Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026

[Link]

TRAUMA SURGERY

Current status of the management of isolated syndesmotic injuries

in Germany
Manuel Mutschler1,2 · Jan‑Hendrik Naendrup3,4 · Thomas R. Pfeiffer3 · Vera Jaecker3 · Dariusch Arbab1,5 ·
Sven Shafizadeh1,6 · Tomas Buchhorn7

Received: 6 October 2021 / Accepted: 10 March 2022 / Published online: 11 April 2022
© The Author(s) 2022

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 assess-
ment 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 · Syndesmotic screw fixation · Suture-button · MRI · Arthroscopy

4
Mutschler Manuel and Naendrup Jan-Hendrik contributed equally Department of Oncology, HaematologyInfectiology
to this work. and Internistic Critical Care Medicine, University
of Cologne, Cologne, Germany
* Manuel Mutschler 5
Department of Orthopaedic Surgery, Klinikum Dortmund,
manuelmutschler@[Link]
Dortmund, Germany
1 6
Witten/Herdecke University, Witten/Herdecke, Germany, Department of Trauma Surgery, Orthopaedic Surgery
Alfred‑Herrhausen‑Straße 50, 58448 and Sports Traumatology, Sana Medical Centre Cologne,
2 Cologne, Germany
Department of Foot Surgery, Waldkrankenhaus Bonn,
7
Johanniter GmbH, Bonn, Germany, Waldstraße 73, 53177 Foot and Ankle Department, Sporthopaedicum
3 Straubing-Regensburg, Straubing, Germany
Department of Trauma Surgery, Orthopaedic Surgery
and Sports Traumatology, Witten/Herdecke University,
Cologne Merheim Medical Centre, Cologne, Germany

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2020 Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026

Introduction the German Society of Orthopaedics and Trauma (Deutsche

Gesellschaft für Orthopädie und Unfallchirurgie—DGOU)
Injuries of the ankle are among the most common injuries in as well as to the Society for Arthroscopy and Joint-Surgery
athletes and one of the most frequent musculoskeletal injuries (AGA—Gesellschaft für Arthroskopie und Gelenkchirur-
presenting in the emergency department [1–3]. While sprains gie). One email reminder followed. The distribution of the
of the lateral ankle ligament complex constitute the most fre- questionnaire to the members was performed exclusively by
quent type of ankle sprain and occur in about three-quarter the societies, therefore the total number of recipients as well
of all ankle sprains, the incidence rate of acute syndesmotic as the response rate remains unknown due to an unknown
ankle injuries is significantly lower at approximately 0.38 per number of respondents being member in both societies. The
1000 athlete exposures, being defined as one athlete partici- response to the questionnaire was collected anonymously,
pating in one competition or practice [4]. In this context, male so that the content did not include direct hints about the
sex and higher level of competition are known risk factors for participating clinics or physicians.
syndesmotic injuries [5]. Syndesmotic injuries mainly result The survey contained 39 questions about the observed
from high-energy ankle trauma, especially involving external incidences of isolated syndesmotic injuries, the routine diag-
rotation force and excessive dorsiflexion, and occur isolated or nostic workup with clinical examination and radiological
in combination with other ligamentous or bony concomitant assessment as well as current treatment strategies.
injuries [6, 7]. The data were statistically analyzed using Microsoft
Although acute syndesmotic injuries are relatively rare, Excel and SPSS (version 26). As this investigation consti-
they can have debilitating long-term effects. If initially tuted a voluntary survey amongst medical professionals, no
undiagnosed or managed improperly, they may lead to poor approval by the local ethics committee was required.
functional outcome, persisting ankle pain or post-traumatic
osteoarthritis [8–11]. Therefore, early recognition and appro-
priate treatment seems to be pivotal. However, syndesmotic Results
injuries are difficult to detect and distinguished from other
ligamentous injuries of the ankle solely based on the history Respondents characteristics
and physical examination [12]. Despite a variety of clinical
tests, none of them entails a sufficient reliability and accu- Each question of the online-questionnaire was on average
racy to identify a syndesmotic injury with adequate certainty answered by 431 ± 113 respondents, of which 76% (478/629)
[13]. Consequently, additional diagnostics such as X-ray, com- were trained as orthopedic and trauma surgeons, 36%
puted tomography (CT), magnet resonance imaging (MRI) or (226/629) were general surgeons and 10% (66/629) were
arthroscopy are used and recommended [14–17]. taking part in a residency program for trauma and orthope-
Regarding the treatment of syndesmotic injuries, several dic surgery. The vast majority of the respondents worked in
approaches are available, each with its own advantages, disad- hospitals (69%, 429/622), 19% (120/622) worked in private
vantages and challenges: Arthroscopic versus open techniques, practice and 12% (73/622) stated that they work in a special-
direct suture repairs and/or tibiofibular fixation methods ized department for foot and ankle surgery. In total, 18%
including screws and suture-button devices [11, 14, 18–21]. (113/622) stated to be certified foot and ankle surgeons.
Also regarding the appropriate and optimal postoperative care
many protocols and controversies exist [22–24]. Incidence of syndesmotic and associated injuries
Beside the fact that many possibilities for the treatment of
syndesmotic injuries exist, the current literature offers little The majority of respondents either treated one to ten patients
information regarding the effective applications of different (40% (237/593)) or up to 20 patients (35% (210/593)) with
therapeutic methods in day-to-day clinical work. Due to this isolated syndesmotic injuries annually. Only 18% (101/593)
lack of descriptive statistics, a survey, consulting German cli- stated to medicate 20 to 40 patients and 7% (41/593) more
nicians, was implemented to gather the current status of the than 40 patients per year. In the respondent’s perspective
treatment of isolated syndesmotic injuries in Germany. (n = 404), associated injuries with acute syndesmotic lesions
mainly involved the lateral ligament complex (51 ± 27%
isolated anterior talofibular ligament (ATFL), 35 ± 23%
Material and methods combined ATFL/calcaneal fibular ligament (CFL) and
21 ± 22% ATFL/CFL/posterior talofibular ligament (PTFL)
Using a cloud-based survey software ([Link] injuries). The deltoid ligament complex was seen affected in
ymonk​ey.​com/), an online-questionnaire about isolated syn- 31 ± 24% and posttraumatic bone edema as well osteochon-
desmotic injuries was designed and sent to all members of dral flake injuries were observed in 55 ± 27% and 21 ± 17%,
respectively.

