# Ins and Outs of the Ankle Syndesmosis from a 2D to 3D CT Perspective  
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1 Faculty of Medicine and Health Sciences, Ghent University, 9000 Gent, Belgium 1  
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1 Faculty of Medicine and Health Sciences, Ghent University, 9000 Gent, Belgium 1  
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2 Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, 9000 Ghent, Belgium 2  
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3 Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands 3  
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4 Department of Orthopedic and Traumatology, Istanbul University-Cerrahpasa, 34320 Istanbul, Turkey 45 CAST-Cerrahpasa Research, Simulation and Design Laboratory, Istanbul University-Cerrahpasa, 34320 Istanbul, Turkey 5  
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6 Department of Orthopedics and Traumatology, Universitatsspital Basel, 4031 Basel, Switzerland 6  
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2 Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, 9000 Ghent, Belgium 2  
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2 Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, 9000 Ghent, Belgium 2  
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risk include athletes, females, children, adolescents, and patients with a history of ankle sprains [7]. The diagnosis of syndesmotic injuries is crucial as untreated or misdiagnosed lesions can lead to irreversible, long-term morbidity such as pain, poor function, mortise incongruence, early osteoarthritis, anterolateral soft tissue impingement, and local synovitis [4; 8; 9; 10]. An accurate diagnosis can be obscured due to the low sensitivity and specificity of the clinical examination tests (i.e., ligament palpation tenderness, external rotation stress test according to Frick, squeeze test, cotton test, and fibula translation test) [11; 12]. Consequently, advanced imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), or arthroscopy are indispensable in current clinical practice [3; 13; 14]. Although arthroscopy is the most reliable method for diagnosis, it is hampered by its invasive nature, cost, and lack of native contralateral reference [9; 10; 13; 14]. Therefore, non-invasive imaging modalities have been broadly described to visualize the syndesmosis and detect injury. However, their true value in diagnosing instability and integrity remains equivocal [8; 14; 15]. Radiographs are poorly sensitive and may be valuable only in cases of severe instability [8; 9]. Furthermore, the position of the hindfoot during radiography affects the measurements subsequently [16]. Supine CT, on the other hand, has improved levels of sensitivity, but it underestimates the extent of subtle lesions due to its non-weight-bearing and non-dynamic nature [3; 10].