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Lower Limb Injury
The ‘stable/unstable’ chronic isolated anterior syndesmotic injury: A presentation of three cases and a new surgical technique
  1. L Laver,
  2. S Massarwa,
  3. G Mann,
  4. O Mei-Dan,
  5. G Maoz,
  6. M Nyska
  1. Department of Orthopedic Surgery and Sports Medicine ‘Me'ir’ Medical Center, Kfar-Saba, Israel
  1. Email: laver17{at}


Background Isolated syndesmotic injuries are reported to comprise 1–11% of all ankle sprains. This number may increase to more than 40% in those involved in high contact and collision sports. These injuries are frequently under-diagnosed often being mistaken for the more common lateral ankle sprains and are inadequately treated as a result, leading to chronic syndesmotic instability. When instability can be objectively documented with clinical and radiographic measures it is defined as mechanical instability. When it is only based on clinical symptoms, it is defined as functional. Symptoms vary from long standing pain, stiffness, recurrent swelling and an instability sensation without actual giving way or mechanical correlation. It may lead often to functional disability and substantial activity restriction. Imaging of the instability may be performed by dynamic ultrasound. However if there is no instability proven in imaging, the surgical decision to explore the syndesmosis is problematic. Proven pathology in the syndesmosis in MRI or CT may serve as relative indication for operation. Surgical options for chronic anterior syndesmotic proven instability include combinations of debridement, ligamentoplasty with varying graft options, syndesmotic screw fixation, translation osteotomy of AITFL insertion and arthroscopic debridement with graft reconstruction and screw fixation – with most techniques reporting satisfying results. There are no clear indications of surgical approach to stable syndesmotic injury.

Setting, participants and methods We present three cases of chronic anterior syndesmotic instability suffering from chronic pain and instability sensation, all of which were stable upon radiographic evaluation including Dynamic US examination. MRI disclosed pathology in the anterior synsesmosis – with mainly scar tissue present. All three cases were operated and proven unstable upon in-operative mechanical examination after debridement of the scar tissue. The anterior syndesmosis was reconstructed using figure of eight suturing of the Chaput process to the anterior Fibula. In 6–18 months followup the patients recovered from their symptoms and returned to full activity.

Results and conclusions In cases of stable symptomatic syndesmosis injuries there is indication for exploration of the anterior syndesmosis and stabilization if proven unstable.

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