Ankle Syndesmotic Injury

Charalampos Zalavras, MD, PhD

David Thordarson, MD

Dr. Zalavras is Associate Professor,

Department of Orthopaedic Surgery,
Keck School of Medicine, University of
Southern California, Los Angeles, CA.
Dr. Thordarson is Professor and Vice
Chair, Department of Orthopaedic
Surgery, Keck School of Medicine,
University of Southern California.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Zalavras and Dr. Thordarson.
Reprint requests: Dr. Zalavras,
Department of Orthopaedic Surgery,
Keck School of Medicine, University of
Southern California, 2025 Zonal
Avenue, Los Angeles, CA 90089-9312.
J Am Acad Orthop Surg 2007;15:330339
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.

330

Abstract
Ankle syndesmotic injury does not necessarily lead to ankle
instability; however, the coexistence of deltoid ligament injury
critically destabilizes the ankle joint. Syndesmotic injury may
occur in isolation or may be associated with ankle fracture. In the
absence of fracture, physical examination findings suggestive of
injury include ankle tenderness over the anterior aspect of the
syndesmosis and a positive squeeze or external rotation test.
Radiographic findings usually include increased tibiofibular clear
space decreased tibiofibular overlap, and increased medial clear
space. However, syndesmotic injury may not be apparent
radiographically; thus, routine stress testing is necessary for
detecting syndesmotic instability. The goals of management are to
restore and maintain the normal tibiofibular relationship to allow
for healing of the ligamentous structures of the syndesmosis.
Fixation of the syndesmosis is indicated when evidence of a
diastasis is present. This may be detected preoperatively, in the
absence of fracture, or intraoperatively, after rigid fixation of the
medial malleolus and fibula fractures. Failure to diagnose and
stabilize syndesmotic disruption adversely affects outcome.

nkle injuries may involve the

distal tibiofibular syndesmosis
and can be associated with a variable
degree of trauma to the soft-tissue
and/or osseous structures that play
an important role in ankle joint stability. Syndesmotic injury may occur solely as a soft-tissue injury or in
association with ankle fracture.
Even though the injury is common,
however, diagnosis of syndesmotic
injury may not be straightforward,
and optimal management remains
controversial.

Anatomy of the
Syndesmosis
The distal tibiofibular syndesmosis consists of the anterior-inferior
tibiofibular ligament (AITFL), interosseous ligament (IOL), interos-

seous membrane, posterior-inferior

tibiofibular ligament (PITFL), and
inferior transverse ligament (ITL)
(Figure 1).
The AITFL originates from the
anterolateral (Chaputs) tubercle of
the tibia and inserts on the anterior
(Wagstaffes) tubercle of the fibula.
The IOL represents the thickened
distal part of the interosseous membrane. The PITFL originates from
the posterior (Volkmanns) tubercle
of the tibia and inserts to the posterior part of the lateral malleolus. The
fibrocartilaginous ITL forms the distal part of the PITFL.

Mechanism of Injury
The mechanism of syndesmotic injury involves an external rotation
force applied to the foot relative to

Journal of the American Academy of Orthopaedic Surgeons

Charalampos Zalavras, MD, PhD, and David Thordarson, MD

Figure 1

Anterior, posterior, and lateral views of select ligaments of the distal tibiofibular syndesmosis: the anterior-inferior tibiofibular
ligament (AITFL); the posterior-inferior tibiofibular ligament (PITFL), of which the inferior transverse ligament (ITL) is part; and the
interosseous ligament (IOL), which represents the thickened distal part of the interosseous membrane. The arrows indicate the
respective location and point to the cross-sectional view. (Reproduced with permission from Hamilton CC: Traumatic Disorders
of the Ankle. New York, NY: Springer-Verlag, 1984.)

the tibia. The injury may be purely

ligamentous, or there may be associated fracture. Associated fractures
include pronation-external rotation
ankle fracture (Weber type C),
supination-external rotation ankle
fracture (Weber type B), and fracture
of the proximal fibula (Maisonneuve).

Diagnosis
Physical Examination
Diagnosis of syndesmotic injury
is based on careful clinical and radiographic evaluation. In the absence of
fracture, symptoms include ankle
pain and tenderness directly over the
anterior aspect of the syndesmosis,
with minimal tenderness over the
anterior talofibular or calcaneofibular ligaments. The squeeze test and
the external rotation test may be
useful for diagnosing purely ligamentous syndesmotic injuries. In
the squeeze test,1 compression of the
fibula to the tibia above the midpoint of the calf causes separation of
the two bones distally2 and pain at
Volume 15, Number 6, June 2007

the area of the syndesmosis. In the

external rotation test, pain over the
syndesmosis is elicited with external rotation of the foot while the leg
is stabilized with the knee flexed at
90.
Radiographic Evaluation
Radiographic evaluation should
include three views of the ankle joint
(anteroposterior [AP], mortise, lateral) as well as two views of the entire length of the tibia and fibula (AP,
lateral). Radiographs are evaluated
for the presence of ankle fracture and
proximal fibula fracture (Figure 2), as
well as for disruption of the normal
relationship between the distal tibia
and distal fibula, which is indicative
of syndesmotic injury. The following
radiographic parameters have been
proposed as indications of syndesmotic injury: increased tibiofibular
clear space, decreased tibiofibular
overlap, and increased medial clear
space3-5 (Figure 3).
Tibiofibular clear space is the distance between the medial border of
the fibula and the lateral border of

