Surgery for the Syndesmosis

What is the syndesmosis?

The two bones in the lower leg are the tibia and the fibula. The point just above the ankle where these two bones meet is called the syndesmosis. It is a joint by definition and has characteristics of other joints in the body. However, it does not function like most joints as there is very little motion between the two bones. Its main functions are to provide stability to the ankle joint and allow motion of the joint.

How does the syndesmosis get injured?

The most common way the syndesmosis is hurt is a twisting or rotational injury to the ankle. The ligaments that support the syndesmosis are needed to stabilize it, and it is these ligaments that are stretched or torn when this type of injury occurs. Ankle sprains can injure the syndesmosis. The ligaments can also be injured when the ankle is broken. The high ankle sprain that is commonly seen in football players refers to an injury to the syndesmosis.

What are the goals of syndesmosis surgery?

Surgery of the syndesmosis is most often due to a traumatic disruption. The goal of surgery is to properly align and stabilize the joint so the ligaments can heal in the correct position.

What signs indicate surgery may be needed?

Your surgeon will examine your ankle. X-rays will be taken and may include a stress X-ray. This is an X-ray that is taken while your doctor carefully twists or stresses your ankle to test the stability of the syndesmosis. If there is an unstable joint, surgery is typically necessary to provide stability.

When should I avoid surgery?

If the syndesmosis is found to be stable, it usually will not require surgical management. If you have other medical conditions that make surgery too risky for your health, your surgeon may recommend non-surgical treatment. If you have any active infections or chronic wounds around your ankle, surgery should be avoided.

General Details of the Procedure

Surgery is typically done on an outpatient basis, but sometimes an overnight stay is required. A general anesthetic is typically used. A nerve block may be used during surgery or to provide pain relief after surgery. The syndesmosis is put into its proper position. It is held in place with screws or suture implants. A plate may also be used. 

Specifics Technique

An incision is made over the outside of the ankle. The fibula bone and syndesmosis are identified and exposed. Using direct vision and live X-ray techniques, the syndesmosis is placed into the correct position. The surgeon then “fixes” the syndesmosis in place with an implant. This typically involves one or two screws that go from the fibula bone into the tibia bone. The screws may be placed through a plate that sits on the fibula bone. Alternatively, a suture device may be used instead of screws.
A stress X-ray is performed to confirm that the syndesmosis is stable. Any additional injuries (e.g. fractures) are repaired if necessary. Stiches are placed to close the incision(s). The leg is then placed in a splint, cast or boot.

What happens after surgery?

After surgery, you will be immobilized in a splint for the first 10 to14 days. You will typically be kept non-weightbearing on the side of your surgery for six to eight weeks. You will then be allowed to advance your weightbearing in a cast or boot. Swelling persists for many months after this surgery. Stiffness can be problem and physical therapy is often necessary.

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
Specific to the syndesmosis, the main complications that can occur after surgery include irritation or failure of the hardware, the development of arthritis in the syndesmosis, and failure of the syndesmosis to heal properly.

Frequently Asked Questions

Does my hardware need to be removed?
Most of the time, orthopaedic hardware does not need​ to be removed. In the case of syndesmosis surgery, your surgeon may recommend removing the screws that go from the fibula to the tibia. Because there is normally motion between these two bones, the screws may cause pain or limit motion. The hardware is not removed until after the syndesmosis is healed. You and your surgeon will discuss what is best for you.
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