syndesmotic injuries are serious injuries around ankle but often neglected or under treated. this may lead to short term and longterm disabilities including early arthritis . treatment of late case and neglected cases often result in suboptimal outcome. in this presentation very experienced senior orthopaedic surgeons present the importance technics and outcome of anatomical repaie of syndesmotic injuries. the presentation is from TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS KOLLAM [QUILON] KERALA INDIA. DR GOKUL DEV IS A WELL KNOWN TRAUMA SURGEON AND DR MOHAMED ASHRAF WAS THE FORMER HOD ORTHOPAEDICS AT GOVT TD MEDICAL COLLEGE ALLEPPEY KERALA WITH MULTIPLE SLIDESHARE UPLOADS

1. syndesmostic injury- anatomical
repair
AUTHOR-DR GOKULDEV V ,ASSISTANT PROFESSOR
dr_gokuldev@yahoo.com
CO-AUTHOR-DR MOHAMED ASHRAF,PROF AND HOD,
[former HOD TDMC ALLEPPEY KERALA]
drashraf369@gmail.com
DEPT OF ORTHOPAEDICS
TRAVANCORE MEDICAL COLLEGE AND MEDICITY HOSPITALS
KOLLAM,KERALA,INDIA

2. EPIDEMIOLOGY
• SYNDESMOSIS INJURIES -20–45% OF MALLEOLAR FRACTURES AND 5–11% OF ANKLE DISTORTIONS1
• 1 MM OF TALAR SHIFT DECREASES CONTACT AREA BY 40%- POST TRAUM DEG CHANGES 2
1.Gardner et al Foot Ankle Int 2006;27:788-792
2. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796.
3. Ramsey PL, Hamilton et al. J Bone Joint Surg Am.
1976;58:356–357.

3. • POSTOPERATIVE SYNDESMOSIS
MALREDUCTION RATES OF 16% DETECTED ON
PLAIN RADIOGRAPHS AND UP TO 52% ON CT
SCAN
1. Lloyd J et al,. Foot Ankle Int. 2006;27:793-796.
2. Ramsey PL, Hamilton et al. J Bone Joint Surg Am. 1976;58:356–357

4. WHAT ARE WE DOING FOR ACCURATE
REDN NOW?
CLOSED REDUCTION AND SCREW FIXATION UNDER C- ARM
CRIF WITH INTRA OP CT- NOT FEASIBLE IN OUR SETUP
CRIF WITH 3D CT IMAGING-NOT FEASIBLE IN OUR SETUP
ALSO DIFFERENT IMPLANT CONFIGURATIONS FOR STABILISATION
• ONE SCREW VS TWO SCREWS VS QUAD SCREWS
• SUTURE BUTTON
• SUTURE BUTTON + SCREW

5. ANATOMY
•Anterior-inferior tibiofibular
ligaments (AITFL)
•Posterior-inferior tibiofibular
ligament (PITFL)
•Interosseous membrane
•Interosseous ligament (IOL)
•Inferior transverse ligament
(ITL)

6. WHY ANATOMICAL
REPAIR?
• ANATOMICAL APPROACH - DECREASES
SYNDESMOSIS MALREDUCTION FROM
33.3% TO 7.4%
• THE POSTERIOR SYNDESMOSIS COMPLEX
COMPRISES THE PITFL AND ITS BONY
FIXATION, THE DORSAL ASPECT OF THE
DISTAL TIBIA, COMMONLY REFERRED TO AS
THE POSTERIOR MALLEOLUS (PM).

7. MRI

8. ULTRASONOGRAPHY

9. RADIOLOGY
• XRAYS PROVIDE SUBTLE SIGNS
OF SYNDESMOTIC INJURY IN
ABSENCE OF FRACTURE

10. RADIOLOGY

11. • INTRA OP THIS LIGAMENT IS
BROAD AND THIN, COMPARED
TO PITFL.
• HENCE MORE SUBSTANCE TEARS
THAN AVULSION #
Posterior tibiofibular ligament
The posterior tibiofibular ligament is stronger than the anterior, and is disposed similarly on
the posterior aspect of the syndesmosis. Its distal, deep part is the inferior transverse
ligament, a thick band of yellow fibres which crosses from the proximal end of the lateral
malleolar fossa to the posterior border of the tibial articular surface
GRAYS ANATOMY 14EDTN

12. RECENT AVULSION# AITFL

13. • MECHANISM OF INJURY ARE EXTERNAL ROTATION
,HYPERDORSIFLEXION AND TALAR EVERSION.
• GRADE 3 LIGAMENT INJURY – DELTOID, MCL IN KNEE ARE FIXED,
WHY NOT AITFL?
Joy G, Patzakis MJ, Harvey Jr JP. J Bone Joint Surg Am 1974;56:979–93.
Van Heest TJ, Lafferty PM. J Bone Joint Surg Am 2014;96:603–13.