the posterior tibia as it extends into

the incisura fibularis. The tibiofibular clear space is measured 1 cm
proximal to the plafond and should
be <6 mm in both the AP and mortise views3 (Figure 3).
Tibiofibular overlap is the overlap
of the lateral malleolus and the anterior tibial tubercle measured 1 cm
proximal to the plafond. In the AP
view, the overlap should be >6 mm
or >42% of the width of the fibula,
whereas in the mortise view it
should be >1 mm3 (Figure 3).
Medial clear space is the distance
between the lateral border of the medial malleolus and the medial border
of the talus, measured at the level of
the talar dome. In the mortise view
with the ankle in neutral position,
the medial clear space should be
equal to or less than the superior
clear space between the talar dome
and the tibial plafond.5 An increase
in the medial clear space indicates a
deltoid ligament injury.
Increased tibiofibular clear space
is considered the most reliable indicator of syndesmotic injury.3,4 Pneu331

Ankle Syndesmotic Injury

Figure 2

Figure 3

Fracture of the proximal fibula indicative of syndesmotic injury. Anteroposterior

(A) and lateral (B) radiographic evaluation of the entire length of the fibula is
essential to avoid missing a Maisonneuve fracture and the associated syndesmotic
injury.

maticos et al4 demonstrated that the

width of the tibiofibular clear space
does not change significantly within
an arc from 5 of external rotation to
25 of internal rotation and therefore
is not dependent on variations in positioning of the extremity relative to
the x-ray beam. In contrast, tibiofibular overlap and medial clear space
progressively decrease with internal
rotation.
Evidence of syndesmotic injury
may not be apparent on static injury
radiographs. Stress (external rotation)
radiographs may be useful for diagnosing latent syndesmotic injury and
for establishing an indication for surgery. Edwards and DeLee6 used stress
radiographs to diagnose syndesmotic
injuries without fracture and classified ankle diastasis as frank (evident
on initial radiographs) or latent (apparent only on stress radiographs).
The commonly used stress mortise
view shows lateral displacement of
the fibula, whereas a stress lateral
view shows posterior displacement.
Cadaveric studies demonstrate that
332

diastasis of the syndesmosis occurs

primarily with posterior displacement of the fibula relative to the tibia.7,8 In both studies, fibular movement was greater in the sagittal than
in the coronal plane.7,8
Other Diagnostic
Modalities
Advanced techniques for diagnosis of syndesmotic injury include
computed tomography (CT), magnetic resonance imaging (MRI), and
arthroscopy. CT is able to detect minor (2- to 3-mm) syndesmotic diastasis not apparent on plain radiographs.9 MRI is highly sensitive and
specific for the diagnosis of syndesmotic injury.10,11 Oae et al11 evaluated 58 patients with distal fibula
fracture or ankle sprain with preoperative MRI and ankle arthroscopy.
MRI had a sensitivity of 100% and
specificity of 93% for diagnosis of
AITFL rupture, using ankle arthroscopy as the benchmark.11 The clinical significance of these diagnostic
modalities in the evaluation and

Normal syndesmotic relationships

include a tibiofibular clear space
(open arrows) <6 mm in both the
anteroposterior and mortise views, as
well as a tibiofibular overlap (solid
arrows) >6 mm or >42% of the width
of the fibula on the anteroposterior
view, or >1 mm on the mortise view.
The overlap is measured 1 cm proximal
to the plafond. (Reproduced from
Stephen D: Ankle and foot injuries, in
Kellam JF, Fischer TJ, Tornetta P III,
Bosse MJ, Harris MB [eds]:
Orthopaedic Knowledge Update:
Trauma 2. Rosemont, IL: American
Academy of Orthopaedic Surgeons,
2000, p 210.)

management of syndesmotic injury

remains unclear.
Nielson et al12 prospectively evaluated 70 patients with ankle fracture, using MRI to determine the
role of radiographic measurements
in the diagnosis of syndesmosis injury. Increased medial clear space
(>4 mm) correlated with rupture of
the deltoid and tibiofibular ligaments; however, normal tibiofibular
overlap and clear space measurements did not preclude syndesmotic
injury. This finding underscores the
importance of clinical history, physical examination, and intraoperative
stress testing to determine stability
of the syndesmosis.

Journal of the American Academy of Orthopaedic Surgeons

Charalampos Zalavras, MD, PhD, and David Thordarson, MD

Associated Fracture
Location
High fibula fracture has traditionally been associated with syndesmotic disruption. Although such a
fracture should alert the treating surgeon to the potential for ankle mortise instability, not all high fibula
fractures are associated with ankle
syndesmosis instability. A proximal
fibula fracture may occur with an external rotation injury that produces
an incomplete syndesmotic injury
and spares the posterior syndesmosis
and the deep deltoid. In a clinical
study of nine patients with high fibula fractures, eight of whom were
treated nonsurgically, a satisfactory
outcome was achieved in eight
patients at mean follow-up of
26 months.13 A proximal fracture
also may occur from direct trauma
to the lateral side of the leg, causing
a fracture of the fibula without distal
instability.14

Effect of Syndesmotic
Injury on Ankle Stability
Cadaveric experiments have demonstrated that the distal tibiofibular
syndesmosis plays a secondary role
in ankle joint stability, whereas the
deltoid ligament is a primary stabilizer. Boden et al15 transected the
syndesmosis, then sequentially divided the interosseous membrane in
1.5-cm increments in two groups of
cadavers: one with intact medial
structures and one with sectioned
deltoid ligament and anteromedial
capsule. The group with intact medial structures, simulating a rigidly
fixed medial malleolus fracture,
demonstrated minimal widening
of the syndesmosis under load
(1.4 mm), even with sectioning of
the interosseous membrane to
15 cm proximal to the ankle. In contrast, the group with a sectioned deltoid ligament demonstrated progressive widening of the syndesmosis
(from 0.5 to 4.5 mm) with disruption
of the interosseous membrane (from
1.5 to 15 cm proximal to the ankle).
Volume 15, Number 6, June 2007

