Abstract
Objective
-
To this day, diagnostic standards and uniform definition for acute, isolated syndesmotic injuries are missing. The aim of the current study was to conduct a systematic review of the classification systems and diagnostics currently applied and to propose a best evidence diagnostic approach.
Methods
-
Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials, and Embase were searched from inception to June 5, 2022, for studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. First, all classifications used in the eligible studies were identified and illustrated according to the individual syndesmotic structures injured. Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intra-operatively), was analyzed, including the applied cutoff criteria.
Results
-
Ten out of 4190 studies, comprising 317 acute ligamentous syndesmotic injuries, met the inclusion criteria. Seven studies facilitated one of the three different classification systems (Calder, West Point, or Sikka classification). Eight studies based their indication for surgery on a combination of clinical and radiographic examinations and two on radiographs only. The most applied clinical tests were the external rotation stress test and squeeze test. The most common radiologic diagnostics were plain radiographs and MRI. Intraoperatively, instability was verified most commonly using arthroscopy.
Conclusion
-
Current classifications and diagnostics for syndesmotic injuries are heterogeneous, often cannot be attributed to the ligaments injured. An evidence-based diagnostic algorithm based on noninvasive diagnostics and an anatomy-based classification for acute syndesmotic instability is presented.
Introduction
Syndesmotic injuries occur in 20% of ankle fracture cases and in approximately 17% of all ankle sprains (1, 2, 3, 4). Isolated syndesmotic injuries are referred to as high ankle sprains. These figures rise to up to 30% in high-impact sports (5). Consequently, orthopedic surgeons are frequently encountered with syndesmotic injuries and must rate their stability.
The syndesmotic complex comprises of three major ligaments, the anterior–inferior tibiofibular ligament (AiTFL), the interosseous ligament (IOL), and the posterior–inferior tibiofibular ligament (PiTFL) (Fig. 1A) (6). It resembles a three-point fixation of the fibula to the tibia ensuring bony mortise stability (Fig. 1B) (7). The PiTFL accounts for about 40–45%, the AiTFL for 35% and the IOM for about 20–25% of the stability of the distal tibiofibular joint (DTFJ) (8). The most common injury mechanism is external rotation in dorsiflexion of the foot.
Schematic illustration of the syndesmotic complex (A) and the increase of fibula range of motion with stepwise rupture of the syndesmotic complex (B). AiTFL, anterior–inferior tibiofibular ligament; IOL, interosseous ligament; PiTFL, posterior–inferior tibiofibular ligament.
Citation: EFORT Open Reviews 9, 1; 10.1530/EOR-23-0097
The syndesmotic complex most often ruptures from anterior to posterior. Biomechanically, an isolated rupture of the AiTFL leads to an increased anterior-to-posterior translation of the fibula, while a rupture of the AiTFL and IOL additionally results in a rotational instability. Only a complete rupture of all three ligaments (AiTFL, IOL, and PiTFL) causes a multiplanar instability of the DTFJ and leads to a frank diastasis (9).
The diagnosis and classification of two-ligament (AiTFL and IOL ruptures) and multiplanar instabilities (AiTFL, IOL, and PiTFL ruptures) remain a challenge (1, 10). Various clinical test and diagnostics have been proposed, ranging from plain radiographs, MRI, to different stress tests. A similar number of varying classification systems have been published, using different combinations of the clinical tests and diagnostics. Yet, to this day, we are missing a uniform diagnostic algorithm and classification system for syndesmotic injuries. An untreated, unstable syndesmotic injury will significantly change the tibiotalar contact area and contact pressure (11), which again result in chronic instability, poor functional outcome, and posttraumatic arthritis (12, 13). Considering these eventually irreversible consequences, it becomes apparent that we must agree on an evidence-based diagnostic algorithm and classification system.
The authors are only aware of of one systematic review on the classification and diagnosis. This was published 7 years ago as a consensus statement by the ESSKA-AFAS (which stands for European Society for Sports Traumatology, Knee Surgery and Arthroscopy – Ankle and Foot Associates) (14). They predominantly focused on the combination of syndesmotic and deltoid injuries. Still, one has to be aware that the syndesmotic complex stabilizes the bony ankle mortise, i.e. the fibula to the tibia, and the deltoid ligament complex the medial ankle. Thus, for isolated syndesmotic injuries, a uniform classification and diagnostic standards, including cutoff values, is still lacking.