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Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026 2021

Diagnostics in syndesmotic injuries Different techniques for the operative stabilization of

isolated syndesmotic injuries were used by the respondents
Asked about the meaning of the physical examination tests in general: fixation with two syndesmotic screws (77%;
for clinical decision making, the majority of respondents 305/396), fixation with one syndesmotic screw (64%;
(66%, 373/566) relied on the external rotation stress test as 252/396), suture technique (44%; 175/396) and fixation
well as the squeeze test (61%, 343/566), followed by the with a suture-button device (41%; 162/396). However,
forced dorsiflexion test (40%, 228/566). An overview of the when asked about the most frequently used technique, 80%
physical examination tests used in day-to-day clinical work of all respondents used syndesmotic screw fixation (42%
for isolated syndesmotic injuries is shown in Fig. 1. one syndesmotic screw, 38% two syndesmotic screws),
As the respondents (n = 566) stated that the diagnosis of followed by suture-button devices in 13%, whereas direct
acute syndesmotic injury is missed in 49 ± 22% of the cases suture techniques were used by 6% of the respondents
during the initial clinical examination on average, further (compare Fig. 3). Syndesmotic screw fixation was per-
diagnostics are needed. In the subsequent work-up, most formed mainly tricortical (78%; 307/395), whereas quad-
clinicians relied on MRI (83%) and X-ray analysis (ante- ricortical syndesmotic screw positioning was performed
rior–posterior X-ray (58%), lateral X-ray (41%), X-ray with in 17% (67/395). The most frequently used positions for
mortise view (38%), anterior–posterior X-ray with weight screws and suture-button devices are illustrated in Fig. 4.
bearing (20%)), as well as sonography (28%). Only 19% Overall, 50% (199/395) of the respondents stated that
of the respondents preferred an angulated MRI parallel to syndesmotic screw fixation and suture-button devices are
the syndesmosis to confirm the diagnosis (n = 566, compare equivalent in the treatment of isolated syndesmotic inju-
Fig. 2). 15% (86/562) of the respondents stated that there is ries with respect to the clinical outcome, 36% (143/395)
a role for arthroscopic evaluation with a hook for the assess- stated that screw fixation is superior to suture-button
ment of isolated syndesmotic injuries. devices whereas 13% (53/395) found suture-button devices
to be superior compared to syndesmotic screw fixation
Operative treatment strategies for acute techniques.
syndesmotic injuries Of all respondents, 97% (376/389) regularly perform
an intraoperative assessment of the syndesmotic screw
According to the respondents (n = 593), 61 ± 35% of all iso- and suture-button positioning, hereby fluoroscopy (72%,
lated syndesmotic injuries were treated operatively in day- 272/376) and 3D-fluroscopy (28%, 104/376) are the most
to-day clinical work. Indications for operative treatment commonly used technical devices. Intraoperative evalua-
were “unstable syndesmotic injuries” (97%) as well as inju- tion of the positioning of the fibula within the incisura was
ries comprising all anatomic parts of the syndesmosis (93%). performed in 62% (243/389), mainly using fluoroscopy
Isolated injuries of the anterior or posterior syndesmosis (59%, 144/243) and 3D-fluroscopy (47%, 115/243).
(25% and 24%, respectively) were less frequently considered
as indication for surgery.