Sectioning of the interosseous membrane from 3 to 4.5 cm proximal to

the ankle resulted in a large increase
in widening of the syndesmosis
(from 1.0 to 1.7 mm).15
Michelson and Waldman16 reported that a fibular fracture 4 cm proximal to the plafond and syndesmotic disruption up to 6 cm did not alter
coupled motion of the talus in the
absence of deltoid injury. However,
when the deep deltoid was cut, the
ankle dislocated at 20 to 30 of
plantar flexion.16
The posterior tibiofibular ligament is attached to the posterior
malleolar fragment; thus, fracture of
the posterior malleolus indicates
increased instability. The key factor
determining the need for intervention, however, is the status of
the deep deltoid ligament. Therefore, disruption of the distal tibiofibular syndesmosis is not in itself an
important factor for ankle instability; however, the coexistence of deltoid injury critically changes ankle
motion and destabilizes the ankle
joint.
Preoperative stress radiographs
may be beneficial in the diagnosis of
deltoid incompetence in the patient
with an intact medial malleolus. In
the patient with an isolated fibula
fracture, the presence of medial tenderness, ecchymosis, and swelling
has been considered an indicator of
deep deltoid ligament injury and
helps differentiate stable Weber type
B supination-external rotation injury
(which can be managed nonsurgically) from unstable injury (which requires surgical management). Recent
studies have demonstrated that clinical examination cannot accurately
diagnose deltoid injury;17 stress radiographs are encouraged to assess
ankle stability and determine the
need for surgical intervention.18-20

Indications for
Syndesmosis Fixation
Boden et al15 attempted to clarify the
indications for syndesmosis fixation

based on their experimental data.

They suggested that stabilization of
the syndesmosis is unnecessary in a
stable fibula fracture (regardless of
location) associated with a rigidly
fixed medial malleolus fracture, and
in a fixed fibula fracture within 3 to
4.5 cm of the ankle joint in association with a deltoid tear.
These guidelines were evaluated
in a prospective clinical study by
Yamaguchi et al.21 Of 21 patients
with a Weber type C ankle fracture,
only the 3 who sustained a fibula
fracture more than 4.5 cm proximal
to the ankle joint associated with a
deltoid tear underwent syndesmosis
fixation. The remaining 18 patients
did not demonstrate syndesmosis
widening >1 mm at final follow-up
(1 to 3 years). The authors concluded
that syndesmosis fixation is indicated only for a fibula fracture located at least 4.5 cm above the ankle
joint in the presence of a deltoid
ligament tear.21 This recommendation is based on two assumptions:
first, that fixation of a medial malleolar fracture is equivalent to an
intact deltoid, and second, that the
interosseous membrane tear is limited to the level of the fibula fracture.

Fixation of a Medial
Malleolar Fracture
Tornetta20 challenged the notion
that injury to the medial side of the
ankle will involve in a mutually exclusive way either the osseous (medial malleolus fracture) or the ligamentous (deltoid) structures. In
27 patients with bimalleolar fracture, anatomic reduction and internal fixation of the medial malleolus
was done, after which the ankle was
evaluated under stress to assess the
medial clear space and the presence
of talar subluxation. In 26% of fractures (7/27), the stress radiograph
demonstrated medial clear space
>4 mm and talar subluxation
>1 mm, indicating that deltoid incompetence was present in conjunc333

Ankle Syndesmotic Injury

Figure 4

Figure 5

Bimalleolar fracture showing osseous

and ligamentous disruption on the
medial side. (Reproduced with
permission from Tornetta P III:
Competence of the deltoid ligament in
bimalleolar ankle fractures after medial
malleolar fixation. J Bone Joint Surg
Am 2000;82:843-848.)

A, Anteroposterior radiograph demonstrating Weber type B supination-external

rotation ankle fracture associated with disruption of the syndesmosis.
B, Syndesmosis fixation with a single 4.5-mm screw.

tion with fracture of the medial malleolus.20 The size of the medial
malleolar fragment was the most
important variable in predicting deltoid competence. The deltoid ligament was spared in supramalleolar
fractures, whereas the deltoid was
incompetent in fractures of the anterior malleolus (Figure 4).
Injury to the medial side may be a
combination of osseous and ligamentous disruption. Anterior colliculus fracture can be fixed when it is
noncomminuted and large enough
(approximately 1 cm 1 cm) to accommodate a screw, but fixation of
the medial malleolus fracture does
not necessarily restore competence
of the deltoid ligament or stability of
the ankle joint.
Yamaguchi et al,21 however, imply that although stability may not
be completely restored by fixation of
the medial malleolus because of concomitant deltoid injury, the degree
of stability established may be
enough for clinical purposes.
334

Interosseous
Membrane Tear
Nielson et al22 prospectively evaluated the MRI scans of patients with
ankle fracture to assess the integrity
of the interosseous membrane. The
authors found that 30 of 73 ankle
fractures were associated with interosseous membrane tears. In 10 of
these 30 fractures (33%), the level of
the interosseous membrane tear did
not correspond to the level of the
fractured fibula. In 7 of 30 fractures
(23%), the tear extended more proximally than the level of the fibula
fracture.22
The interosseous membrane tear
may extend proximal to the level of
the fibula fracture, and it may not be
possible to judge the stability of the
syndesmosis by the location of the
fibula fracture. A low fibula fracture
(Weber type B) does not exclude the
need for syndesmosis fixation18,23
(Figure 5, A); syndesmotic instability has been described with low fibula fracture. In a recent series of 51

ankle fractures managed with syndesmotic fixation, 15 (30%) were

Weber type B fractures, whereas 36
(70%) were Weber type C fractures.24 This study did not have a
control group, however, so the fact
that syndesmosis screws were used
does not mean that they were necessary for a satisfactory clinical result.

