➢ Ankle syndesmotic injuries are common with or without malleolar ankle fractures.
➢ The ankle syndesmosis is made of the anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, inferior transverse ligament, and interosseous ligament.
➢ Normal syndesmosis widening can be up to 1.5 mm.
➢ The syndesmosis helps to prevent excessive fibular motion during locomotion.
➢ Clinical examinations to diagnose a syndesmotic injury are inaccurate.
➢ Initial injury and intraoperative stress radiographs help to confirm the diagnosis.
➢ Effective treatment requires accurate reduction and stable fixation allowing syndesmotic ankle ligament healing, limited syndesmotic motion, and restoration of stable ankle mechanics.
➢ Nonoperative treatment for isolated syndesmotic injury is appropriate in a majority of cases.
➢ Screw or suture-button methods of stabilization are similar in results and outcome.
➢ Optimal screw size, length, and position have not been fully elucidated.
➢ Timing of weight-bearing is controversial.
➢ Timing and option of fixation removal are controversial.
Ankle injuries involving the tibiofibular syndesmosis can result from various mechanisms of trauma. Varying levels of soft-tissue injury can result in syndesmotic compromise. Prior studies have found that up to 40% of all athletic injuries are ankle sprains1-3 and it was estimated that 5% to 10% of those, with the prevalence climbing to 35% in collision sports4,5, involved disruption of the tibiofibular syndesmosis6,7. The prevalence of syndesmotic injury has been estimated at 23% of all ankles with fractures6, with disruption prevalences as high as 39% to 45% of ankles with operatively treated lateral malleolar fractures8,9.
Despite being a relatively common injury, much debate remains regarding the definitive fixation of the disrupted tibiofibular syndesmosis. A recent survey highlighted the variability with regard to the treatment of these injuries10. That study highlighted the differences in reduction technique, the number of screws and cortices used in fixation, postoperative weight-bearing status, screw removal, and the reasons for screw removal.
Given the variations in operative technique and postoperative management in patients with tibiofibular syndesmotic injuries, it is important that orthopaedic surgeons remain versed in current literature and evidence.
The tibiofibular syndesmosis consists of the soft-tissue connections of the distal aspect of the tibia and fibula. The fibular notch on the distal aspect of the tibia is concave lateral, providing a syndesmotic articulation with the distal aspect of the fibula. The ligamentous stability of the syndesmosis is provided by the anterior inferior tibiofibular ligament, the posterior inferior tibiofibular ligament, the inferior transverse ligament, and the interosseous ligament (Fig. 1). The anterior inferior tibiofibular ligament originates from the lateral malleolus and inserts on the anterolateral tibial tubercle. The interosseous ligament lies deep to the anterior inferior tibiofibular ligament. It provides the main lateral ligamentous restraint to proximal migration of the talus and represents the thickened portion of the distal interosseous membrane. The posterior inferior tibiofibular ligament originates from the posterior tibial tubercle and inserts on the posterior aspect of the lateral malleolus. The fibrocartilaginous inferior transverse ligament forms the inferior portion of the posterior inferior tibiofibular ligament.
A recent cadaveric study described the vascular supply to the tibiofibular syndesmosis11. Those investigators found that the primary vascular supply to the anterior syndesmotic ligaments was the perforating branch of the peroneal artery, which passed through the interosseous ligament approximately 3 cm proximal to the ankle joint. In 62% of fifty specimens, the perforating branch of the peroneal artery was the only vessel to supply the anterior syndesmotic ligaments. With the anterior ligaments more likely to be damaged in syndesmotic injuries12,13, the vascular supply is susceptible as well, given its proximity.
As the foot moves through its normal range of motion from 50° of plantar flexion to 20° of dorsiflexion, the mortise subsequently widens by up to 1.5 mm as the fibula rotates externally and translates laterally14,15. While in dorsiflexion, the wider portion of the anterior aspect of the talus occupies a greater area of the mortise, and this is regarded as the safest ankle position. The opposite situation occurs during plantar flexion, as the wider portion of the talus moves out of the mortise and is replaced by the narrower posterior portion, therefore theoretically decreasing ankle stability16,17. Throughout plantar flexion, the talus will internally rotate18,19, causing increasing posterolateral wedging and slight supination20. Thus, as dorsiflexion occurs, the talus has to pronate, which may explain why hyperdorsiflexion or external-rotation mechanisms cause injury to the tibiofibular ligaments14,20.
