[Arthroscopy in the treatment of acute and chronic syndesmotic injuries of the ankle joint].

Abstract

Objective: Identification and treatment of concomitant intra-articular pathologies, verification of syndesmotic instability, debridement of syndesmotic structures in chronic injuries, reduction, and retention of the fibula in the distal tibiofibular joint.

Indications: Acute and chronic two- or three-ligamentous syndesmotic ruptures in active patients.

Contraindications: Soft tissue injuries, general risk factors, e.g., circulatory disorders, diabetic foot syndrome, complex regional pain syndrome.

Surgical technique: Diagnostic arthroscopy of the ankle joint using anterolateral and -medial portals; identify and treat concomitant intra-articular pathologies; verify syndesmotic instability by inserting an instrument > 4 mm into the incisura fibularis; in case of chronic syndesmotic injuries, debridement of syndesmotic structures, and if necessary debridement of the deltoid ligament complex; reduction of the fibula in the incisura fibularis; retention of the fibula using a screw or flexible implant.

Postoperative management: Partial weight-bearing with 20 kg for 6 weeks, no immobilization, exercise for the mobility of the ankle joint, X‑ray after 6 weeks, then increase of weight-bearing.

Results: Acute syndesmotic injuries: 19 patients (37 ± 13 years) were examined 38 ± 17 months after arthroscopically assisted treatment of an acute syndesmotic injury. 53% suffered a two-ligament injury, 16% a three-ligament injury, and in 32% a bony syndesmotic injury. Grade II cartilage damage was observed in 35%, grade IV damage in 20%, and loose bodies were removed in 16%. 94% of patients achieved a treatment outcome in line with the healthy reference population for the Olerud and Molander Ankle Score (OMAS; primary outcome parameter) and Foot and Ankle Ability Measure (FAAM). Type of syndesmotic injury and severity of cartilage damage had no significant influence on treatment outcomes. Chronic syndesmotic injuries: a systematic literature search identified 17 studies with 196 patients following surgically treated chronic syndesmotic injuries, 16 of which were retrospective case series and one prospective case series. Arthroscopically assisted surgery was performed in 13 studies. Regardless of the surgical technique, surgery resulted in an improvement in the American Orthopaedic Foot and Ankle Society (AOFAS) score in 10 studies. Overall, the study quality was low and the information on complications, secondary diastasis, treatment results, etc. was very limited.