The aim of the current study was to conduct a systematic review on the classification systems and diagnostics applied to grade and diagnose syndesmotic instability in studies reporting the outcome of surgically treated acute, isolated syndesmotic injuries. The applied classification systems and diagnostics were discussed with current literature and a best evidence diagnostic approach was proposed.
Materials and methods
The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (15). The study was a priori registered at Prospero (CRD42022352940).
Search strategy
Medline (PubMed), Scopus, Cochrane Central Register of Controlled Trials (aka CENTRAL), and Embase were searched from inception to June 5, 2022. The review question was framed according to the Population, Intervention, Comparison, Outcomes and Study (PICOS) criteria (Table 1). The search strategy was built upon the principal strategies of Syndesmosis AND Surgery. The entire search strategy is presented in Supplementary 1 (see the section on supplementary materials given at the end of this article).
PICOS criteria defining the inclusion and exclusion criteria.
| Population |
|
| Intervention | Surgical treatment, independent of the treatment strategy chosen. |
| Comparison | n.a. |
| Outcomes | Any objective outcome, including imaging, PROMs, VAS, and range of motion |
| Study | Clinical studies. No restriction per the type of study unless they included at least six patients. |
A grey literature search for conference proceedings was performed in Scopus and EMBASE and a general search in OpenGrey (http://www.opengrey.eu). In addition, all references of the studies included and systematic reviews identified were hand reviewed to find studies not found through the generic electronic search.
Study selection and data extraction
Each database was searched separately, and the resulting datasets exported to EndnoteTM (version 20.1; Clarivate). After removal of duplicates, the final dataset was exported to CovidenceTM (Melbourne, Australia). The complete screening (title/abstract, full text) and data extraction process was conducted by two independent reviewers (FTS, SFB) and conflicts were discussed with a third reviewer (HP).
Data extraction was based on standardized data extraction sheets in Excel (version 16, Microsoft, Redmond, WA, USA), including level of evidence, study details, general demographics (number of patients, lost to follow-up, age, sex, etc.), injury defining information (diagnostic algorithm, classification system, and distribution of injuries), surgical treatment (closed, open, arthroscopically assisted), type of fixation, associated injuries such as intra-articular (i.a.) pathologies, postoperative treatment protocol, follow-up time, complications, and outcome.
Quality assessment
Quality assessment was again conducted by two authors independently (SFB, FTS). According to the Joanna Briggs Institute (JBI) critical appraisal checklists for the various study types (16), the methodological quality of the included studies was evaluated. The JBI critical assessment checklist for cohort studies comprises of eleven items, and for case series of ten items. A JBI score >70% is considered good, medium if 50–70%, and poor for scores <50%.
Data analysis
First, all classifications used in the eligible papers were identified and illustrated according to the individual syndesmotic structure injured or ruptured (AiTFL, IOL, PiTFL). Second, the indication for surgery and stabilization, based on the diagnostics applied and the time point assessed (pre- or intraoperatively), were analyzed, including the applied cutoff criteria.
Statistical analysis
Due to the great heterogeneity of the studies available, the data analysis was conducted descriptively only. The data shown are given as mean ± s.d.
Results
Figure 2 depicts the study selection process. A total of 4190 studies were screened for title and abstract and 206 for full text. Eighteen studies included combined patient cohorts with ligamentous and fracture cases but did not present the results individually. All corresponding authors but one (contact details not available (17)) were contacted to provide the data for ligamentous and fracture cases separately. Only Cherney et al. (18) replied, stating that only one patient had a purely ligamentous injury. Consequently, all 18 studies had to be excluded. Finally, ten studies (19, 20, 21, 22, 23, 24, 25, 26, 27, 28), comprising 317 acute ligamentous syndesmotic injuries, were eligible for further analyses.
Study selection flowchart according to the PRISMA guidelines.
Citation: EFORT Open Reviews 9, 1; 10.1530/EOR-23-0097
For the study by Kent et al. (24) only the study arm on acute injuries was included. The overall study quality per the JBI score was good (82 ± 14%; case series: 85 ± 14%; cohort studies: 69 ± 5%). The mean patient age within the included studies was 27 ± 6 years, 19 ± 21% of the included patients were female and the mean follow-up time was 32 ± 15 months. Supplementary Table 1 depicts an overview over the included studies.
