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The Journal of Bone and Joint Surgery, Vol 77, Issue 6 847-856, Copyright © 1995 by Journal of Bone and Joint Surgery, Inc
The tibiofibular syndesmosis. Evaluation of the ligamentous structures, methods of fixation, and radiographic assessment
JS Xenos, WJ Hopkinson, ME Mulligan, EJ Olson and NA Popovic
Department of Surgery, Walter Reed Army Medical Center, Washington, D.C. 20307-5001, USA.
Twenty-five fresh-frozen cadaveric specimens were used to evaluate the role
of the syndesmotic ligaments when the ankle is loaded with external
rotation torque. An apparatus was constructed that allowed pure
external-rotation torque to be applied through the ankle with the foot in
neutral flexion. The apparatus provided solid fixation of the tibia while
allowing free movement of the fibula in all planes. The syndesmotic
ligaments were incrementally sectioned, and direct measurements of
anatomical diastasis were made. Mortise and lateral radiographs were made
at each increment under both loaded (5.0 newton-meters) and unloaded
conditions. After all structures of the syndesmosis had been divided, the
syndesmosis was reduced and was repaired with one or two screws. The
strength of the repair was measured with incremental increases in torque of
1.0 newton-meter. The radiographs were measured by three independent
observers in a blind fashion. In order to evaluate intraobserver error,
each observer was randomly given forty radiographs to reinterpret.
Diastasis and rotation were found to be related to the amount of injury of
the ligament (p < 0.0001). After the entire syndesmosis had been
divided, application of a 5.0-newton-meter torque resulted in a mean
diastasis of 7.3 millimeters. The subsequent repair of the anterior
tibiofibular ligament with suture failed at a mean of 2.0 newton-meters
(range, 1.0 to 6.0 newton-meters) of torque. Repair with two screws was
found to be stronger than repair with one, with the first construct failing
at a mean of 11.0 newton-meters (range, 5.0 to 15.0 newton-meters) and the
second, at a mean of 6.2 newton-meters (range, 2.0 to 10.0 newton-meters)
(p = 0.0005). Failure of the screw fixation was not associated with the
maximum previous diastasis (p = 0.13). Measurements of anatomical diastasis
were compared with measurements made on the mortise and lateral
radiographs. Measurements on the stress mortise radiographs had a weak
correlation with diastasis (r = 0.41, p < 0.0001). However, measurements
on the stress lateral radiographs had a higher correlation (r = 0.81, p
< 0.0001). Additionally, interobserver correlation was significantly
higher for the measurements on the lateral radiographs (r = 0.87, p <
0.0001) than for those on the mortise radiographs (r = 0.56, p <
0.0001). Intraobserver correlation for the three observers was poor with
regard to the measurements on the mortise radiographs (r = 0.12, 0.42, and
0.25). The respective correlations for the measurements on the lateral
radiographs were r = 0.81, 0.90, and 0.89.(ABSTRACT TRUNCATED AT 400 WORDS)
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