Syndesmotic Behavior after Sequential Sectioning: Simulation of Ligamentous Ankle Injuries in Vitro
Authors: Blom Robin P. , Emanuel Kaj S. , Knupp Markus , Sierevelt Inger N. , Kerkhoffs Gino M.M.J. , Stufkens Sjoerd A. 
Published: October 2019

Category: Ankle, Trauma, Distal Tibiofibular Joint Introduction/Purpose: Ankle fractures are often associated with ligamentous injuries of the distal tibiofibular syndesmosis and the deltoid ligament. These injuries may predispose to instability, early joint degeneration and long-term ankle dysfunction. In the classic article of Boden it was made clear that injuries of the syndesmotic ligaments were of no importance in absence of a deltoid ligament rupture. Even in the presence of a deltoid ligament rupture, the interosseous membrane withstood lateralization of the talus in fixated fibula fractures up to 4.5 mm above the ankle joint. However, detection of ligamentous injuries and the need for treatment remain subject of ongoing debate. Syndesmotic injuries are often treated operatively by temporary fixation performed with positioning screws. But do isolated syndesmotic injuries need to be treated operatively at all? Methods: Ten fresh-frozen, exarticulated through the knee, human cadaveric lower limbs were tested under axial compressive loads of 50 and 700 N, simulating non-weightbearing and weightbearing conditions. All specimens were tested with different foot positions (plantigrade, dorsiflexion, inversion, eversion, and 10 Nm external rotational torque) during sequential sectioning of the syndesmotic ligaments and the deltoid ligament. We triangulated Boden’s classic findings with an active motion capture system (0.1 mm accuracy) to track the translations and rotations of the fibula relative to the tibia. Results: Isolated sectioning of the AITFL resulted in an increase of external fibula rotation up to 8.9 degrees (doubling the physiological 4.0 degrees) with an external rotation stress of 10 Nm in non-weightbearing conditions. However, weightbearing appeared somewhat protective, reducing the external rotation to 7.9 degrees. Sectioning of all syndesmotic ligaments with an intact deltoid ligament resulted in a syndesmotic widening of 0.9 mm in weightbearing conditions with a plantigrade foot. Dorsiflexion of the foot resulted in a significant increase of syndesmotic widening for all conditions of the syndesmotic ligaments. Sectioning of the deltoid ligament resulted in a significant increase of all fibula translations in all foot positions during weightbearing conditions. Conclusion: The results of our study have implications for common ligamentous ankle injuries and their treatment. In isolated syndesmotic injuries with a plantigrade foot, weightbearing seemed protective and limiting syndesmotic widening probably due to the saddle shape of the tibiotalar surface. Conservative treatment in a cast seems justifiable. External rotation stress causes the “open-book-phenomenon” in isolated AITFL injuries, especially in non-weightbearing conditions. Protection with cast or surgery is necessary. The deltoid ligament prevents lateralization of the talus but allows increased syndesmotic widening and external rotation of the fibula in dorsiflexion and external rotation stress due to the shape of the talus.