Classification systems
An illustration of the classification systems used in the studies included is depicted in Fig. 3. Seven out of the ten studies facilitated one of the following classification systems: Calder classification (n = 4) (19, 21, 24, 25), West Point classification (n = 2) (23, 28), and Sikka classification (n = 1) (26). The remaining three studies simply classified the injuries into stable or unstable (20, 22, 27).
Illustration of the classification systems facilitated in the herein identified studies, included in the ESSKA-AFAS consensus guidelines (14), and other classification systems: *Not included in the ESSKA-AFAS consensus guideline classifications. AiTFL, anterior–inferior tibiofibular ligament; ERST, external rotation stress test; IOL, interosseous ligament; neg., negative; PiTFL, posterior–inferior tibiofibular ligament; pos., positive; RX, x-ray.
Citation: EFORT Open Reviews 9, 1; 10.1530/EOR-23-0097
Indication for surgery and stabilization
The diagnostics used to set the indication for surgery (preoperative) and stabilization (intraoperative) are depicted in Fig. 4. Overall, eight studies based their indication for surgery (preoperative) on a combination of clinical and radiographic examinations (19, 21, 22, 23, 24, 25, 26, 27). The remaining two studies based their indication for surgery solely on radiographs (20, 28). The most applied clinical tests were the external rotation stress test (ERST) (n = 5; (19, 21, 23, 24, 25)) and squeeze test (n = 5; (19, 21, 22, 23, 24)), and the most common radiologic diagnostics MRI (n = 9; (19, 20, 21, 22, 23, 24, 25, 26, 27) and plane radiographs (n = 7; (19, 20, 22, 23, 26, 27, 28)). The most frequently applied cutoff criteria, independent of the actual radiologic tool, were 2 mm (n = 5; (23, 25, 27)) and ‘suspicion of widening’ (n = 6; (19, 26, 27)).
Overview of the diagnostic tests used in the included studies. Each black square resembles a single study in which this test was used within the authors’ diagnostic algorithm. AP, anterior–posterior; CT, computed tomography; ERST, external rotation stress test; IntraOP, intraoperative; n.s., not specified; PreOP, preoperative; RX, x-ray.
Citation: EFORT Open Reviews 9, 1; 10.1530/EOR-23-0097
Seven studies verified syndesmotic instability intraoperatively (19, 20, 21, 23, 24, 25, 27). This was most often done by arthroscopy (n = 5) (19, 21, 24, 25, 27) with cutoff values in the stressed state ranging from 2 mm (27) to 4.5 mm (19).
Discussion
The aim of this systematic review was to identify the classification systems and diagnostics applied to grade and diagnose syndesmotic instability in studies reporting on the outcome of surgically treated acute, isolated syndesmotic injuries.
The most often used classification systems were the Calder, West Point, or Sikka classification. The most applied clinical tests were the ERST and squeeze test. The most common radiological diagnostics were plain radiographs and MRI. Arthroscopy was most used to verify syndesmotic instability intraoperatively. The results highlight the great heterogeneity in the classification systems used and diagnostics applied for acute, isolated syndesmotic injuries.
Figure 3 combines the clinically applied classification systems identified in the systematic literature review (1, 19, 29), reported in the ESSKA-AFAS expert panel consensus guideline (14), and a further classification identified during the literature review for this study (30). Only classification systems applicable preoperatively were included. Intraoperative classification systems, i.e. based on a hook test or arthroscopy, were not included. The different classification systems were grouped, whenever possible, per the specific syndesmotic ligaments injured. Five studies did not clearly state on the ligaments injured and could therefore not be grouped (1, 9, 31, 32, 33). This overview highlights the enormous heterogeneity we are currently facing when classifying syndesmotic injuries. This heterogeneity includes varying terminology, missing the differentiation between stable and subtle unstable injuries, and an incorporation of deltoid ligament injuries into the classification systems. Although most classification systems used grades, most commonly I through III (1, 19, 29, 30, 31, 32, 33, 34), these grades either cannot be clearly attributed to the individual syndesmotic ligaments injured or refer to different states of syndesmotic instability which further increases the confusion (Fig. 3). A clear differentiation between a one-ligament rupture (AiTFL) and a two-ligament rupture (AiTFL + IOL) is only provided in three classification systems (19, 29, 30). Yet this differentiation is crucial, as it has considerable implications for the further treatment, i.e. nonoperative vs operative (19). Finally, five (9, 19, 29, 31, 34) out of the nine classification systems identified incorporate injuries to the deltoid ligament complex into their classification system. In 2016, the ESSKA-AFAS expert panel published a consensus and guideline paper entitled ‘Classification and diagnosis of acute isolated syndesmotic injuries’ (14). They concluded that the injury to the deltoid ligament is the predominant differentiator between a stable and a latent unstable syndesmotic injury. This is remarkable, as the role of the deltoid ligament complex on the stability of the distal tibiofibular joint is not yet clear and currently intensively debated. Furthermore, various studies have highlighted the essential role of the IOL for distal tibiofibular joint stability (35, 36, 37, 38, 39, 40, 41). Therefore, the authors believe that any classification system for syndesmotic injuries should solely focus on the syndesmotic complex and the individual ligaments injured. A consistent and reproducible classification system is needed to ensure a comparability between studies and for the development of evidence-based treatment guidelines.
