Tips, Quips, and Pearls| Volume 49, ISSUE 5, P495-500, September 2010

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Tri-ligamentous Reconstruction of the Distal Tibiofibular Syndesmosis: A Minimally Invasive Approach


      The distal tibiofibular syndesmosis provides stability to the ankle mortise, and it is composed of the anterior inferior tibiofibular, posterior inferior tibiofibular, interosseous, and inferior transverse tibiofibular ligaments and the interosseous membrane. Subacute or chronic syndesmosis injuries can present after missed diagnosis in the acute period or after failed or inadequate nonoperative management. It can result in chronic ankle pain and progressive degeneration of the ankle. Reconstructive options for chronic syndesmosis disruption include arthroscopic debridement and screw fixation, arthrodesis of the syndesmosis, advancement of the anterior tibiofibular ligament, reconstruction of the interosseous and anterior inferior tibiofibular ligament, or tri-ligamentous reconstruction of the syndesmosis. We describe a minimally invasive technique of nearly anatomical reconstruction of the 3 syndesmotic ligaments. The syndesmosis is debrided and reduced under arthroscopic guidance and anatomical reduction of the syndesmosis can be achieved. Although we describe this technique for surgeons to consider, we recognize that a thorough clinical review of the method, complete with objective and subjective clinical outcome measurements, is warranted before widespread use of the technique.


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        • Bartoníček J.
        Anatomy of the tibiofibular syndesmosis and its clinical relevance.
        Surg Radiol Anat. 2003; 25: 379-386
        • Smith K.M.
        • Kovacich-Smith K.J.
        • Witt M.
        Evaluation and management of high ankle sprains.
        Clin Podiatr Med Surg. 2001; 18: 443-456
        • Sora M.C.
        • Strobl B.
        • Staykov D.
        • Forster-StreZeur S.
        Evaluation of the ankle syndesmosis: a plastination slices technique.
        Clin Anat. 2004; 17: 513-517
        • Zwipp H.
        • Rammelt S.
        • Grass R.
        Ligamentous injuries about the ankle and subtalar joints.
        Clin Podiatr Med Surg. 2002; 19: 195-229
        • Thordarson D.B.
        • Motamed S.
        • Hedman T.
        • Ebramzadeh E.
        • Bakshian S.
        The effect of fibular malreduction on contact pressure in an ankle fracture malunion model.
        J Bone Joint Surg. 1997; 79A: 1809-1815
        • Harper M.C.
        Delayed reduction and stabilization of the tibiofibular syndesmosis.
        Foot Ankle Int. 2001; 22: 15-18
        • Ogilvie-Harris D.J.
        • Reed S.C.
        Disruption of the ankle syndesmosis: diagnosis and treatment by arthroscopic surgery.
        Arthroscopy. 1994; 10: 561-568
        • Beumer A.
        • Heijboer R.P.
        • Fontijne W.P.J.
        • Swierstra B.A.
        Late reconstruction of the anterior distal tibiofibular syndesmosis. Good outcomes in 9 patients.
        Acta Orthop Scand. 2000; 71: 519-521
        • Morris M.W.
        • Rice P.
        • Schneider T.E.
        Distal tibiofibular syndesmosis reconstruction using a free hamstring autograft.
        Foot Ankle Int. 2009; 30: 506-511
        • Zamzami M.M.
        • Zamzam M.M.
        Chronic isolated distal tibiofibular syndesmotic disruption: diagnosis and management.
        Foot Ankle Surg. 2009; 15: 14-19
        • Grass R.
        • Rammelt S.
        • Biewener A.
        • Zwipp H.
        Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis.
        Foot Ankle Int. 2003; 24: 392-397
        • Hoefnageis E.M.
        • Waites M.D.
        • Wing I.D.
        Biomechanical comparison of the interosseous tibiofibular ligament and the anterior tibiofibular ligament.
        Foot Ankle Int. 2007; 28: 602-604
        • Beumer A.
        • van Hemert W.L.
        Radiographic measurement of distal tibiofibular syndesmosis has limited use.
        Clin Orthop Relat Res. 2004; 423: 227-234
        • Chan K.B.
        • Lui T.H.
        Isolated anterior syndesmosis diastasis without fracture.
        Arch Orthop Trauma Surg. 2007; 127: 321-324
        • Lui T.H.
        • Ip K.Y.
        • Chow H.T.
        Comparison of radiological diagnosis and arthroscopic diagnosis of distal tibiofibular syndesmosis disruption in acute ankle fracture.
        Arthroscopy. 2005; 21: 1370-1374
        • Nielson J.H.
        • Gardner M.J.
        • Peterson M.G.E.
        • Sallis J.G.
        • Potter H.G.
        • Helfet D.L.
        • Lorich D.G.
        Radiographic measurements do not predict syndesmotic injury in ankle fractures. An MRI study.
        Clin Orthop Relat Res. 2005; 436: 216-221