Intraoperative
Assessment
Intraoperative assessment of syndesmotic stability is based on the Cotton test25 and imaging evaluation.
The Cotton test involves placing a
bone hook or key elevator on the fibula and applying a distraction force
in an attempt to separate the fibula
from the tibia. A 3- to 4-mm lateral
shift of the talus indicates syndesmotic instability. Under imaging,
applying external rotation stress on
the ankle joint may demonstrate increased tibiofibular clear space, decreased tibiofibular overlap, and in-

Journal of the American Academy of Orthopaedic Surgeons

Charalampos Zalavras, MD, PhD, and David Thordarson, MD

creased medial clear space. Our

preferred method is to obtain a fluoroscopic external rotation stress
mortise view for evaluating the medial clear space; this view is the easiest to interpret.
A recent study by Jenkinson et
al19 prospectively investigated the
predictive value of the biomechanical criteria for syndesmosis fixation
described by Boden et al.15 The authors compared static preoperative
radiographs with intraoperative fluoroscopic stress testing in external
rotation ankle fractures. Intraoperative fluoroscopy detected syndesmotic instability that was not predicted by biomechanical criteria in
4 of 7 (57%) pronation-external rotation injuries, and in 10 of 30 (33%)
supination-external rotation injuries.19 Overall, unpredicted syndesmotic instability was intraoperatively demonstrated in 37% of fractures.
The degree of instability after rigid
bimalleolar fixation was small
(mean difference, 1.9 mm of tibiofibular clear space between the injured
and the contralateral ankle), and relevance of this residual instability to
adverse clinical outcome was not
demonstrated.19
Routine intraoperative testing is
necessary for detection of syndesmotic instability, and the decision
whether to perform syndesmosis fixation must be individualized to each
patient. In our opinion, fixation of
the syndesmosis is indicated whenever intraoperative evidence of syndesmotic diastasis is present after
rigid fixation of medial malleolus
and fibula fractures. However, the
clinically relevant degree of syndesmotic instability has not been established.

Management
With syndesmotic injury, the goal of
management is to restore and maintain the normal tibiofibular relationship to allow healing of the ligamentous structures of the syndesmosis.
Volume 15, Number 6, June 2007

Syndesmotic Injury Without

Fracture
Syndesmotic injury may occur in
the absence of fracture (syndesmotic or high ankle sprain). Hopkinson
et al1 reported that syndesmotic
sprain accounted for approximately
1% of ankle sprains (15/1,344) sustained by cadets at the United States
Military Academy. Syndesmotic injuries have also been reported in athletes.26,27
Edwards and DeLee6 classified
acute syndesmotic sprain into three
categories: sprain without diastasis,
sprain with frank diastasis (evident
on initial radiographs), and sprain
with latent diastasis (normal initial
radiograph but instability apparent
on stress radiographs).
Syndesmotic sprain usually is not
associated with diastasis or instability. In the absence of syndesmotic diastasis or instability, the patient can
be treated nonsurgically. Nonsurgical management begins with rest,
ice, compression, and elevation.
Subsequently, a nonweight-bearing
cast is used for 2 to 3 weeks, after
which time the patient is allowed to
progressively bear weight as tolerated using a walking boot. In the series
by Hopkinson et al,1 13 of 15 syndesmotic injuries were managed nonsurgically, whereas 2 injuries associated with ankle instability were
treated surgically. The recovery time
for patients with syndesmotic sprain
was considerably longer compared
with patients with severe nonsyndesmotic ankle sprain (55 versus 28
days). In the 10 syndesmotic injuries
evaluated at a mean 20-month
follow-up, no ankle was unstable.
Interosseous calcification was observed in 9 of 10 ankles.1
Syndesmotic sprain occasionally
may be associated with ankle instability. Edwards and DeLee6 reported
on six patients with syndesmotic instability without fracture. Diastasis
was evident on routine radiographs,
and all patients underwent syndesmotic screw fixation. When initial
radiographs are negative and clinical

examination is suggestive of syndesmosis injury, stress radiographs may

be useful for diagnosing a latent diastasis. In the series by Hopkinson et
al,1 one of seven patients with syndesmotic injury demonstrated latent
instability on stress radiographs; this
patient underwent transfixation of
the syndesmosis. Other authors
have proposed nonsurgical management of syndesmotic sprain with
latent diastasis with a nonweightbearing cast for 4 to 6 weeks, provided that anatomic reduction of the
fibula can be achieved and maintained.27
Syndesmotic Injury
Associated With Fracture
Restoration of the proper tibiofibular relationship involves regaining
fibular length and reestablishing correct rotation and position of the fibula relative to the tibia. Accurate
restoration of fibula length, which is
necessary to avoid talar subluxation,
is achieved with open anatomic reduction and stable fixation of the fibula fracture in external-rotation type
ankle fracture. When the fibula fracture is located in the middle or proximal one third of the diaphysis,
length and rotation may be restored
indirectly. Michelson et al28 evaluated 26 ankle fractures on CT. Internal
rotation of the proximal fibula relative to the tibia occurred in 19 of
these fractures. However, a subsequent CT evaluation of externalrotation type ankle fractures showed
internal rotation of the proximal fibula in 1 of 26 ankles and demonstrated that the distal fibular fragment
rotates externally relative to the
proximal fibular fragment.29 As
such, the reverse movement (internal rotation of the distal fibular fragment) should be used to assist reduction of the fibula in the proper
location against the tibia, into the
fibular notch.
When the fibula fracture is treated indirectly, proper length and rotation are assessed by intraoperative
imaging of the involved ankle joint.
335

