Department of Foot & Ankle Surgery, Amandeep Hospital, Amritsar, India.
J Orthop Surg (Hong Kong). 2023 May-Aug;31(2):10225536231182349. doi: 10.1177/10225536231182349.
The distal tibiofibular syndesmosis (DTFS) is more frequently injured than previously thought. Early diagnosis and appropriate treatment is essential to avoid long term complications like chronic instability, early osteoarthritis and residual pain. Management of these injuries require a complete understanding of the anatomy of DTFS, and the role played by the ligaments stabilizing the DTFS and ankle. High index of suspicion, appreciating the areas of focal tenderness and utilizing the provocative maneuvers help in early diagnosis. In pure ligamentous injuries radiographs with stress of weight bearing help to detect subtle instability. If these images are inconclusive, then further imaging with MRI, CT scan, stress examination under anesthesia, and arthroscopic examination facilitate diagnosis. An injury to syndesmosis frequently accompanies rotational fractures and all ankle fractures need to be stressed intra-operatively under fluoroscopy after fixation of the osseous components to detect syndesmotic instability. Non-operative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. Anatomic reduction of the syndesmosis is critical, and currently both trans-syndesmotic screws and suture button fixation are commonly used for syndesmotic stabilization. Chronic syndesmotic instability (CSI) requires debridement of syndesmosis, restoration of ankle mortise with or without syndesmotic stabilization. Arthrodesis of ankle is used a last resort in the presence of significant ankle arthritis. This article reviews anatomy and biomechanics of the syndesmosis, the mechanism of pure ligamentous injury and injury associated with ankle fractures, clinical, radiological and arthroscopic diagnosis and surgical treatment.
下胫腓联合(DTFS)损伤比以前认为的更为常见。早期诊断和适当的治疗对于避免慢性不稳定、早期骨关节炎和残留疼痛等长期并发症至关重要。这些损伤的管理需要全面了解 DTFS 的解剖结构,以及稳定 DTFS 和踝关节的韧带所起的作用。高度怀疑、了解焦点压痛区域并使用激发性手法有助于早期诊断。在纯韧带损伤中,负重应力的 X 线片有助于检测细微的不稳定。如果这些图像不确定,则进一步进行 MRI、CT 扫描、麻醉下应力检查和关节镜检查有助于诊断。下胫腓联合损伤常伴有旋转骨折,所有踝关节骨折在固定骨成分后,均需要在透视下进行术中应力检查,以检测下胫腓联合不稳定。稳定的损伤适合非手术治疗。不稳定的损伤应手术治疗。下胫腓联合的解剖复位至关重要,目前,下胫腓联合螺钉和缝线纽扣固定均常用于下胫腓联合稳定。慢性下胫腓联合不稳定(CSI)需要清除下胫腓联合,恢复踝关节距骨,必要时进行下胫腓联合稳定。如果存在严重的踝关节关节炎,则踝关节融合术是最后的选择。本文综述了下胫腓联合的解剖学和生物力学、纯韧带损伤和与踝关节骨折相关的损伤的机制、临床、放射学和关节镜诊断以及手术治疗。