The second aim of the current systematic review was to identify the most commonly used preoperative diagnostics to diagnose syndesmotic instability, i.e. differentiate between stable and unstable syndesmotic injuries. The most commonly applied diagnostics were MRI and plain radiographs. Interestingly, the external rotation stress test under fluoroscopy was facilitated only in two studies preoperatively (27, 28) and in none intraoperatively. Furthermore, only two of the classification systems identified recommended to apply the ERST under fluoroscopy (Fig. 3) (30, 32). This was surprising, as this test is the working horse to assess syndesmotic stability in ankle fracture cases (42, 43, 44). Moreover, a just recently published systematic review assessed the value of the ERST under fluoroscopy to detect subtle syndesmotic instability (45). Based on the ERST under fluoroscopy, the MCS was capable of differentiating between intact, two-ligament (AiTFL + IOL), three-ligament (AiTFL + IOL + PiTFL), and three-ligament + deltoid ruptures. The ERST under fluoroscopy has several advantages over MRI or arthroscopy: It is a dynamic examination and can be applied both in the outpatient clinic 5–7 days after injury without additional anesthesia and intraoperatively. It can be conducted bilaterally and therefore does not rely on predefined cutoff values, as arthroscopic probing, for example, does; thus, the healthy, uninjured side can serve as a reference. Finally, it is widely available and cost-efficient.
Based on these considerations, the authors have defined a best-evidence diagnostic algorithm for acute, isolated syndesmotic injuries (Fig. 5). ‘Acute’ was defined as, in accordance with the ESSKA-AFAS expert panel, within the first 21 days (14). The clinical examination should include the Ottawa foot and ankle rules (46) and syndesmosis-specific tests. Yet, clinical tests can only indicate a syndesmotic injury but not clearly differentiate between stable and unstable syndesmotic injuries (14, 47, 48, 49). In case there is the clinical suspicion for a syndesmotic lesion, an MRI should be obtained. MRI allows to clearly identify an intact AiTFL (stable) or a complete rupture of the AiTFL and PiTFL (unstable). In case the AiTFL is injured/ruptured but the PiTFL is intact, a bilateral ERST under fluoroscopy should be obtained. A widening of the MCS of the injured compared to the contralateral side, indicates an unstable (AiTFL + IOL rupture) syndesmotic injury. The subsequent injury should then be classified according to the specific syndesmotic ligaments injured. Additional injuries, such as injuries to the deltoid ligament complex, should be classified separately.
Overview of the MUM diagnostic flowchart for the diagnosis of isolated ligamentous injuries to the syndesmosis. AiTFL, anterior–inferior tibiofibular ligament; ERST, external rotation stress test; IOL, interosseous ligament; lig., ligament; MCS, medial clear space; PiTFL, posterior–inferior tibiofibular ligament.
Citation: EFORT Open Reviews 9, 1; 10.1530/EOR-23-0097
Conclusion
Currently available classification systems for syndesmotic injuries are heterogeneous, often cannot clearly be attributed to the ligaments injured, and associate injuries to the syndesmotic and deltoid ligament complexes. Similarly, current studies on isolated, syndesmotic injuries use different and often insufficient diagnostics to diagnose syndesmotic instability. The classification system and diagnostic algorithm introduced in this paper aim at providing a precise terminology and a noninvasive, best diagnostic approach to identify acute syndesmotic instability.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-23-0097.