Ankle Syndesmotic Injury

In the mortise view, attention

should be paid to restoration of the
medial clear space, tibiofibular overlap, and tibiofibular clear space. The
dense subchondral bone of the distal
tibia should be at the same level as a
small spike seen on the fibula, resulting in an unbroken Shentons
line of the ankle.30 The lateral view
should also be evaluated to ensure
the proper position of the fibula relative to the tibia in the sagittal
plane.
Syndesmosis Fixation
The optimal method of syndesmosis fixation remains to be determined. Controversies surround implant selection (ie, size of screws,
number of cortices engaged, composition of implants), position of the
ankle joint during syndesmosis fixation, postoperative weight-bearing
status, and the need and timing for
implant removal.
Screw Size

Both 3.5- and 4.5-mm screws have

been used for syndesmotic fixation.
In a cadaveric study,31 their biomechanical properties were found to be
similar. The larger head of the
4.5-mm screw may facilitate screw
removal in the clinic, but it may
cause patient discomfort (Figure 5, B).
Number of Cortices

Syndesmotic screw fixation may

involve a total of three or four cortices of the fibula and tibia. A cadaveric study using a 4.5-mm screw engaging four cortices demonstrated
decreased tibiotalar external rotation.32 Engaging three cortices may
allow greater physiologic motion,
which more commonly leads to
hardware loosening rather than to
failure.33,34 Engaging four cortices
improves syndesmosis stability, but
it is unclear whether it results in any
difference in clinical outcome.
In a prospective randomized
study, Hoiness and Stromsoe35 compared fixation of the syndesmosis
with two tricortical 3.5-mm screws
336

(n = 34) with fixation with one quadricortical 4.5-mm screw (n = 30). No

differences in pain, ankle dorsiflexion, and function were observed at
1 year. However, in this study, the
number of cortices was not the only
variable of the fixation technique
that differed between groups.
Screw Composition

Metal screws traditionally have

been used for syndesmosis fixation.
However, they require removal to restore the biomechanics of the syndesmosis; when left in place, they
may break or loosen. Bioabsorbable
screws have been proposed as an alternative because they eliminate the
need for removal.36-38 Hydrolysis and
degradation of the bioabsorbable
implant will gradually reduce its
strength39 and lead to failure of the
implant sometime after initiation of
weight bearing, which is believed to
restore normal motion of the syndesmosis.36
Thordarson et al37 compared a
4.5-mm polylactide bioabsorbable
screw with a stainless steel screw of
the same size in a cadaveric model of
syndesmotic injury. No differences
in load to failure and stiffness were
noted between the two groups.
In a subsequent randomized clinical trial, Thordarson et al38 tested
the hypothesis that syndesmosis
fixation with a polylactide screw,
which retains 80% of its tensile
strength at 4 weeks, is equivalent to
stainless screw fixation. Seventeen
patients were randomized to bioabsorbable syndesmotic screw fixation
and 15 to stainless steel screw fixation. At a mean 11-month follow-up,
there was no medial clear space widening or loss of syndesmosis reduction in any patient, and there was no
difference in subjective complaints or
range of motion of the ankle joint between the two groups. Bioabsorbable
screw fixation did not result in osteolysis or inflammatory reactions.38
In a prospective clinical study,
Hovis et al36 evaluated the use of
polylevolactic acid bioabsorbable

screws for fixation of the syndesmosis. None of the 23 patients available

for long-term follow-up (mean,
34 months) demonstrated medial
clear space widening, loss of syndesmosis reduction, osteolysis, or inflammatory reactions. Recent cadaveric40 and clinical studies41 found no
differences between bioabsorbable
and metallic screws.

Surgical Technique
Syndesmotic screws should be inserted parallel to the ankle joint in
the coronal plane. A screw that is
not parallel to the joint may either
shorten or lengthen the fibula. A cadaveric study indicated that placement of a syndesmotic screw at a
distance of 2 cm proximal to the ankle joint resulted in less syndesmotic widening compared with a screw
placed at 3.5 cm proximal to the
joint.42 A clinical study, however,
found no difference in outcome in
patients who had a syndesmotic
screw placed 2 cm proximal to the
joint versus 3 to 5 cm proximal.43 In
the transverse plane, the screw
should follow a 25 to 30 oblique direction from posterolateral to anteromedial because the fibula is located posterior to the tibia (Figure 6).
The screw that is not directed anteriorly may miss the tibia.
During syndesmotic screw insertion, reduction should be held with
a clamp to avoid shifting of the drill
holes. Each screw should be fully
threaded and not inserted in lag fashion. The drill should be centered on
the fibula to avoid fracturing the
bone.
It has been proposed that the ankle joint should be in a position of
maximum dorsiflexion during screw
insertion. This recommendation is
based on the anatomy of the talar
dome, which is trapezoidal in shape,
with the posterior part of the talus
2.5 mm narrower than the anterior
part. This anatomic fact creates the
concern that syndesmotic screw fixation with the ankle in plantar flex-