Mechanism of Injury
Although many mechanisms are possible, the most common pattern for tibiofibular syndesmotic disruption is external rotation with hyperdorsiflexion14,21-24. This pattern results in a widening of the fibula in relationship to the tibia, disrupting the syndesmotic ligaments and subsequently destabilizing the talus14. Studies have shown that the first structure to be damaged in the externally rotated foot in either pronation or eversion is the anterior inferior tibiofibular ligament25,26.
Injuries to the syndesmosis may be purely ligamentous, as in proximal ankle sprains seen during sports, or fractures that may be incurred by falling on stairs, curbs, or ice. Fracture patterns that are associated with syndesmotic injuries include the supination-external rotation ankle fracture (Weber B)27, the pronation-external rotation ankle fracture (Weber C), or a fracture of the proximal aspect of the fibula (Maisonneuve)28,29.
Although fibular position and controlled motion are necessary for proper syndesmotic function and stable ankle motion with talar location within the mortise30, the ligaments around the tibiofibular syndesmosis act to prevent excessive fibular motion. In a cadaveric study, the anterior inferior tibiofibular ligament, deep posterior inferior tibiofibular ligament, interosseous ligament, and superficial posterior ligament provided 35.5%, 32.7%, 21.6%, and 8.7%, respectively, of the ligamentous resistance in the syndesmosis31. Previous cadaveric studies have found that, under external rotation loading with medial instability, the critical transition zone for syndesmotic disruption is 3.0 to 4.5 cm proximal to the plafond32. In another cadaveric study of external rotation forces, Xenos et al.33 found that sectioning the anterior tibiofibular ligament resulted in 2.3 mm of diastasis. With subsequent 2-cm sectioning of the interosseous ligament, the diastasis increased by approximately 0.5 mm. With disruption of all syndesmotic ligaments, the resultant diastasis was 7.3 mm.
The importance of maintaining proper ankle mortise alignment and tibiotalar contact to prevent substantial joint changes has been demonstrated in many studies18,34-36. In a study by Burns et al.37, the investigators found that progressive sectioning of syndesmotic ligaments that are axially loaded in pronation-external rotation injuries results in negligible differences in tibiotalar contact area and peak pressures, and only slight syndesmotic widening (a mean of 0.24 mm). However, with deltoid ligament transection, diastasis averaged 0.73 mm, tibiotalar contact area was reduced to 39%, and there was a 42% increase in the peak pressure. Lateral displacement of the talus by 1 mm decreases surface contact by 40%34,36, whereas displacement of 3 mm reduces contact by >60%34. Articular surface congruency has also been shown to contribute to ankle stability38,39.
History and Physical Examination
The patient’s history should include prior operations, mechanism of injury, location of pain, ability to bear weight, and any feelings of instability. The mechanism of injury may indicate the possibility of a syndesmotic injury. In patients with isolated syndesmotic injuries, physical examination may reveal ankle pain and tenderness directly over the anterior syndesmosis40,41. Patients may also report pain with weight-bearing or when pushing off of the injured ankle42. Reduced passive dorsiflexion may also indicate syndesmotic injury43. The use of clinical stress testing may be useful in assessing syndesmotic integrity (Table I). A study using magnetic resonance imaging (MRI) as the standard found a sensitivity of 30% and a specificity of 93.5% for the squeeze test and a sensitivity of 20% and a specificity of 84.8% for the external rotation test44. The external rotation test has the lowest false-positive results and interobserver variance45. It is important to note that syndesmotic injuries may be missed in clinical diagnosis in up to 20% of patients45.
The initial radiographic evaluation should include two full-length views of the tibia and fibula (anteroposterior and lateral) and three views of the ankle joint (anteroposterior, lateral, and mortise). Full-length radiographs should be evaluated for a proximal fibular fracture (Fig. 2). These radiographs will help in identifying the presence of a fracture, the possible mechanism of injury, and the anatomic relationship of the distal aspects of the tibia and fibula to initially help in evaluating the syndesmosis.
