Syndesmotic Ligament Allograft Reconstruction for Treatment of Chronic Diastasis

Advancements in minimally invasive treatment of deltoid ligament injuries combined with distal tibiofibular syndesmosis injuries

The deltoid ligament (medial collateral ligament) and the syndesmosis (a composite ligamentous structure at the distal tibiofibular junction) are critical for maintaining ankle stability. In cases of high-energy ankle fractures, these structures are often injured simultaneously, leading to instability and potential long-term complications such as post-traumatic arthritis. This review aims to explore advancements in minimally invasive techniques for the treatment of combined deltoid ligament and syndesmosis injuries, with a focus on optimizing surgical outcomes and reducing patient morbidity. Current treatment strategies primarily involve cortical screws for syndesmosis stabilization and anchor fixation for deltoid ligament repair. Recent innovations, such as bioabsorbable screws, suture-button devices with elastic micromotion, and syndesmotic plates, have demonstrated potential in improving biomechanical stability while minimizing complications. Furthermore, minimally invasive techniques, including arthroscopic repairs with suture anchors, as well as ligament reconstruction using autografts, allografts, or synthetic ligaments, are becoming increasingly popular. By incorporating these advancements, the field is moving toward more effective and patient-centered approaches to achieve anatomical and functional restoration under minimally invasive principles. Future research should focus on further validating these techniques and identifying the most effective strategies for complex injuries.

Chronic syndesmotic instability - Current evidence on management

This review article discusses the current evidence on the management of chronic syndesmotic instability. Conservative treatment has a limited role, and surgical intervention is most commonly reported as the mainstay of treatment, however the literature consists of small case series and descriptions of operative techniques, and thus the evidence base for any treatment is weak. Surgical options include arthroscopic debridement alone, static fixation with cortical screws, dynamic fixation with suture-button devices, and ligamentous repair or augmentation.

Salvage of Chronic Syndesmosis Instability: A Retrospective Review With Mid-Term Follow-Up

Malreduced syndesmotic injuries lead to poor outcomes. No consensus exists regarding preferred surgical treatment. This study aims to assess clinical and radiographic outcomes in patients undergoing distal tibiofibular arthrodesis or stabilization. Retrospective review identified patients undergoing distal tibiofibular arthrodesis or stabilization between 2003 and 2019. Surgical factors, revision surgeries, and American Orthopedic Foot and Ankle Score ankle-hindfoot scores were collected. Radiographs were independently evaluated by 4 surgeons. Seventy patients were included. Mean American Orthopedic Foot and Ankle Score scores (n = 33) improved from 48 ± 16 preoperatively to 85 ± 14 (p < .001) at a median follow-up of 31.1 months. Mean Kellgren scores (n = 47) increased from 2.1 ± 1 to 2.5 ± 1 (p < .001) and the mean medial clear space decreased from 3.2 mm ± 0.8 mm to 2.8 mm ± 0.8 mm (p <.001) with no differences between the arthrodesis and stabilization groups. Zero patients progressed to arthroplasty or fusion. Patients demonstrated significant functional improvement after distal tibiofibular arthrodesis and stabilization. Progression of arthritis, while statistically significant, was not clinically significant.

Evidence-Based Surgical Treatment Algorithm for Unstable Syndesmotic Injuries

Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.

The Failed Deltoid Ligament in the Valgus Misaligned Ankle-How to Treat?

This article deals with the treatment of a chronically failed deltoid ligament complex in the valgus misaligned ankle. This is a challenging task in every orthopedic foot and ankle surgery. Before embarking on any surgery that relates to the deltoid ligament complex, it is mandatory to analyze any underlying cause that could promote the impairment. Once this is done, it might be of value in considering anatomic reconstructions. The article provides an anatomic reconstruction technique, which should help address the problem.