Journal of the American Academy of Orthopaedic Surgeons

Charalampos Zalavras, MD, PhD, and David Thordarson, MD

ion may limit dorsiflexion, since the

wider anterior part of the talar dome
must be accommodated in the mortise, which may lead to overtightening of the syndesmosis, with adverse
mechanical consequences.32
However, Tornetta et al44 demonstrated in a cadaveric study that syndesmotic compression with the ankle in plantar flexion does not limit
dorsiflexion and maximal dorsiflexion of the ankle during fixation of
the syndesmosis is not necessary to
avoid loss of dorsiflexion. This observation may facilitate management because dorsiflexion recreates
the deforming force of external rotation and may contribute to malreduction of an unstable syndesmosis.
In this study, however, the authors
used an unloaded method of testing
to assess resultant range of motion;44
thus, the optimal position of the ankle during screw insertion remains
controversial.
In the presence of a bony avulsion
of the insertion of a syndesmotic ligament, open reduction and internal
fixation with a screw can be performed, provided the bony fragment
is large enough. This bony fragment
will most commonly be the bony insertion of the AITFL on the tibia (ie,
Chaputs tubercle). With good fixation, syndesmotic transfixation may
not be necessary.

Authors Preferred
Method
We use one syndesmotic screw
when simultaneously fixing an associated fibula fracture. For the middle
or proximal shaft fibula fracture that
is not stabilized, we prefer to use
two syndesmotic screws (Figure 7).
The degree of instability and the size
of the fibula should be considered
when selecting screw size and determining the number of cortices to be
engaged. In the presence of minimal
instability and in a fibula of small
size, we use a 3.5-mm screw, engaging three cortices. We prefer a
4.5-mm screw through four cortices
Volume 15, Number 6, June 2007

Figure 6

Proper placement of a syndesmotic

screw. In the transverse plane, the
screw should follow a 25 to 30
oblique direction from posterolateral to
anteromedial. (Reproduced with
permission from Carr J: Malleolar
fractures and soft tissue injuries of the
ankle, in Browner BD, Jupiter JB,
Levine AM, Trafton PG [eds]: Skeletal
Trauma, ed 3. Philadelphia, PA: WB
Saunders, 2003, vol 2, p 2309.)

in the presence of increased instability in the fibula of larger dimensions.

We currently use metallic screws because of difficulty in acquiring bioabsorbable ones.

Postoperative
Management
Controversy exists regarding postoperative weight-bearing status and the
need for screw removal. A commonly used postoperative regimen
includes no weight bearing until
screw removal, at a minimum of
12 weeks, to allow enough time for
healing of the disrupted syndesmotic
ligaments. Recurrence of syndesmotic diastasis following early screw
removal has been described.9,45
Alternatively, weight bearing can
be initiated with the syndesmotic
screw(s) in place. In such instances,
the patient should be warned that
screw loosening and/or breakage may
occur.
We prefer to keep the patient non
weight-bearing for 6 weeks, after
which the patient begins weight
bearing in a short leg walking cast for
2 weeks, followed by use of a soft ankle brace for 4 weeks. At 12 weeks,
we remove the syndesmotic screws.

Figure 7

Syndesmosis fixation with two screws

in the presence of a proximal third
(Maissonneuve) fracture of the fibula
that was not stabilized.

Outcomes
Failure to diagnose and stabilize syndesmotic disruption adversely affects outcome.24,46-49 Pettrone et al48
evaluated subjective patient response, objective clinical outcome,
and radiographic results of 146 ankle
fractures with a minimum 1-year
follow-up using a scoring system
ranging from 0 to 12 points (12 being
the best possible outcome). The authors reported that preoperative syndesmotic instability (demonstrated
by abnormal tibiofibular overlap or
clear space on AP radiograph) was
not a predictive indicator of the final
result. Patients with syndesmotic
instability evident on injury radiographs had a score of 8.38, compared
with 8.96 in patients with stable
syndesmosis. The difference was not
significant. However, postoperative
syndesmotic instability significantly compromised the final outcome
(8.11 versus 8.96 points, P = 0.03).48
Leeds and Ehrlich47 studied the
results of 34 ankle fractures at a
mean 4-year follow-up and conclud337

Ankle Syndesmotic Injury

ed that adequate reduction of the

syndesmosis had a marked effect on
the clinical outcome and incidence
of ankle arthrosis. Chissell and
Jones49 reviewed 43 Weber type C
ankle fractures at a mean 4.5-year
follow-up. Nonanatomic reduction
of the syndesmosis was present in
44% of patients with fair or poor
outcome (7/16), compared with 22%
of patients with excellent or good
outcome (5/23).49
Weening and Bhandari24 reviewed
the functional outcome of 39 patients with syndesmotic screw fixation at a mean 18-month follow-up.
Overall, patients achieved functional status similar to that of US population norms, as assessed by the
functional index of the Short Musculoskeletal Functional Assessment
questionnaire (range, 0-100, with 0
as the best score). Reduction of the
syndesmosis was the only significant predictive factor for functional
outcome. Patients with a reduced
syndesmosis had a mean score of
10.2 versus a score of 17 in patients
with a nonreduced syndesmosis (P =
0.04).24 Associated ankle dislocation
showed a trend toward decreased
function. Patient age, number of cortices, presence of medial malleolar
fracture, and screw removal were
not significantly associated with
functional outcome.

