removal due to complications such as loosening or breakage (Shen et al., 2024). More recently, dynamic fixation with suture-button devices has gained popularity. These implants allow micromotion, better mimic natural biomechanics, and may lead to superior functional outcomes with fewer hardware-related problems (Shen et al., 2024; Journal of Clinical Orthopaedics & Trauma, 2024). Nevertheless, some variability exists in outcomes, and surgeon preference continues to play a major role in fixation choice.

Outcomes of Surgical Management

Evidence suggests that patients undergoing surgical stabilisation of unstable syndesmosis injuries can achieve good to excellent outcomes. Dynamic fixation has been associated with earlier weight-bearing, lower reoperation rates, and improved patient-reported scores compared to screws in several studies, though some meta-analyses show no clear superiority (Shen et al., 2024). Among professional athletes, return to play following surgical management is possible, with one large series showing successful return in over 80% of cases after isolated unstable injuries (D’Hooghe et al., 2020). For chronic syndesmotic instability, a systematic review demonstrated that various surgical strategies—including screw fixation, arthrodesis, and arthroscopic debridement—achieved high rates of success, with screw fixation performing particularly well (Parlamas et al., 2013).

Conclusion

Syndesmosis injuries represent a complex spectrum of ankle trauma with significant implications for long-term function. While stable cases may be managed conservatively, surgical intervention is essential for unstable injuries or those associated with fractures. Both screw fixation and suture-button devices remain widely used, and the choice should be individualised according to injury characteristics and surgeon experience. Ongoing research is needed to refine surgical techniques and identify which fixation method offers the best long-term outcomes.

References

  • D’Hooghe, P., Grassi, A., Alkhelaifi, K., et al. (2020) ‘Return to play after surgery for isolated unstable syndesmotic ankle injuries (West Point grade IIB and III) in 110 male professional football players: a retrospective cohort study’, British Journal of Sports Medicine, 54(19), pp. 1168–73.

  • Hunt, K.J. and Wallace, S.B. (2022) ‘Syndesmosis Injuries: Surgical Indications, Techniques, and Outcomes’, in D’Hooghe, P., Hunt, K.J. and McCormick, J.J. (eds.) Ligamentous Injuries of the Foot and Ankle. Cham: Springer. pp. 147–157.

  • Parlamas, G., Hannon, C.P., Murawski, C.D., et al. (2013) ‘Treatment of chronic syndesmotic injury: a systematic review and meta-analysis’, Knee Surgery, Sports Traumatology, Arthroscopy, 21, pp. 1931–1939.

  • Shen, W., Tian, D., Xue, Y., et al. (2024) ‘Efficacy and safety of different fixation methods for acute syndesmosis injuries: protocol for a network meta-analysis of randomised and observational studies’, BMJ Open, 15(8), e092184.

  • Journal of Clinical Orthopaedics & Trauma (2024) ‘Current evidence on management’, Journal of Clinical Orthopaedics & Trauma.

Stuart McKayComment