The radiographic signs that indicate possible syndesmotic disruption include increased tibiofibular clear space, decreased tibiofibular overlap, and increased medial clear space (Fig. 3)46-49. The tibiofibular clear space is the distance between the lateral border of the posterior tubercle of the tibia and the medial aspect of the fibula48. In a radiographic cadaveric study, Harper and Keller found that the tibiofibular clear space should be <6 mm on the anteroposterior and mortise views48. Sclafani50 found that the tibiofibular clear space in patients without ankle injury was never >5 mm. Tibiofibular clear space is considered to be a more reliable measurement as it is not affected by positioning of the ankle relative to the radiographic beam47,48. However, Nielson et al.51 found no association between the tibiofibular clear space or overlap measurements on radiographs and syndesmotic injuries seen on MRI.
The tibiofibular overlap is the distance between the lateral malleolus and the anterior tibial tubercle of the tibia as measured from 1 cm proximal to the plafond48. The normal tibiofibular values were reported as an overlap of >6 mm or 42% of the fibular width on the anteroposterior view and an overlap of >1 mm on the mortise view (Fig. 3). Medial clear space is defined as the distance between the lateral border of the medial malleolus and the medial aspect of the talus measured at the level of the talar dome41. With the ankle in the neutral position, the medial clear space should be equal to or less than the superior clear space between the dome and the plafond as measured on the mortise view46. Study results have been conflicting as to the dependability of using the medial clear space as a marker for deltoid disruption. In the study by Nielson et al.51, a >4-mm medial clear space was associated with the disruption of the deltoid ligament and tibiofibular ligaments with relatively high sensitivity but low specificity. However, a study by Schuberth et al.52 using arthroscopy in patients undergoing open reduction and internal fixation showed that the widening of the medial clear space on radiographs is not a reliable marker of deltoid ligament disruption. With a criterion of a ≥4-mm medial clear space, they found a false-positive rate of 53.6%.
Previous authors have argued that standard radiographic parameters are poor predictors syndesmotic stability46,51-53. Studies involving stress radiographs of the foot have shown substantial diastasis through different techniques and views33,54; however, stress radiographs are occasionally used in the preoperative setting of acute ankle fractures20,53. If in doubt, stress views should enhance the preoperative diagnosis of syndesmotic injury. Computed tomography (CT) is a reliable modality capable of detecting diastasis and/or subluxation of the syndesmosis not otherwise appreciated on radiographs55-57. The use of MRI has also been shown to be highly sensitive and specific for detecting syndesmotic disruptions58-60.
Studies have shown that arthroscopy of the ankle can be an effective modality in identifying syndesmotic disruptions61,62. In fifty-two patients, Takao et al. found that a syndesmotic injury could be accurately diagnosed in 100% of cases by arthroscopy, in 64% of cases by anteroposterior radiographs, and in 71% of cases by mortise radiographs, and that MRI could accurately diagnose 96% of anterior inferior tibiofibular ligament injuries and 100% of posterior inferior tibiofibular ligament injuries62. Arthroscopy has also been recommended for the evaluation of syndesmotic injury and persistent pain following definitive treatment63. Arthroscopy has been previously reported as a useful tool in the diagnosis of subtle syndesmotic disruption in a Maisonneuve fracture missed by conventional radiographs and CT64.
Syndesmotic Injuries with Associated Fractures
Injury to the tibiofibular syndesmosis has clear associations with various fracture patterns. Syndesmotic injuries are most often associated with Lauge-Hansen supination-external rotation (Weber B) and pronation-external rotation (Weber C) injuries. Given the cadaveric study by Boden et al.32, syndesmotic disruption is typically associated with Weber-C fractures; however, a previous study evaluating fifty-one patients with syndesmotic injuries found that 20% of them were in Weber-B fracture patterns65. Stark et al.9 found that it was common to have syndesmotic instability after fixation of supination-external rotation stage-4 Weber-B lateral malleolar fractures, as 39% of ninety-three patients displayed laxity with intraoperative stress testing. It has been shown that 33% to 45% of operatively treated supination-external rotation stage-4 fractures display syndesmotic instability with intraoperative stress testing8,53. Those studies highlighted the necessity of intraoperative stress testing, as previous cadaveric and biomechanical criteria are insufficient to correctly assess the syndesmosis9,53.
