Ankle Syndesmotic Injuries: A Systematic Review

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The syndesmosis is critical in maintaining the structural integrity of the distal tibiofibular joint, and perhaps as much as 10% of all ankle fractures are accompanied by a syndesmotic injury. The purpose of this study is to review all relevant literatures on the treatment of syndesmotic ankle fractures.

Materials and Methods:

A systematic review was conducted using PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. The keyword selection was designed to capture all levels I to IV evidence English-language studies that reported clinical and/or radiographic outcomes. All case reports and studies with a minimum follow-up of <1 year were excluded. In total, 18 studies with 951 patients and ankles were selected for inclusion. P-value of 0.05 was set as statistically significant.


The studies ranged from January 1974 through August 2014, and the average age was 43.7±5.6 years with 57.4% of patients being male. All studies evaluated the efficacy of open reduction internal fixation. Metallic screws were the primary mode of fixation in 16 studies, whereas none of the studies evaluated the efficacy of nonoperative or endoscopic treatment. Totally, 148 screws were reported broken at the time of final follow-up, and syndesmotic screws were removed 8.5±3.7 weeks after surgery. The average time to clinical follow-up was 43.0±56.7 months. Postoperative visual analog scale pain scores (maximum 10) were 2.3±1.3, American Orthopaedic Foot and Ankle Society scores were 88.7±4.1, and Olerud-Molander scores were 80.1±5.3. Only 4 studies reported 14 complications (2.8±3.1), whereas 5 studies reported 8 revision operations (1.0±1.3).


This systematic review primarily confirms that syndesmotic injuries are successfully treated with open reduction internal fixation. Syndesmotic screws are commonly removed within first 3 months after surgery.

Level of Evidence:

Level IV—systematic review of levels I to IV studies.

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