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

2. 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

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

4. Implant removed—8 months later, ongoing pain

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

6. Intraoperative Frick test (external rotation)
Syndesmosis stressed
Syndesmosis unstressed

7. Intraoperative Frick test (external rotation)

8. 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 May;24(5):392–397.

9. Reconstruction of the interosseous ligament

10. Debridement of medial clear space (MCS)

11. Fixation of graft and syndesmotic screw

12. Correction
Syndesmotic screw and partial weight bearing for 8 weeks

13. 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 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 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 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.