Intraoperative assessment of the syndesmosis is traditionally done in one of two ways. The hook test entails distracting the fibula in the coronal plane with a bone hook and assessing with a fluoroscopic mortise view. Widening by >2 mm suggests the need for syndesmotic fixation66. In the external rotation stress test, the tibia is stabilized with one hand and an external rotation force is applied to the foot. The test is positive if the medial clear space is ≥5 mm66. Pakarinen et al.66 found excellent specificity and interobserver reliability for both tests; however, the sensitivity remains low, suggesting that many syndesmotic injuries may go undiagnosed. Jenkinson et al.53 attempted to standardize the external rotation test using a fracture reduction F-tool with a linear strain gauge and comparison with the uninjured side. They found that surgeons using this protocol were able to deliver more consistent and precise forces to the ankle. Candal-Couto et al.54 found that hook tests performed in the sagittal plane show greater movement than in the coronal plane and appear to have greater sensitivity.
Although the majority of syndesmotic injuries are associated with distal-third fibular fractures, this is not always the case. A fracture of the proximal aspect of the fibula with external rotation, commonly referred to as a Maisonneuve fracture, should prompt the treating surgeon to evaluate for syndesmotic injury, but the fracture does not always result in instability. In a study of nine patients with high fibular fractures, eight patients were treated nonsurgically and one patient was treated surgically; the one operative case and seven of the eight operative cases had good results67. Pankovich68 described three mechanisms of proximal fibular fractures, supination-external rotation, pronation-abduction, and pronation-external rotation, and advised that the advanced stages of all mechanisms should receive early operative treatment.
In patients with isolated syndesmotic sprains, several grading systems have been proposed21,69,70. Mulligan69 stratified the grade of sprain on the basis of patient symptoms, syndesmotic stability, and radiographic imaging. Similar to the study by Williams et al.42, immobilization and weight-bearing status are then guided by symptom severity, amount of instability, and functional ability. For grade I, sprains without diastasis, patients may bear weight as tolerated and may be immobilized for zero to three days. For grade II, sprains with latent diastasis, patients may require three to seven days of immobilization, with full weight-bearing after one to two weeks. For grade III, sprains with frank diastasis, patients require more than seven days of immobilization, with a minimum of two to three weeks of non-weight-bearing69.
Several authors have discussed three or four-phase rehabilitation programs for syndesmotic sprains22,42,69-71. The first phase is governed by joint protection, reduction of inflammation, and pain-free walking. Patients then progress to the next phase when pain, edema, and minimal antalgic gait are present. In this second phase, the return of strength, mobility, and a normal gait are the main goals. Patients then progress to the final stages when they can walk normally, jog, and hop repetitively without difficulty. These following stages of all programs are directed at advanced motions with the goals of returning to athletic activity or pain-free activities of strenuous daily living.
Tibiofibular syndesmotic disruptions with associated fractures can also be treated nonoperatively. Nonoperative treatment has been recommended in Weber-B or low Weber-C ankle fractures when the deltoid ligament and the posterior aspect of the syndesmosis are intact20,32,72-76.
Operative intervention has often been performed for syndesmotic sprains refractory to nonoperative treatment, for persistent syndesmotic instability despite definitive fixation, and in many Weber-C fractures. Many fractures that occur with associated fractures of the fibula and additional malleolar injuries will require surgical intervention to stabilize the ankle. However, in certain fracture patterns, the clinical necessity of fixing the syndesmosis remains unclear. In another study, Pakarinen et al.66 operatively stabilized supination-external rotation stage-4 fractures. After positive intraoperative external rotation stress testing, the patients were then randomized to either syndesmotic fixation or no syndesmotic fixation. The investigators found no difference in functional outcome or pain at the one-year follow-up.
The importance of an accurate ankle and syndesmotic reduction (Fig. 4, A) cannot be overstated to improve functional outcomes and to prevent posttraumatic arthritis34,36,65,77-79. Malreduction of the tibiofibular joint (Fig. 4, B) may be caused by improper reduction of the fibula, the syndesmotic injury, or even the syndesmotic screw80. A previous cadaveric study found that when the reduction clamp is placed 1 cm proximal to the mortise and in the neutral anatomic axis, it reduces the fracture more accurately but may produce slight overcompression (Fig. 5)81. With oblique clamping, the investigators found that malreduction is possible. The recent study by Miller et al.82 supported this as well. Those investigators found that clamps placed at 15° and 30° caused external rotation displacement of the fibula and overcompression of the syndesmosis. In addition, eccentrically applied clamps anterior to the plane of the distal tibiofibular joint can translate the fibula anterior to the tibia. Several studies have revealed that malreductions might be present in 26% to 52% of cases79,83-86. Studies have demonstrated that radiographs and fluoroscopy provide inaccurate assessments of reduction, specifically with external rotation of the fibula83-85. Several authors have described various techniques in efforts to prevent malreduction. Ruan et al. described the use of intraoperative three-dimensional fluoroscopy to detect subtle malalignments in the syndesmosis87. However, a recent study by Davidovitch et al.88 suggested that intraoperative CT imaging may not reduce the rate of syndesmotic malreduction. Direct visualization of the reduction has been proven to reduce the number of malalignments79,86. However, given that the anatomic difference between the ankles of an individual is small57, Summers et al.89 found that by comparing images of the mortise and lateral talar dome of the injured ankle with those of the uninjured ankle intraoperatively, the use of CT or direct visualization may not be necessary.
