Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Injury. 2009 Nov;40(11):1137-42. doi: 10.1016/j.injury.2009.03.011. Epub 2009 Jun 12.
To review the literature concerning articles evaluating the delayed operative treatment of isolated syndesmotic instability.
The main databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1988 to September 2008 to identify studies relating to the late reconstruction of the distal tibiofibular syndesmosis after isolated syndesmotic injury. The level of evidence of the included articles was scored.
Fifteen articles were identified, involving 94 ankles with a delayed reconstruction for isolated syndesmotic instability.
In subacute (6 weeks to 6 months) total ruptures the focus is to restore the normal anatomy by repair of the ruptured ligament with placement of a syndesmotic screw. On base of the literature in combination with experience in clinical practice some guidelines are formulated. If inadequate remnants of the anterior inferior tibiofibular ligament (AITFL) are present, a tendon graft can be used. The insertion of the AITFL on the tibia can be medialised with a bone block and fixed with a screw. For the treatment of persistent widening and late instability these reconstruction techniques have to be used combined with debridement and placement of a syndesmotic screw to protect the reconstruction. Most adequate treatment for chronic syndesmotic instability (>6 months) is the creation of a synostosis to stabilise the distal tibiofibular joint. Late repairs give satisfactory but less favourable outcome as compared to properly treated acute injuries. It is not easy to regain complete stability by means of these secondary procedures.
回顾有关孤立性踝关节下胫腓联合（syndesmosis）不稳定延迟手术治疗的文献。
从 1988 年至 2008 年 9 月，在主要数据库 Pubmed/Medline、Cochrane 系统评价数据库、Cochrane 临床试验注册库、当前对照试验和 Embase 中搜索，以确定与孤立性下胫腓联合损伤后延迟重建远端胫腓联合有关的研究。对纳入文章的证据水平进行评分。
共确定了 15 篇文章，涉及 94 例因孤立性下胫腓联合不稳定而延迟重建的踝关节。
在亚急性（6 周至 6 个月）完全断裂中，重点是通过修复断裂的韧带并用下胫腓联合螺钉固定来恢复正常解剖结构。基于文献并结合临床实践经验，制定了一些指南。如果前下胫腓韧带（AITFL）的残端不足，可以使用肌腱移植物。可以用骨块将 AITFL 的插入点向内侧移位，并使用螺钉固定。对于持续性增宽和晚期不稳定的治疗，这些重建技术必须与清创和放置下胫腓联合螺钉结合使用，以保护重建。对于慢性下胫腓联合不稳定（>6 个月），最合适的治疗方法是形成骨融合以稳定远侧胫腓关节。与适当治疗的急性损伤相比，晚期修复的结果令人满意，但不太理想。通过这些二级手术很难完全恢复稳定性。