Fig. 1  Frequency distribution of

the clinical tests that respond-
ents consider being meaningful
for clinical decision making
in the physical examination of
syndesmotic injuries (multiple
answers possible)

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2022 Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026

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

Postoperative care of the respondents stated not to allow full weight bearing
until screws were removed. 70% (255/365) used an ortho-
With respect to postoperative care, most syndesmotic sis in the aftercare management, whereas walker devices
screws were removed (92 ± 20%, n = 359), mainly after (76%, 193/254) followed by ankle orthosis (30%, 75/254)
6 weeks (92%), followed by 12 weeks (7%). Only 2% of the and cast immobilization (16%, 41/254) were predominantly
respondents stated not to remove the syndesmotic screws at used. Also when using suture-button devices, most surgeons
all. In case of syndesmotic screw fixation, 96% (350/365) recommended partial weight bearing for 6 weeks (75%,

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Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026 2023

Fig. 4  A Frequency distribution

of the placement of the first syn-
desmotic screw. B Frequency
distribution of the placement of
the second syndesmotic screw
if a second syndesmotic screw
was placed (18% of the respond-
ents do not place a second
syndesmotic screw)

143/191). Orthoses were used in 82% (162/198), especially recent meta-analysis proclaimed an initial clustering of test
walker devices, (59%, 95/162), ankle orthoses (35%, 56/162) including high sensitivity tests (e.g., palpation or forced
and cast immobilization (7%, 11/162). dorsiflexion), followed by clinical test with a high specific-
ity (e.g., squeeze test) [25]. However, clinical tests alone
are only of limited accuracy in the detection of isolated
Discussion syndesmotic injuries and in the decision whether surgery
is needed or not [13, 25]. This is in line with the results
Based on the Germany-wide online-survey, the presented of the present study, where nearly half of the respondents
results illustrate the current status of diagnostics and indicated that clinical examination is not valid to thor-
treatment of non-fracture-related syndesmotic injuries in oughly detect all fresh syndesmotic injuries and that MRI
Germany. The majority of surgeons rely on external rota- is frequently used in the advanced diagnostic work-up.
tion stress test and squeeze test for making the diagnosis However, MRI has only limited sensitivity for concomitant
of unstable isolated syndesmotic injuries. In contrast to intra-articular injuries such as cartilage damage [26–28].
arthroscopy, MRI is highly valued in the advanced diagnos- These lesions are reported to be associated with unstable
tic work-up of isolated syndesmotic injuries. Unstable and injuries of the syndesmosis in up to 50% of patients [29].
complete injuries of the syndesmosis are commonly treated The recent study also reported that at least 19% of these
with syndesmotic screw fixation (80%) with the vast major- lesions needed therapeutic intervention, so consequently
ity of hardware being removed routinely in the postoperative the current status of care is likely to overlook a potentially
follow-up. Suture-button devices continue to be less com- treatable concomitant injury. Therefore, arthroscopy was
monly used. However, it has to be stated that the results of proposed for evaluation of both concomitant injuries and
the present survey only consist of pure descriptive statis- syndesmotic instability. In contrast to MRI examination,
tics. Consequently, no therapeutic recommendations can be ankle arthroscopy allows direct visualization both statically
derived. as well as under applied stress load and high accuracy for
There is a variety of clinical tests to identify syndes- the diagnosis of syndesmotic instabilities was demonstrated
motic injuries, however, due to limited diagnostic accuracy [17, 30–32]. Arthroscopy was therefore even proclaimed
clinicians cannot rely on a single test to diagnose the integ- as the ultimate benchmark for the detection of syndesmotic
rity of the syndesmosis with certainty [13]. This clinical instability due to its use in visualization of intraoperative
problem is reflected in the present study, showing that the joint reduction and evaluation of stability after fixation
respondents use a variety of different tests, especially exter- [33, 34]. Although arthroscopy is gaining importance in
nal rotation stress test, squeeze test and forced dorsiflexion the treatment of ankle pathologies [35], in our study only
test, to identify syndesmotic injuries. In accordance with 15% of the participants reported that arthroscopy is part of
the clinical usage of multiple diagnostic examinations, a their diagnostic algorithm.

