SLR - August 2022 - Clint Jiroux, DPM, MS
Reference: Hunt K., Bartolomei, J., Challa, S. C., McCormick, J. J., D'Hooghe, P., Tuffiash, M., & Amendola, A. (2021). Significant variations in surgical construct and return to sport protocols with syndesmotic injuries: an ISAKOS global perspective. Journal of ISAKOS, 7(1), 13–18. https://doi.org/10.1016/j.jisako.2021.10.005Level of Evidence: Level IV
Scientific Literature Review
Reviewed by: Clint Jiroux, DPM, MS
Residency Program: Mount Auburn Hospital, Cambridge, Massachusetts
Podiatric Relevance: Syndesmotic injury and the available fixation constructs are numerous, with each having their own biomechanical characteristics. Static versus dynamic fixation comparatively are two unique constructs to stabilize the inured syndesmosis. Decision making of the type of fixation is specific to patient demographic and trauma scenarios. Ankle injuries are one of the most common injuries of the lower extremity, which if involve a syndesmotic injury, can lead to longer recover time and extended time to play for athletes. The foot and ankle specialist should understand the available fixation options.
Methods: The authors surveyed participants in six national and internal orthopedic and foot and ankle societies. Participants were invited to answer twenty-seven questions including their demographics, indications for treatment of syndesmotic injuries, preferred treatment/technique, and post-op management. The athlete scenarios were stratified into moderate impact, high impact, and very high impact athletes with/without deltoid injury for all categories. All responses were counts and percentages.
Results: The study surveyed 742 providers in total. Flexible devices were the preferred device construct (47.1 percent), followed by screws (29.6 percent), hybrid fixation (flexible and screw combination, 18 percent) and other (5.3 percent). There was considerable inter-respondent variability regarding the return to activity times for athletes in syndesmotic repair. Variability was dependent on the presence or absence of a deltoid ligament repair. No widely accepted MRI finding as an indication for operative repair, with (63.9 percent) respondents stating there was not a sole indication. Less than a quarter (145/609; 23.8 percent) indicating that an interosseus membrane injury > 5 centimeters as a sole indicator for operative treatment. A posterior inferior talofibular ligament or deltoid injury accounted for 20.7 percent of sole indication for operative treatment. Radiographically evidence of >2 millimeters of medial clear space widening on stress test, (71 percent) of responders stated as a sole indication of operative treatment.
Conclusion: The authors of the study concluded that they witnessed consistency regarding the diagnostic criteria indicating surgical intervention. In the study, most of the participants preferred flexible fixation over screw or hybrid. I agree with findings in the article that flexible fixation due to its is the most prevalent and allows for a dynamic fixation of the syndesmosis would see a higher trend. There is less risk in malediction compared to screw fixation and allows a biomechanical advantage to other constructs. In my own practice it will be patient specific. I believed that the BMI, PMH (diabetes/peripheral neuropathy) and level of activity of the patient should all contribute to the decision-making process of syndesmotic fixation construct. A high clinical suspicion of syndesmotic injury should be considered when higher level ankle trauma is seen, and imaging can ultimately help confirm the diagnosis.