Abstract
Ankle sprains in the athlete are one of the most common injuries, and syndesmosis type sprains seem to becoming diagnosed at an increasing rate. There still exists a paucity of information on optimal conservative and operative management.
Treatment
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Because of the spectrum of injury, there is a spectrum of treatment.
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if there is mortise widening, operative stabilization is required
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if the mortise is normal, even with external rotation stress test positive, conservative treatment has been employed.
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staged conservative regimen directed at reducing pain and swelling acutely, at regaining range of motion and strength subacutely, and then progressed to functional training and finally return to sport. The timeframe for these was in the range of 2 to 6 weeks without very specific progression criteria.
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In the athlete, pain with rotational stress, greater severity of sprain, may treat operatively to stabilize the syndesmosis and aggressive rehab with earlier return to sport
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Tightrope vs screw fixation vs both
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Use of arthroscopy
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Chronic sprains with recalcitrant pain and functional instability usually require operative treatment.
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very poor evidence exists as to the timing or type of procedure. Arthroscopy is required to confirm the diagnosis, treat intraarticular problems, and provide fixation of the distal tibiofibular syndesmosis. The postoperative regimen used is generally the same as the one used when treating an acute syndesmosis disruption.
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Tight rope vs Screw Fixation
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clinical studies tightrope fixation has been acceptable and comparable to screw fixation
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laboratory studies demonstrate comparable construct stability in the laboratory/cadaveric setting
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indications for tightrope fixation are becoming more clear with more experience
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my indications:
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syndesmotic sprains with complete or incomplete disruption
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fractures with syndesmotic disruption augment with screws, leave in place following screw removal
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Summary and Controversies
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Syndesmotic or high ankle sprains continue to be a common injury that result in significant time lost from sport
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The conclusion that can be drawn from the current evidence is that the current diagnostic process probably fails to clearly assess the severity of the injury, which reduces the likelihood of accurately predicting the time lost from sport.
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Syndesmosis sprains can be a significant injuries that result in an inability to play sports for significant periods of time(up to 137 days).
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We need to be able to identify the more severe ones earlier in order to improve their treatment, perhaps lead to operative stabilization
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Tightrope fixation avoids screw removal, minimally invasive, permanent stabilization