ICMJE Conflict of Interest Statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.
Funding Statement
The authors received no financial or material support for the research, authorship, and/or publication of this article.
Author contribution statement
FTS reviewed the literature, wrote and edited the manuscript, contributed to data synthesis and assisted in illustration. WB supervised the study and reviewed the manuscript. HP supervised the study, reviewed the manuscript, and was responsible for the project administration. SFB conceptualized the study idea and the methodology, reviewed the literature, wrote the manuscript, designed the figures, and contributed to data synthesis.
References
- 1↑
Gerber JP, Williams GN, Scoville CR, Arciero RA, & Taylor DC. Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot and Ankle International 1998 19 653–660. (https://doi.org/10.1177/107110079801901002)
- 2↑
Hopkinson WJ, St Pierre P, Ryan JB, & Wheeler JH. Syndesmosis sprains of the ankle. Foot and Ankle 1990 10 325–330. (https://doi.org/10.1177/107110079001000607)
- 3↑
Court-Brown CM, McBirnie J, & Wilson G. Adult ankle fractures--an increasing problem? Acta Orthopaedica Scandinavica 1998 69 43–47. (https://doi.org/10.3109/17453679809002355)
- 4↑
Lindsjo U. Operative treatment of ankle fractures. Acta Orthopaedica Scandinavica 1981 189 1–131. (https://doi.org/10.3109/ort.1981.52.suppl-189.01)
- 5↑
Mulcahey MK, Bernhardson AS, Murphy CP, Chang A, Zajac T, Sanchez G, Sanchez A, Whalen JM, Price MD, Clanton TO, et al.The epidemiology of ankle injuries identified at the National Football League combine, 2009–2015. Orthopaedic Journal of Sports Medicine 2018 6 2325967118786227. (https://doi.org/10.1177/2325967118786227)
- 6↑
Yammine K, Jalloul M, & Assi C. Distal tibiofibular syndesmosis: a meta-analysis of cadaveric studies. Morphologie: Bulletin de l’Association des Anatomistes 2022 106 241–251. (https://doi.org/10.1016/j.morpho.2021.10.004)
- 7↑
Williams BT, Ahrberg AB, Goldsmith MT, Campbell KJ, Shirley L, Wijdicks CA, LaPrade RF, & Clanton TO. Ankle syndesmosis: a qualitative and quantitative anatomic analysis. American Journal of Sports Medicine 2015 43 88–97. (https://doi.org/10.1177/0363546514554911)
- 8↑
Ogilvie-Harris DJ, Reed SC, & Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy 1994 10 558–560. (https://doi.org/10.1016/s0749-8063(0580014-3)
- 9↑
Edwards GS Jr, & DeLee JC. Ankle diastasis without fracture. Foot and Ankle 1984 4 305–312. (https://doi.org/10.1177/107110078400400606)
- 10↑
Chun DI, Cho JH, Min TH, Park SY, Kim KH, Kim JH, & Won SH. Diagnostic accuracy of radiologic methods for ankle syndesmosis injury: a systematic review and meta-analysis. Journal of Clinical Medicine 2019 8. (https://doi.org/10.3390/jcm8070968)
- 11↑
Burns WC 2nd, Prakash K, Adelaar R, Beaudoin A, & Krause W. Tibiotalar joint dynamics: indications for the syndesmotic screw–a cadaver study. Foot and Ankle 1993 14 153–158. (https://doi.org/10.1177/107110079301400308)
- 12↑
Ray R, Koohnejad N, Clement ND, & Keenan GF. Ankle fractures with syndesmotic stabilisation are associated with a high rate of secondary osteoarthritis. Foot and Ankle Surgery 2019 25 180–185. (https://doi.org/10.1016/j.fas.2017.10.005)
- 13↑
Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, & Amendola A. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthopaedic Journal 2005 25 44–46.
- 14↑
van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, & Denaro V. Classification and diagnosis of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surgery, Sports Traumatology, Arthroscopy 2016 24 1200–1216. (https://doi.org/10.1007/s00167-015-3942-8)
- 15↑
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021 372 n71. (https://doi.org/10.1136/bmj.n71)
- 16↑
Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Lisy K, Qureshi R, Mattis P, et al.Chapter 7: Systematic reviews of etiology and risk. In JBI Manual for Evidence Synthesis. Aromataris E, & Munn Z Eds. JBI 2020. (https://doi.org/10.46658/JBIMES-20-08)
- 17↑
Henkemeyer H, Burri C, & Bargon G. Results of surgical management of 42 syndesmoses injuries. Helvetica Chirurgica Acta 1976 43 485–486.
