There have been few reports with efficient treatments for neglected distal tibiofibular syndesmosis disruption. Here we will report four cases of successful anatomical reconstruction with autologous gracilis tendon, using the interference fit anchoring (IFA) system.

All four cases were males between 20 and 58 years of age at the time of surgery (mean age 36 years). The post-injury period to surgery was between 7 and 59 months (mean 20.1 months), with the consultation period being from 5 to 19 months (mean 9.5 months). Radiographs at the time of injuries were all malleolar fractures of pronation-external rotation (PE) stage 3 in the Lauge-Hansen classification.

Stress tests for distal tibiofibular syndesmosis were positive in all cases (dilation more than 2 mm). Arthroscopic drilling was conducted in two cases with a cartilaginous injury of trochlea of talus. Distal tibiofibular syndesmosis was anatomically repositioned and was fixed with screws after bony and soft tissues within the tibiofibular syndesmosis were removed and fibular adhesion was dissected. Ipsilateral autologous gracilis tendon was passed through foramen in the insertion of the anterior inferior tibiofibular tendon on tibia and fibula, and was fixated using the IFA system.

The preoperative Japanese society for surgery of the foot (JSSF) score was from 26 to 74 points (mean 43.5) and postoperative JSSF score was from 67 to 100 (mean 89.5). In a case where there was a poor outcome, five years of post injury had passed before the surgery. Although the JSSF score improved to 67 points postoperatively (from the preoperative score of 26) in this case, arthroscopic arthrodesis was conducted 5 months postoperatively due to persistent pain.

Anatomical reconstruction with autologous gracilis tendon using the IFA system showed a favorable functional prognosis overall. However, there was a case with progressive degenerated changes of injured distal tibiofibular syndesmosis due to a prolonged post-injury period resulted in a poor outcome.