Fixation of the syndesmosis remains a hot topic in foot and | Figure 1

KennethAllen
Orthopedic Surgery

Fixation of the syndesmosis remains a hot topic in foot and ankle injuries with many different angles on the issue, one of which being over-compression. While some believe this phenomenon to be irrelevant, others (including myself) believe that it is a factor in patient outcomes, with residual pain and dysfunction in an otherwise anatomically reduced ankle being related to a tight syndesmosis. While clinical outcome studies seem to be lacking still, this article in FAI from 2016 by Haynes et al demonstrates that adequate reduction is achieved with around 130N, and that over-compression (as determined by a difference of 1mm) is possible with utilizing a reduction clamp too forcefully. The associated image is from a case of mine demonstrating significant increase in the tibia-fibula overlap with clamp application by a resident, resulting in the talus being spit out of the ankle mortise. Keys in using clamp reduction are matching the joint line and the vector of the syndesmosis to avoid malreduction, and not using excessive force. For those wondering what 130N equates to in a real life application, unpublished data with a load cell shows it's similar to the pressure needed to crumple an empty beer can. Hopefully everyone will have a chance to apply some orthopaedic knowledge over this holiday weekend to practice for their next case...

Similar cases

\ while riding young daughter's bike, 32 yo male's ankle slips under bike while pedaling and is run over taking the full force of the man's weight: pre and post-reduction

\ Follow up case to open ankle fracture dislocation

1. We reduced/fixed the medial malleolus
2. Reduced the fibula (making sure it is out to length), then applied 1/3 tubular overlapping plates to get a long enough plate for desired fixation
3. Reduced the syndesmosis with a large clamp over fibula and medial tibia and secured with fiberwire “tightrope” fixation
   On the lateral approach to the fibula what nerve do you have to watch out for? And what do you do when the patient says they can’t move or feel their foot after surgery?

\ Ankle fracture, provisionally reduced and splinted, morphine and entonox used, the patient preferred not to be sedated, where does he go from here and why is reduction in ED important?

\ A 28M presented to my clinic after a reported ankle sprain 4 weeks ago. The patient has had previous sprains which he reports recovering well from but notes this one is “different.” He continues to have difficulty with weight bearing even in a brace and has not been able to return to anything beyond walking, which he notes is painful. His exam showed tenderness along the distal syndesmosis instead of the anterolateral distal fibula. X-rays were negative for any fractures about the ankle or length of the fibula, and he was unable to tolerate a syndesmosis stress exam in clinic. I elected to take him to the OR for arthroscopy and likely syndesmosis stabilization. His c-arm image showed diminished tib-fib overlap even without stress. Arthroscopy stress demonstrates hemorrhagic tissue and a clear A to P instability with external rotation, as well as some diastasis. I elected to perform a two-suture button stabilization with finger reduction technique as the remainder of the arthroscopy demonstrated no other intra-articular findings.