Summary
Injury to the distal tibiofibular syndesmosis occurs secondary to an external rotation force and may be associated with ankle fracture. The
concomitant presence of deltoid injury is an important factor leading to
instability of the ankle joint. Radiographs may demonstrate signs of
syndesmotic injury, such as increased tibiofibular clear space, decreased tibiofibular overlap, and
increased medial clear space. However, the diagnosis may not be
straightforward.
Preoperative determination of the
need for syndesmosis fixation based
338

on predetermined criteria may not

be accurate. Routine intraoperative
stress testing is recommended for
detection of syndesmotic instability.
Intraoperative evidence of syndesmotic diastasis after rigid fixation of
the medial malleolus and fibula fractures warrants syndesmosis fixation.
The proper tibiofibular relationship
should be restored and maintained
by screw fixation until healing of the
syndesmotic ligaments is achieved.
Satisfactory clinical outcome is
associated with adequate reduction
and stabilization of the syndesmosis.
Controversies still surround the size
of screws, number of cortices engaged, composition of implants, the
position of the ankle joint during
syndesmosis fixation, postoperative
weight-bearing status, and the need
for and timing of implant removal.
Overall, there is no evidence strongly supporting one technique over the
other, which may mean that each
technique can be effective when applied properly.

5.

6.

7.

8.

9.

10.

11.

References
Evidence-based Medicine: Level I/II
prospective randomized studies are
noted in references 21, 35, 38, and
47. The remaining references are level III/IV case-control, cohort studies
or expert opinion (references 25-27,
and 34).
Citation numbers printed in bold
type indicate references published
within the past 5 years.

12.

13.

14.

15.
1.

Hopkinson WJ, St Pierre P, Ryan JB,

Wheeler JH: Syndesmosis sprains of
the ankle. Foot Ankle 1990;10:325330.
2. Teitz CC, Harrington RM: A biochemical analysis of the squeeze test
for sprains of the syndesmotic ligaments of the ankle. Foot Ankle Int
1998;19:489-492.
3. Harper MC, Keller TS: A radiographic
evaluation of the tibiofibular syndesmosis. Foot Ankle 1989;10:156-160.
4. Pneumaticos SG, Noble PC, Chatziioannou SN, Trevino SG: The effects of
rotation on radiographic evaluation of
the tibiofibular syndesmosis. Foot

16.

17.

18.

Ankle Int 2002;23:107-111.

Beumer A, van Hemert WL, Niesing
R, et al: Radiographic measurement of
the distal tibiofibular syndesmosis
has limited use. Clin Orthop Relat
Res 2004;423:227-234.
Edwards GS Jr, DeLee JC: Ankle diastasis without fracture. Foot Ankle
1984;4:305-312.
Xenos JS, Hopkinson WJ, Mulligan
ME, Olson EJ, Popovic NA: The tibiofibular syndesmosis: Evaluation of
the ligamentous structures, methods
of fixation, and radiographic assessment. J Bone Joint Surg Am 1995;77:
847-856.
Candal-Couto JJ, Burrow D, Bromage
S, Briggs PJ: Instability of the tibiofibular syndesmosis: Have we been
pulling in the wrong direction?
Injury 2004;35:814-818.
Ebraheim NA, Lu J, Yang H, Mekhail
AO, Yeasting RA: Radiographic and
CT evaluation of tibiofibular syndesmotic diastasis: A cadaver study.
Foot Ankle Int 1997;18:693-698.
Vogl TJ, Hochmuth K, Diebold T, et
al: Magnetic resonance imaging in the
diagnosis of acute injured distal tibiofibular syndesmosis. Invest Radiol
1997;32:401-409.
Oae K, Takao M, Naito K, et al: Injury
of the tibiofibular syndesmosis: Value
of MR imaging for diagnosis. Radiology 2003;227:155-161.
Nielson JH, Gardner MJ, Peterson
MG, et al: Radiographic measurements do not predict syndesmotic injury in ankle fractures: An MRI study.
Clin Orthop Relat Res 2005;436:216221.
Merrill KD: The Maisonneuve fracture of the fibula. Clin Orthop Relat
Res 1993;287:218-223.
Harris IA, Jones HP: The fate of the
syndesmosis in type C ankle fractures: A cadaveric study. Injury 1997;
28:275-277.
Boden SD, Labropoulos PA, McCowin
P, Lestini WF, Hurwitz SR: Mechanical considerations for the syndesmosis screw: A cadaver study. J Bone
Joint Surg Am 1989;71:1548-1555.
Michelson JD, Waldman B: An axially
loaded model of the ankle after pronation external rotation injury. Clin
Orthop Relat Res 1996;328:285-293.
McConnell T, Creevy W, Tornetta P
III: Stress examination of supination
external rotation-type fibular fractures. J Bone Joint Surg Am 2004;86:
2171-2178.
Ebraheim NA, Elgafy H, Padanilam T:
Syndesmotic disruption in low fibular
fractures associated with deltoid liga-

