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Syndesmosis Repair: Ankle Surgery Explained

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

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Things worth knowing about "Syndesmosis repair"

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

What is Syndesmosis Repair?

Syndesmosis repair is a surgical procedure in orthopedic and trauma surgery aimed at reconstructing the distal tibiofibular syndesmosis following an injury. The syndesmosis refers to the fibrous joint connecting the tibia (shinbone) and fibula (calf bone) just above the ankle joint. It consists of several ligaments, primarily the anterior and posterior tibiofibular ligaments and the interosseous membrane. This connection is essential for the stability and normal function of the ankle joint.

Causes and Indications

Syndesmosis injuries typically occur during ankle sprains, ankle fractures, or combined injuries. Common causes include:

Forceful external rotation or pronation of the foot
Sports injuries, especially in soccer, basketball, or skiing
Falls from height
Road traffic accidents

Syndesmosis repair is indicated when a complete ligamentous rupture results in an unstable ankle joint and conservative management is insufficient. It is particularly common in higher-grade ankle fractures such as Weber B and Weber C fractures, where operative stabilization of the syndesmosis is necessary.

Diagnosis

Diagnosis of a syndesmotic injury is established through:

Clinical examination: Tenderness over the anterior syndesmosis, positive squeeze test, positive external rotation test
X-ray imaging: Assessment of fracture lines and joint space
Magnetic resonance imaging (MRI): Visualization of ligaments and soft tissue
Computed tomography (CT): Used in complex injury patterns or unclear findings

Surgical Technique

During syndesmosis repair, the ruptured ligaments between the tibia and fibula are directly sutured and reconstructed. The surgical steps typically include:

Reduction: Restoring the correct anatomical alignment of the tibia and fibula.
Ligament suture: The torn ligaments are re-approximated using absorbable or non-absorbable sutures.
Additional stabilization: The syndesmosis is often further secured using a syndesmotic screw or a TightRope device (a flexible suture-button construct), either temporarily or permanently.
Intraoperative imaging: Fluoroscopic control is performed to confirm correct joint alignment.

Postoperative Care and Rehabilitation

Structured rehabilitation after surgery is critical for a successful outcome:

Immobilization: The ankle is immobilized in a cast or orthotic boot for several weeks.
Gradual weight-bearing: Progressive loading is typically initiated after four to six weeks.
Physiotherapy: Targeted exercise to restore strength, range of motion, and proprioception.
Screw removal: If a syndesmotic screw was used, it is generally removed in a second procedure after eight to twelve weeks.

Risks and Complications

As with any surgical procedure, syndesmosis repair carries certain risks:

Wound infections
Nerve or vascular injuries
Deep vein thrombosis
Implant failure or screw breakage
Persistent instability or joint stiffness
Post-traumatic ankle arthritis

Prognosis

When performed correctly and followed by consistent rehabilitation, the prognosis after syndesmosis repair is generally favorable. The majority of patients achieve full or near-full restoration of ankle function. Return to sport is typically possible within three to six months, depending on the severity of the injury and the individual healing process.

References

Egol, K. A. et al. - Handbook of Fractures. 5th edition. Wolters Kluwer, Philadelphia, 2014.
Switaj, P. J. et al. - Diagnosis and Treatment of Syndesmotic Injuries. In: Orthopedic Clinics of North America, 47(1), 143-153, 2016. PubMed PMID: 26614929.
Williams, B. T. et al. - Syndesmosis Injuries in Acute Ankle Fractures. In: Journal of the American Academy of Orthopaedic Surgeons, 23(12), 751-760, 2015. PubMed PMID: 26510624.

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