Common pitfalls in syndesmotic rupture management: a clinical audit

Syndesmotic injuries occur in up to 11% of all ankle injuries. Whereas the optimal fixation of syndesmotic injuries remains controversial, pitfalls in their management can lead to poor outcomes.

This is a retrospective study of all ankle fractures operated on at a level 1 trauma center over a 7-year period. All cases with syndesmotic fixation were classified and patients' notes and x-rays were reviewed. The timing of definitive syndesmotic fixation, the type of fixation (screw size and number, number of cortices), and the number of unplanned, syndesmotic-related reoperations were recorded. Seventy syndesmotic ruptures were operated on during the study period.

There were 19 unplanned reoperations. The 3 reasons for reoperation identified were failure to diagnose the syndesmotic injury 9/19 (47%), failure to achieve an anatomic reduction 6/19 (31%), and loss of reduction due to fixation failure 4/19 (21%). The type of fixation was not correlated with the failure rate, nor were the experience of the surgeon, the gender or the age of the patient.

The reoperation rate for syndesmotic fixation may be higher than previously thought. In order to reduce the pitfalls in their treatment, we emphazise the importance of 3 critical points in the management of these injuries: suspect the injury, document the stability of the syndesmosis, and reduce the fibula anatomically.

Level III, retrospective comparative series.