14. Why fix
• ANATOMICALLY FIXED POSTERIOR MALLEOLAR FRACTURE MAY
RESTORE THE POSTERIOR FIBULAR INCISURA, WHICH AIDS IN THE
SUBSEQUENT REDUCTION OF THE FIBULA INTO ITS GROOVE,
CORRECTLY TENSIONS THE PITFL AND IMPROVES SYNDESMOTIC
STABILITY.
• WHY NOT FIX AITFL?
Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures
provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–71.
Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Posterior malleolar stabilization of
syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 2010;468:1129–35.

16. Inadequately reduced ankle
syndesmosis as evidenced by the TFL

17. How we do it?
AITFL AWAITING
REPAIR

18. PASSING SUTURES

19. ADDITIONAL STABILISATION
• SYNDESMOTIC SCREW FIXATION
• FIBER TAPE ENDOBUTTON

20. Repaired AITFL

21. Postop rehab
• NON WEIGHT BEARING TILL 10 DAYS / SUTURE
REMOVAL
• TOE TOUCH WEIGHT BEARING WAS GIVEN AFTER
SUTURE REMOVAL IN A FUNCTIONAL CAST FOR NEXT 3
WEEKS
• ONCE CAST REMOVED ON 4-5TH WEEK, PROGRESSIVE
IMPROVEMENT OF ROM AS TOLERATED AND
ISOMETRIC STRENGTHENING
• 6-7TH WEEK- DORSIFLEXION STRETCHING AND
PROGRESSIVE WEIGHT BEARING,ONCE SYNDESMOTIC
SCREW IS REMOVED
• 8-9TH WEEK-RESISTIVE STRENGTHENING, ACHIEVE FULL
ROM

22. METHODS
20 patients were included in this study, all age groups
Male
75%
Female
25%
GENDER
0
5
10
15
BIMAL TRIMAL
6
14
TYPE OF FRACTURE
0
5
10
15
age 20-50 age > 50
12
8
AGE

23. statistics
• 14 patients had posterior malleolus fracture with avulsion of AITFL
• 4 patients had only anterior syndesmotic injury
Posterior malleolus was fixed with T-plate through posterolateral
approach.
Anterior separate incision for additional stabilization and exploration of
AITFL and repair using ethibond 1-0.
20%
70%
10%
LIGAMENT INJURY ANTERIOR ONLY AND
COMBINED
ANT COMB without

24. FUNCTIONAL
OUTCOME-
OMAS

25. RESULTS
Average scores at 82.3 in 3 months and 90.7 in 6 months follow up
for 16 patients(Olerud-Molander Ankle Score)
Average score 78.4 in 2 patients in 3 months and 6 months
69.3 in 2 patients in 6 months follow up.
We find that there is early return of patients to there occupation
when anatomical repair was done.

26. Conclusion
• Conventional treatment -unacceptably high rate of malreduction, -led
to a paradigm shift in the approach to a newer concept of anatomical
repair.
• LIGAMENTS NEED ACCURATE APPOSITION FOR PERFECT HEALING-
GAP LEADS TO SCARRING AND ELONGATION
• The principle -‘directly fix what is broken and repair what is torn’.
• The approach is effective in reducing the rate of syndesmosis
malreduction, increasing the biomechanical strength of syndesmosis
fixation.
Mak MF, Stern R, Assal M. Repair of syndesmosis injury in ankle fractures: Current state of the art. EFORT Open Rev. 2018
Jan 25;3(1):24-29. doi: 10.1302/2058-5241.3.170017. PMID: 29657842; PMCID: PMC5890127.

27. THANKYOU
“DIRECTLY FIX WHAT IS
BROKEN AND REPAIR
WHAT IS TORN”

28. Medicity
kollam
kerala
india