Journal of the American Academy of Orthopaedic Surgeons

Charalampos Zalavras, MD, PhD, and David Thordarson, MD

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

ment injury. Clin Orthop Relat Res

2003;409:260-267.
Jenkinson RJ, Sanders DW, Macleod
MD, Domonkos A, Lydestadt J: Intraoperative diagnosis of syndesmosis
injuries in external rotation ankle
fractures. J Orthop Trauma 2005;19:
604-609.
Tornetta P III: Competence of the deltoid ligament in bimalleolar ankle
fractures after medial malleolar fixation. J Bone Joint Surg Am 2000;82:
843-848.
Yamaguchi K, Martin CH, Boden SD,
Labropoulos PA: Operative treatment
of syndesmotic disruptions without
use of a syndesmotic screw: A prospective clinical study. Foot Ankle
Int 1994;15:407-414.
Nielson JH, Sallis JG, Potter HG,
Helfet DL, Lorich DG: Correlation of
interosseous membrane tears to the
level of the fibular fracture. J Orthop
Trauma 2004;18:68-74.
Snedden MH, Shea JP: Diastasis with
low distal fibula fractures: An anatomic rationale. Clin Orthop Relat
Res 2001;382:197-205.
Weening B, Bhandari M: Predictors of
functional outcome following transsyndesmotic screw fixation of ankle
fractures. J Orthop Trauma 2005;19:
102-108.
Cotton F: The ankle and foot, in: Dislocations and Joint Fractures. Philadelphia, PA: WB Saunders, 1910, pp
535-588.
Boytim MJ, Fischer DA, Neumann L:
Syndesmotic ankle sprains. Am J
Sports Med 1991;19:294-298.
Clanton TO, Paul P: Syndesmosis injuries in athletes. Foot Ankle Clin
2002;7:529-549.
Michelson JD, Magid D, Ney DR,
Fishman EK: Examination of the
pathologic anatomy of ankle fractures. J Trauma 1992;32:65-70.
Tang CW, Roidis N, Vaishnav S, Patel
A, Thordarson DB: Position of the distal fibular fragment in pronation and
supination ankle fractures: A CT eval-

Volume 15, Number 6, June 2007

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

uation. Foot Ankle Int 2003;24:561566.

Weber BG: Lengthening osteotomy of
the fibula to correct a widened mortice of the ankle after fracture. Int
Orthop 1981;4:289-293.
Thompson MC, Gesink DS: Biomechanical comparison of syndesmosis
fixation with 3.5- and 4.5-millimeter
stainless steel screws. Foot Ankle Int
2000;21:736-741.
Needleman RL, Skrade DA, Stiehl JB:
Effect of the syndesmotic screw on ankle motion. Foot Ankle 1989;10:1724.
Heim D, Heim U, Regazzoni P: Malleolar fractures with ankle joint instabilityexperience with the positioning screw [German]. Unfallchirurgie
1993;19:307-312.
Marsh JL, Saltzman CL: Ankle fractures, in Bucholz RW, Heckman JD
(eds): Rockwood and Greens Fractures in Adults, ed 5. Philadelphia,
PA: Lippincott Williams and Wilkins,
2001, vol 2, pp 2001-2090.
Hoiness P, Stromsoe K: Tricortical
versus quadricortical syndesmosis
fixation in ankle fractures: A prospective, randomized study comparing
two methods of syndesmosis fixation.
J Orthop Trauma 2004;18:331-337.
Hovis WD, Kaiser BW, Watson JT,
Bucholz RW: Treatment of syndesmotic disruptions of the ankle with
bioabsorbable screw fixation. J Bone
Joint Surg Am 2002;84:26-31.
Thordarson DB, Hedman TP, Gross
D, Magre G: Biomechanical evaluation of polylactide absorbable screws
used for syndesmosis injury repair.
Foot Ankle Int 1997;18:622-627.
Thordarson DB, Samuelson M, Shepherd LE, Merkle PF, Lee J: Bioabsorbable versus stainless steel screw
fixation of the syndesmosis in
pronation-lateral rotation ankle fractures: A prospective randomized trial.
Foot Ankle Int 2001;22:335-338.
Rokkanen PU: Absorbable materials
in orthopaedic surgery. Ann Med
1991;23:109-115.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

Cox S, Mukherjee DP, Ogden AL, et

al: Distal tibiofibular syndesmosis
fixation: A cadaveric, simulated fracture stabilization study comparing
bioabsorbable and metallic single
screw fixation. J Foot Ankle Surg
2005;44:144-151.
Kaukonen JP, Lamberg T, Korkala O,
Pajarinen J: Fixation of syndesmotic
ruptures in 38 patients with a malleolar fracture: A randomized study
comparing a metallic and a bioabsorbable screw. J Orthop Trauma 2005;
19:392-395.
McBryde A, Chiasson B, Wilhelm A,
Donovan F, Ray T, Bacilla P: Syndesmotic screw placement: A biomechanical analysis. Foot Ankle Int
1997;18:262-266.
Kukreti S, Faraj A, Miles JN: Does position of syndesmotic screw affect
functional and radiological outcome
in ankle fractures? Injury 2005;36:
1121-1124.
Tornetta P III, Spoo JE, Reynolds FA,
Lee C: Overtightening of the ankle
syndesmosis: Is it really possible?
J Bone Joint Surg Am 2001;83:489492.
Reckling FW, McNamara GR,
DeSmet AA: Problems in the diagnosis and treatment of ankle injuries.
J Trauma 1981;21:943-950.
Joy G, Patzakis MJ, Harvey JP Jr: Precise evaluation of the reduction of severe ankle fractures. J Bone Joint
Surg Am 1974;56:979-993.
Leeds HC, Ehrlich MG: Instability of
the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle
fractures. J Bone Joint Surg Am 1984;
66:490-503.
Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB: Quantitative
criteria for prediction of the results after displaced fracture of the ankle.
J Bone Joint Surg Am 1983;65:667677.
Chissell HR, Jones J: The influence of
a diastasis screw on the outcome of
Weber type-C ankle fractures. J Bone
Joint Surg Br 1995;77:435-438.

339