Ankle and syndesmosis instability: consensus and controversies

Abstract

Ankle sprains are mainly benign lesions, but if not well addressed can evolve into permanent disability. A non-treated lateral, syndesmotic or medial ankle instability can evolve into ankle osteoarthritis. For this reason, diagnosis and treatment of these entities is of extreme importance.In general, acute instabilities undergo conservative treatment, while chronic instabilities are better addressed with surgical treatment. It is important to identify which acute instabilities are better treated with early surgical treatment.Syndesmosis injuries are frequently overlooked and represent a cause for persistent pain in ankle sprains. Unstable syndesmotic lesions are always managed by surgery.Non-treated deltoid ligament ruptures can evolve into a progressive valgus deformity of the hindfoot, due to its links with the spring ligament complex. This concept would give new importance to the diagnosis and treatment of acute medial ligament lesions.Multi-ligament lesions are usually unstable and are better treated with early surgery. A high suspicion rate is required, especially for combined syndesmotic and medial lesions or lateral and medial lesions.Ankle arthroscopy is a powerful tool for both diagnostic and treatment purposes. It is becoming mandatory in the management of ankle instabilities and multiple arthroscopic lateral/syndesmotic/medial repair techniques are emerging. Cite this article: EFORT Open Rev 2021;6:420-431. DOI: 10.1302/2058-5241.6.210017.

Keywords: ankle instability; ankle sprains; arthroscopy; deltoid ligament lesion; lateral instability; medial instability; syndesmosis instability; syndesmotic instability.

Fig. 1

Right ankle arthroscopy: chronic avulsion of the lateral ligament complex (A – distal fibular tip).

Fig. 2

Right ankle arthroscopy: re-attachment of the lateral ligament complex after the author’s arthro-Brostrom procedure (B – talus; C – tibial plafond).

Fig. 3

Left ankle arthroscopy: syndesmosis lesion diagnosis using a 4.5 mm shaver cannula that can penetrate through the syndesmotic space (A – tibial plafond; B – talus; C – fibula).

Fig. 4

Right ankle arthroscopy: a deltoid ligament acute rupture (C) with interposition between the talus (B) and medial malleolus (A). This is one of the causes of inadequate reduction of bimalleolar equivalent fractures (A – tibial plafond; B – talus; C – fibula).

Fig. 5

Right ankle arthroscopy: multiple ligamentar lesion with and acute deltoid rupture (C) and syndesmosis rupture (see Fig. 6). (A – medial malleolus; B – talus; C – Deltoid ligament).

Fig. 6

Right ankle arthroscopy: syndesmosis disruption (F – front view of the syndesmosis). (tibial plafond; E – fibula; F syndesmosis).

Fig. 7

Left ankle arthroscopy: acute deltoid rupture of the anteromedial bundle (A) with a wide space between the talus (C) and the medial malleolus (B).

Fig. 8

Left ankle arthroscopy: the result of the arthroscopic repair with anchor and correction of the medial clear space (A – deltoid ligament; B – medial malleolus; C – talus).