Current status of the management of isolated syndesmotic injuries in Germany

Abstract

Introduction: Although non-fracture-related syndesmotic injuries of the ankle are relatively rare, they may lead to poor clinical outcome if initially undiagnosed or managed improperly. Despite a variety of literature regarding possibilities for treatment of isolated syndesmotic injuries, little is known about effective applications of different therapeutic methods in day-to-day work. The aim of this study was to assess the current status of the treatment of isolated syndesmotic injuries in Germany.

Materials and methods: An online-questionnaire, capturing the routine diagnostic workup including clinical examination, radiologic assessment and treatment strategies, was sent to all members of the German Society of Orthopedic Surgery and Traumatology (DGOU) and Association of Arthroscopic and Joint Surgery (AGA). Statistical analysis was performed using Microsoft excel and SPSS.

Results: Each question of the questionnaire was on average answered by 431 ± 113 respondents. External rotation stress test (66%), squeeze test (61%) and forced dorsiflexion test (40%) were most commonly used for the clinical examination. In the diagnostic workup, most clinicians relied on MRI (83%) and conventional X-ray analysis (anterior-posterior 58%, lateral 41%, mortise view 38%). Only 15% of the respondents stated that there is a role for arthroscopic evaluation for the assessment of isolated syndesmotic injuries. Most frequently used fixation techniques included syndesmotic screw fixation (80%, 42% one syndesmotic screw, 38% two syndesmotic screws), followed by suture-button devices in 13%. Syndesmotic screw fixation was mainly performed tricortically (78%). While 50% of the respondents stated that syndesmotic screw fixation and suture-button devices are equivalent in the treatment of isolated syndesmotic injuries with respect to clinical outcome, 36% answered that syndesmotic screw fixation is superior compared to suture-button devices.

Conclusions: While arthroscopy and suture-button devices do not appear to be widely used, syndesmotic screw fixation after diagnostic work-up by MRI seems to be the common treatment algorithm for non-fracture-related syndesmotic injuries in Germany.

Keywords: Ankle syndesmotic injury; Arthroscopy; MRI; Suture-button; Syndesmotic screw fixation.

Fig. 1

Frequency distribution of the clinical tests that respondents consider being meaningful for clinical decision making in the physical examination of syndesmotic injuries (multiple answers possible)

Fig. 2

Frequency distribution of medical imaging that respondents consider being meaningful for clinical decision making for the diagnostic work-up of syndesmotic injuries (multiple answers possible)

Fig. 3

Frequency distribution of the preferred techniques for the operative stabilization of syndesmotic injuries

Fig. 4

A Frequency distribution of the placement of the first syndesmotic screw. B Frequency distribution of the placement of the second syndesmotic screw if a second syndesmotic screw was placed (18% of the respondents do not place a second syndesmotic screw)