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Syndesmosis Reconstruction: Surgery & Recovery

Syndesmosis reconstruction is a surgical procedure to restore the ligamentous connection between the tibia and fibula after injury to the ankle joint.

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Syndesmosis reconstruction is a surgical procedure to restore the ligamentous connection between the tibia and fibula after injury to the ankle joint.

What is Syndesmosis Reconstruction?

Syndesmosis reconstruction is a surgical procedure aimed at restoring the distal tibiofibular syndesmosis – the ligamentous connection between the tibia (shinbone) and fibula (calf bone) at the level of the ankle joint. This structure is essential for maintaining the stability and proper alignment of the ankle, enabling normal weight-bearing and movement. When this connection is severely damaged due to trauma or chronic instability, surgical reconstruction becomes necessary.

Causes and Indications

Reconstruction of the syndesmosis is indicated when the ligaments are so severely injured that they can no longer provide sufficient joint stability. Common causes and clinical situations requiring this procedure include:

Severe ankle sprains with complete ligament rupture
Bimalleolar or trimalleolar fractures involving the syndesmosis
Maisonneuve fractures (high fibular fracture with syndesmotic disruption)
Chronic syndesmotic instability following unrecognized or inadequately treated injuries
Post-traumatic ankle osteoarthritis resulting from prolonged instability

Diagnosis

Diagnosis of a syndesmotic injury is based on clinical examination and imaging:

Physical examination: Specialized tests such as the squeeze test and the external rotation stress test are used to assess instability.
X-rays: Evaluation of the tibiofibular clear space and overlap, as well as medial clear space.
Magnetic resonance imaging (MRI): Detailed assessment of the ligaments and soft tissues to determine the extent of injury.
Computed tomography (CT): Precise bone assessment, especially in complex fractures.

Treatment: Surgical Techniques

The surgical technique chosen for syndesmosis reconstruction depends on the severity of injury, whether the injury is acute or chronic, and individual patient factors:

Acute Reconstruction

For recent injuries, syndesmotic screw fixation is commonly used to temporarily stabilize the tibiofibular relationship. An increasingly popular alternative is the use of suture-button devices (e.g., the TightRope system), which provide dynamic stabilization and allow earlier mobilization compared to rigid screws.

Chronic Reconstruction

In cases of long-standing instability, more complex reconstruction is often required. Surgeons may use tendon grafts (e.g., from the plantaris or gracilis tendon) or ligament reconstruction techniques to permanently replace the destroyed ligamentous structures.

Arthroscopic Assistance

The procedure is frequently performed with arthroscopic assistance to assess cartilage integrity and address any additional intra-articular pathology at the same time.

Postoperative Care and Rehabilitation

Postoperative rehabilitation is crucial to a successful outcome and typically includes:

Immobilization: A cast or orthotic boot is worn for several weeks initially.
Physiotherapy: Targeted exercises to restore strength, proprioception, and range of motion.
Progressive weight-bearing: Gradual increase in load under medical supervision.
Screw removal: When syndesmotic screws are used, removal is typically performed after 8–12 weeks.
Return to sport: Athletes may return to full activity after several months, depending on individual recovery.

Risks and Complications

As with any surgical procedure, syndesmosis reconstruction carries potential risks, including:

Wound or joint infection
Nerve or vascular injury
Implant failure or loosening
Malreduction of the syndesmosis
Post-traumatic ankle osteoarthritis
Recurrent instability due to inadequate healing

References

Schnetzke M, Vetter SY, Porschke F, Grutzner PA, Guehring T. Outcome of anatomic ligament repair and secondary procedures of the distal tibiofibular syndesmosis. J Orthop Surg Res. 2019;14(1):171.
Schepers T. The syndesmotic screw and early weight bearing: a review of the literature. Foot Ankle Surg. 2011;17(1):3-6.
Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994;10(5):558-560.

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