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Syndesmotic Ankle Fractures

Michelson, James, D., MD; Wright, Michael, MD; Blankstein, Michael, MD

Journal of Orthopaedic Trauma: January 2018 - Volume 32 - Issue 1 - p 10–14
doi: 10.1097/BOT.0000000000000937

Objectives: The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several clinical questions that arise in the treatment of such injuries.

Data Sources: The English language literature was searched using PubMed, EMBASE, and Web of Science. The search terms were “syndesmosis” or “syndesmotic” in combination with the terms “ankle fracture” or “fracture.” The included dates were between 1967 and July 2015.

Study Selection: Inclusion criteria were number of patients >20, patient age ≥18 years, follow-up ≥1 year, ankle fracture classification was reported, criteria for surgery was reported, technique of surgery was reported, and a validated outcome measure was used. Studies limited to biomechanical or imaging investigations were excluded.

Data Extraction: Information was abstracted using a standardized template, which encompassed the inclusion criteria together with the study type, postoperative regimen, and complications. Study quality was evaluated using the modified CONSORT statement and Coleman criteria. Study bias was assessed, and methodological quality was rated. Any difference in ratings was resolved by consensus.

Data Synthesis: None.

Conclusions: The overall quality of the studies was poor. The number or placement of syndesmotic screws or the breakage of trans-syndesmotic screws postoperatively had no adverse effect on outcomes (both with moderate strength of evidence). The use of alternative fixation devices (bioabsorbable and endobutton) had poor strength of evidence, as did the opinion that nondisplaced, unstable by stress test, syndesmotic injuries required fixation. There are insufficient data that link subtle rotational syndesmotic malreduction to clinical outcomes.

Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, Burlington, VT.

Reprints: James D. Michelson, MD, Department of Orthopaedics and Rehabilitation, University of Vermont College of Medicine, 418A Stafford Hall, 95 Carrigan Drive, Burlington, VT 05401 (e-mail:

The authors report no conflict of interest.

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Each of the authors contributed to the design of the study, collection of data, analysis, interpretation of the results, and drafting of the manuscript. The final version has been approved by all the authors, and all accept responsibility for the integrity of the content of the manuscript.

Accepted June 16, 2017

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