- 18↑
Cherney SM, Cosgrove CT, Spraggs-Hughes AG, McAndrew CM, Ricci WM, & Gardner MJ. Functional outcomes of syndesmotic injuries based on objective reduction accuracy at a minimum 1-year follow-up. Journal of Orthopaedic Trauma 2018 32 43–51. (https://doi.org/10.1097/BOT.0000000000001000)
- 19↑
Calder JD, Bamford R, Petrie A, & McCollum GA. Stable versus unstable Grade II high ankle sprains: a prospective study predicting the need for surgical stabilization and time to return to sports. Arthroscopy 2016 32 634–642. (https://doi.org/10.1016/j.arthro.2015.10.003)
- 20↑
Chen KH, Chen CH, Huang YM, Lee HH, & Tsuang YH. Injury mechanism affects the stability of suture-button syndesmosis fixation. Journal of Orthopaedic Surgery and Research 2020 15 599. (https://doi.org/10.1186/s13018-020-02141-3)
- 21↑
D'Hooghe P, Grassi A, Alkhelaifi K, Calder J, Baltes TPA, Zaffagnini S, & Ekstrand J. 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 2020 54 1168–1173. (https://doi.org/10.1136/bjsports-2018-100298)
- 22↑
Förschner PF, Beitzel K, Imhoff AB, Buchmann S, Feuerriegel G, Hofmann F, Karampinos DC, Jungmann P, & Pogorzelski J. Five-year outcomes after treatment for acute instability of the tibiofibular syndesmosis using a suture-button fixation system. Orthopaedic Journal of Sports Medicine 2017 5 2325967117702854. (https://doi.org/10.1177/2325967117702854)
- 23↑
Harris NJ, Nicholson G, & Pountos I. Anatomical reconstruction of the anterior inferior tibiofibular ligament in elite athletes using InternalBrace suture tape. Bone and Joint Journal 2022 104–B 68–75. (https://doi.org/10.1302/0301-620X.104B1.BJJ-2021-0542.R2)
- 24↑
Kent S, Yeo G, Marsland D, Randell M, Forster B, Lutz M, & Okano S. Delayed stabilisation of dynamically unstable syndesmotic injuries results in worse functional outcomes. Knee Surgery, Sports Traumatology, Arthroscopy 2020 28 3347–3353. (https://doi.org/10.1007/s00167-020-05962-1)
- 25↑
Kim JS, & Shin HS. Suture anchor augmentation for acute unstable isolated ankle syndesmosis disruption in athletes. Foot and Ankle International 2021 42 1130–1137. (https://doi.org/10.1177/10711007211015188)
- 26↑
Latham AJ, Goodwin PC, Stirling B, & Budgen A. Ankle syndesmosis repair and rehabilitation in professional rugby league players: a case series report. BMJ Open Sport and Exercise Medicine 2017 3 e000175. (https://doi.org/10.1136/bmjsem-2016-000175)
- 27↑
Nishikawa DRC, Saito GH, de Oliveira Junior AS, Mendes AAM, Devito LP, & Prado MP. Clinical outcomes of isolated acute instability of the syndesmosis treated with arthroscopy and percutaneous suture-button fixation. Archives of Orthopaedic and Trauma Surgery 2021 141 1567–1574. (https://doi.org/10.1007/s00402-021-03813-3)
- 28↑
Taylor DC, Tenuta JJ, Uhorchak JM, & Arciero RA. Aggressive surgical treatment and early return to sports in athletes with grade III syndesmosis sprains. American Journal of Sports Medicine 2007 35 1833–1838. (https://doi.org/10.1177/0363546507304666)
- 29↑
Sikka RS, Fetzer GB, Sugarman E, Wright RW, Fritts H, Boyd JL, & Fischer DA. Correlating MRI findings with disability in syndesmotic sprains of NFL players. Foot and Ankle International 2012 33 371–378. (https://doi.org/10.3113/FAI.2012.0371)
- 30↑
Press CM, Gupta A, & Hutchinson MR. Management of ankle syndesmosis injuries in the athlete. Current Sports Medicine Reports 2009 8 228–233. (https://doi.org/10.1249/JSR.0b013e3181b7ec0c)
- 32↑
Marymont JV, Lynch MA, & Henning CE. Acute ligamentous diastasis of the ankle without fracture. Evaluation by radionuclide imaging. American Journal of Sports Medicine 1986 14 407–409. (https://doi.org/10.1177/036354658601400514)
- 33↑
Massobrio M, Antonietti G, Albanese P, & Necci F. Operative treatment of tibiofibular diastasis: a comparative study between transfixation screw and reabsorbable cerclage. Preliminary result. Clinica Terapeutica 2011 162 e161–e167.