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2024 Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026

The treatment method of choice for injuries to all parts The present study also revealed that syndesmotic screws
of the syndesmosis clearly appears to be surgical. However, are routinely removed after 6 weeks. This contrasts with
only a quarter of the respondents indicated that they would current literature mainly from the US, where a routine
consider surgical treatment for isolated injuries of the ante- removal of syndesmotic screws is only advised in case of
rior or posterior syndesmosis, although cadaveric studies complaints related to hardware or malreduction and screws
show that cutting the anterior syndesmosis already leads to are left in situ for at least 3 to 9 months [43, 44]. Moreo-
significantly increased anterior–posterior translation and ver, a recent systematic review illustrated no evidence to
rotational instability of the fibula [36]. Knowing that even support routine removal of syndesmotic screws in regard to
1 mm of talus subluxation leads to significant change of functional outcome, but found an association with higher
contact forces in the tibiotalar joint, the risk of cartilage financial costs and morbidity [45, 46]. Therefore, the cur-
damage and osteoarthritis is potentially high even in iso- rent practice regarding routine hardware removal should be
lated injuries of the AITFL (anterior inferior tibiofibular questioned critically.
ligament) or PITFL (posterior inferior tibiofibular ligament) The present study does have its limitations. As the entirety
[37]. Thus, even in isolated injuries of the AITFL or PITFL, of recipients remained unclear, not every question addressed
a thorough clinical examination should be performed and by all respondents and there was potential for multi-address-
surgical therapy might be considered, especially in young ing, the basic population as well as the response rate can-
and active patients. not be reported. This entails a risk for selection bias that
In the last decade, suture-button devices have become participating departments and clinicians do not mirror the
increasingly popular and are extensively discussed in recent current status of treatment of isolated syndesmotic injuries
literature. Improved functional outcomes and rehabilitation in Germany. High shares of clinicians treating less than ten
as well as lower rates of broken implants are often cited non-fracture-related injuries of the syndesmosis underlines
as evidence to promote the usage of suture-button devices the rarity of this injury and entails the risk that no standard
[38, 39]. Additionally, the data of the present study suggests of care has been developed. Again, it has to be stated that the
that more than 90% of the respondents routinely remove the results of the present survey only consist of pure descriptive
hardware after syndesmotic screw fixation, so consequently statistics and that no therapeutic recommendations can be
suture-button devices imply the advantage of being less inva- derived. However, high shares of surgeons with small num-
sive postoperatively. However, suture-button devices have bers of annual cases also indicate that probably a relatively
not yet found its way into broad clinical application, as only wide cross section of clinicians was convinced to answer
13% of the respondents reported using suture-button devices. the questionnaire, which is indicative of the validity of the
While half of the respondents stated that syndesmotic screw results.
fixation and suture-button devices are equivalent in the treat-
ment of syndesmotic injuries, more than a third think that
screw fixation is superior to suture-button devices. There- Conclusions
fore, the prolonged transfer into daily clinical work might be
due to persistent doubt regarding the effectiveness of suture- The treatment of non-fracture-related syndesmotic injuries
button devices. However, a recent biomechanical analysis is characterized by a variety of diagnostic and therapeutic
reinforced doubts, showing increased sagittal instability with possibilities. For the first time, a descriptive analysis was
ankle inversion after suture-button fixation while tricortical performed to describe this variety and to provide insight
screw fixation restored the intact ankle tibiofibular kinemat- into the current status quo in Germany. Up to the present
ics [36]. In addition, the question, whether suture button day, syndesmotic screw fixation after diagnostic work-up
devices are superior with respect to malreduction, remains by MRI seems to be the most common treatment algorithm
controversial [40, 41]. Further biomechanical studies as well for non-fracture-related syndesmotic injuries. New fixa-
as clinical studies with long-term follow-up are needed to tion techniques, such as suture button devices, which have
shine a light on this issue. been shown to be at least equivalent with respect to clinical
Evaluation of the correct alignment of the syndesmosis outcomes, do not appear to be in wide use in daily clini-
after reduction remains challenging. Intraoperative malro- cal routine. Most syndesmotic screws are removed after 6
tations occur frequently and are associated with posttrau- weeks, while no evidence for an advantage of routine hard-
matic arthrosis as well as chronic syndesmotic instability. ware removal exists. Although the clinical significance of
However, malrotations are difficult to detect especially when arthroscopy and intraoperative 3D visualization has been
using conventional radiographs. That is why intraoperative scientifically shown, the present study illustrated that they
3D visualization is highly recommended [42, 43]. In contrast seem to play only a minor role in daily clinical routine in
to this recommendation, only 28% of all respondents used Germany.
3D intraoperative visualization after syndesmotic fixation.

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Archives of Orthopaedic and Trauma Surgery (2023) 143:2019–2026 2025

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