Even though syndesmotic screw fixation was once considered the gold standard, a variety of constructs are available; these include one or two screws, 3.5 or 4.5 mm in diameter, placed suprasyndesmotically or transsyndesmotically, with tricortical or quadricortical purchase, and metallic or bioabsorbable in composition. In an ankle cadaveric study with both the anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament transected, a single 3.5-mm screw inserted at 1 cm or 3 cm (transsyndesmotic) above the joint line restored normal stability of the ankle joint with simulated weight-bearing90. The screw inserted at 5 cm proximal (suprasyndesmotic) to the joint line did not restore ankle stability. With controversy existing regarding symptomatic screws and their removal, the use of a suture button for syndesmotic fixation may provide a valid option with more natural physiological motion occurring at the syndesmosis. Because high rates of chondral injuries are noted intraoperatively, arthroscopic debridement or arthrotomy to assess the injury and outcome prognosis has been suggested91.
Ankle injuries with tibiofibular disruptions may be treated nonoperatively (Table II). Several studies have demonstrated that substantially greater recovery time is required for the nonoperative treatment of syndesmotic sprains compared with lateral ankle sprains92-94. A recent study of National Football League (NFL) players receiving corticosteroid injections as part of their rehabilitation program showed that these players returned to play faster than players who did not receive corticosteroid injections95. Although validated functional outcome scores were not collected, Taylor et al.96 used a subjective scoring system and found a good to excellent score in 86% of forty-four collegiate football players treated conservatively. Patients experiencing fair outcomes all had recurrent ankle sprains, and eleven of twenty-two patients with final radiographs displayed heterotopic ossification. Nussbaum et al.71 reported that, at a six-month follow-up, thirty-five cases had excellent outcomes and eighteen cases had good outcomes utilizing that same system; however, of the fifty-three patients, six had occasional ankle pain or stiffness and four reported recurrent sprains. They also found that time lost from competition was related to the period during which there was tissue tenderness. Nonoperative management research did not employ consistent methods of diagnosing or grading syndesmotic sprains; thus, injury severity may be variable among the studies.
A number of studies have found no major differences with regard to functional outcomes among several screw parameters and characteristics. A study comparing one 4.5-mm quadricortical screw with two 3.5-mm tricortical screws did find a significant difference in functional outcome (p = 0.025) and pain (p = 0.017) at three months favoring the tricortical group, but these differences were not seen at the one-year follow-up97. Wikerøy et al.98 also found no difference in functional outcomes in patients with tricortical fixation compared with those with quadricortical fixation at the 8.4-year follow-up. To our knowledge, there have been no major differences in functional outcomes with regard to 3.5-mm and 4.5-mm screws99, tricortical and quadricortical screws100,101, transsyndesmotic and suprasyndesmotic screws102, stainless steel and titanium screws101, or metal and bioabsorbable screws (Table III)103-108. In the intermediate-term follow-up recently published by Sun et al.108, the authors found nearly equivalent functional outcome scores in both the metallic group and the bioabsorbable group; foreign body reactions were more common in the latter group.
A systematic review by Schepers109 compared suture buttons with syndesmotic screws. It was found that the American Orthopaedic Foot & Ankle Society (AOFAS) scores in patients treated with suture buttons was 89.1 points, with a mean follow-up of nineteen months. The AOFAS score in patients treated with syndesmotic screws was 86.3 points, with a mean follow-up of forty-two months. Implant removal was required in 10% of patients treated with suture-button screws compared with 51.9% of patients treated with screws or bolts. The recent study by Naqvi et al. found that, in twenty-three patients, there was a greater malreduction rate in syndesmotic injuries treated with screws (21.7% [five patients]) compared with those treated with suture buttons (0% [zero patients])110. The additional cost of using suture buttons compared with that of using syndesmotic screws may be justified given the reduced need for additional surgery while maintaining similar outcome scores and ankle stability (Table IV)109-112.
