Case for small group discussion Syndesmotic injury Case for small group discussion AOTrauma—Foot & Ankle Module 7: Ankle arthritis Stefan Rammelt, DE

Case description 36-year-old woman 9 months after malleolar fracture treated operatively Nonweight bearing for 6 months Diastasis after removal of syndesmotic screw Pain over medial malleolus and syndesmosis, increasing after weight bearing, swelling Regular pain medication

Discussion points What type of deformity is present? Which problems might arise from leaving as is? from intervening? What would be your operative plan?

Implant removed—8 months later, ongoing pain

X-rays and CT scans—standing (17 months after injury)

Intraoperative Frick test (external rotation) Syndesmosis stressed Syndesmosis unstressed

Intraoperative Frick test (external rotation)

Peroneus longus ligamentoplasty Principle—reconstruction of anterior inferior tibiofibular ligament (AITFL), inferior transverse tibiofibular ligament (IOTFL), posterior inferior tibiofibular ligament (PITFL) Grass R, Rammelt S, Biewener A, et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int. 2003 May;24(5):392–397.

Reconstruction of the interosseous ligament

Debridement of medial clear space (MCS)

Fixation of graft and syndesmotic screw

Correction Syndesmotic screw and partial weight bearing for 8 weeks

Take-home messages Radiographic landmarks—tibiofibular and medial clear space Exact reduction of distal fibula into the tibial incisura Syndesmostic screw removed after 8 weeks Anatomical ligamentoplasty (half of peroneus longus tendon) for chronic instability Reconstruction of all three major components Correction of bony malunions as needed Frick H. [Diagnosis, therapy and results of acute instability of the syndesmosis of the upper ankle joint (isolated anterior rupture of the syndesmosis)]. Orthopäde. 1986 Nov;15(6):423–426. German. Grass R, Rammelt S, Biewener A, et al. Peroneus longus ligamentoplasty for chronic instability of the distal tibiofibular syndesmosis. Foot Ankle Int. 2003 May;24(5):392–397. Rammelt S, Zwipp H, Grass R. Injuries to the distal tibiofibular syndesmosis: an evidence-based approach to acute and chronic lesions. Foot Ankle Clin. 2008 Dec;13(4):611–633, vii–viii. Grass et al. Foot Ankle Int. 2003;24:392–397. Frick. Orthopäde. 1986;15:423–426. Rammelt et al. Foot Ankle Clin. 2008;13:611–633, vii–viii.