- 34↑
Porter DA. Evaluation and treatment of ankle syndesmosis injuries. Instructional Course Lectures 2009 58 575–581.
- 36↑
Close JR. Some applications of the functional anatomy of the ankle joint. Journal of Bone and Joint Surgery. American Volume 1956 38-a 761–781.
- 37↑
Outland T. Sprains and separations of the inferior tibiofibular joint without important fracture. American Journal of Surgery 1943 59 320–329. (https://doi.org/10.1016/S0002-9610(4390419-2)
- 38↑
Hoefnagels EM, Waites MD, Wing ID, Belkoff SM, & Swierstra BA. Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament. Foot and Ankle International 2007 28 602–604. (https://doi.org/10.3113/FAI.2007.0602)
- 39↑
Rammelt S, Zwipp H, & Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot and Ankle Clinics 2008 13 611–633. (https://doi.org/10.1016/j.fcl.2008.08.001)
- 40↑
McCullough CJ, & Burge PD. Rotatory stability of the load-bearing ankle. An experimental study. Journal of Bone and Joint Surgery 1980 62-B 460–464.
- 41↑
Snedden MH, & Shea JP. Diastasis with low distal fibula fractures: an anatomic rationale. Clinical Orthopaedics and Related Research 2001 382 197–205. (https://doi.org/10.1097/00003086-200101000-00027)
- 42↑
Purcell KF, Bergin PF, Russell GV, Graves ML, Jones LC, & Spitler CA. Tibial shaft and Pilon fractures with associated syndesmotic injury: a matched cohort assessment. Journal of Orthopaedic Trauma 2022 36 157–162. (https://doi.org/10.1097/BOT.0000000000002252)
- 43↑
Kellam PJ, Dekeyser GJ, Haller JM, Rothberg DL, Higgins TF, & Marchand LS. Predicting syndesmotic injury in OTA/AO 44-B2.1 (Danis-Weber B) fractures. Journal of Orthopaedic Trauma 2021 35 473–478. (https://doi.org/10.1097/BOT.0000000000002052)
- 44↑
Hunt KJ, Phisitkul P, Pirolo J, & Amendola A. High ankle sprains and syndesmotic injuries in athletes. Journal of the American Academy of Orthopaedic Surgeons 2015 23 661–673. (https://doi.org/10.5435/JAAOS-D-13-00135)
- 45↑
Spindler FT, Herterich V, Holzapfel BM, Bocker W, Polzer H, & Baumbach SF. A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries. EFORT Open Reviews 2022 7 671–679. (https://doi.org/10.1530/EOR-22-0037)
- 46↑
Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, Stewart JP, & Maloney J. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993 269 1127–1132. (https://doi.org/10.1001/jama.269.9.1127)
- 47↑
Netterstrom-Wedin F, & Bleakley C. Diagnostic accuracy of clinical tests assessing ligamentous injury of the ankle syndesmosis: a systematic review with meta-analysis. Physical Therapy in Sport 2021 49 214–226. (https://doi.org/10.1016/j.ptsp.2021.03.005)
- 48↑
Sman AD, Hiller CE, & Refshauge KM. Diagnostic accuracy of clinical tests for diagnosis of ankle syndesmosis injury: a systematic review. British Journal of Sports Medicine 2013 47 620–628. (https://doi.org/10.1136/bjsports-2012-091702)
- 49↑
Schwieterman B, Haas D, Columber K, Knupp D, & Cook C. Diagnostic accuracy of physical examination tests of the ankle/foot complex: a systematic review. International Journal of Sports Physical Therapy 2013 8 416–426.