Posterior Malleolar Fixation
Posterior malleolar fractures of varying sizes are commonly associated with ankle fractures113. In a study evaluating pronation-external rotation ankle injuries, MRI demonstrated an intact posterior inferior tibial fibular ligament with associated posterior malleolar fractures114. Posterior malleolar fixation yielded better stabilization of the syndemosis in this cadaveric study, with restoration of 70% of normal syndesmotic stiffness after posterior malleolar fixation compared with 40% after syndesmotic fixation alone114. Posterior malleolar fixation may also improve the accuracy of ankle fracture reduction, resulting in improved fibular reduction in terms of rotation, length, and translation115.
Implant Failure and Screw Removal
Fixation of the syndesmosis results in alterations to normal biomechanics and fibular motion116,117; thus, the added shear stress when weight-bearing may cause syndesmotic screws to fatigue and break117,118. Previous studies have shown 7% to 91% of screws loosening or breaking100,118-121. A recent study evaluating screw diameter and breakage revealed that 3.5-mm screws were more likely to break than 4 or 4.5-mm screws122. Despite this, there was no difference in the loss of reduction according to screw diameter.
Previously, authors have argued against screw removal due to added cost, risk of infection, recurrent diastasis, and questionable improvement in outcomes100,119,120,123-125. Recurrent diastasis may occur following screw removal, as studies have shown such recurrence in 6.6% to 15.8% of cases in which screws had to be removed at six to eight weeks because of breakage or loosening123,125. Also, complications of screw removal may be as high as 22.4%123. Conflicting evidence exists with regard to the removal of screws and their functional outcomes; however, it trends toward favoring prudent removal. Miller et al.126 found improved subjective and objective outcomes following screw removal at four months postoperatively. The study by Hamid et al. discovered that patients with broken screws experienced the best clinical outcomes119. Manjoo et al.120 also found improved outcomes in patients with loosened, broken, or removed screws. However, the recent study by Tucker et al. found no difference in outcomes in patients with screw removal127.
The limited evidence with regard to screw loosening, breakage, and removal suggests that the elimination of rigid syndesmotic fixation and the allowance of normal fibular motion may be associated with improved outcomes. With the lack of studies with a high level of evidence, screw removal on a case-by-case basis appears appropriate.
Heterotopic ossification following syndesmotic disruption has been described previously and its influence on outcome is controversial49,96,128-131. Taylor et al. found that eleven of twenty-two patients with follow-up radiographs had developed heterotopic ossification, and although no differences in the ankle function ratings or symptoms existed, ossification in ankles was associated with recurrent sprains96. Other reports have described persistent pain with syndesmotic ossification and synostosis necessitating surgical excision130,131. Hopkinson et al.128 did identify interosseous calcification as one of the factors in syndesmotic sprains with prolonged recovery times. The rate of development of frank synostosis following ankle fracture has been reported to be as high as 18%49. A study evaluating synostosis described patients reporting no symptoms and near normal range of motion129; however, Phillips et al.132 showed worse outcome scores in patients with synostosis.
Factors Affecting Outcomes
Several studies have identified injury and patient characteristics that negatively affect outcomes. Studies have shown that increasing the number of fractured malleoli leads to notably poorer outcomes133,134. In operatively treated ankle fractures, Egol et al.135 found that greater age, male sex, absence of diabetes, and a lower American Society of Anesthesiologists (ASA) class all predicted better functional outcomes at a one-year follow-up. A recent study also identified age, body mass index, and duration of plaster immobilization as negative indicators136. Mendelsohn et al.137 demonstrated a more frequent loss of syndesmotic reduction for obese patients (15%) compared with that for normal-weight patients (1.8%).
Ankle syndesmotic injuries are common with or without malleolar ankle fractures. Injury and intraoperative stress radiographs help to confirm the diagnosis. Accurate reduction and stable fixation allowing syndesmotic ankle ligament healing, limited syndesmotic motion, and stable ankle mechanics are desired (Table V). The timing of weight-bearing and potential hardware removal are controversial.
Source of Funding: There was no source of external funding for this study.
Investigation performed at the Orthopaedic Associates of Michigan, Grand Rapids, Michigan
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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