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Importance of Syndesmotic Reduction on Clinical Outcome After Syndesmosis Injuries

Andersen, Mette R. MD, PhD*,†; Diep, Lien M. MSc; Frihagen, Frede MD, PhD§; Castberg Hellund, Johan MD, PhD; Madsen, Jan E. MD, PhD†,§; Figved, Wender MD, PhD*

doi: 10.1097/BOT.0000000000001485
Original Article

Objectives: To evaluate the relationship between syndesmosis reduction and outcome.

Design: Retrospective cohort study.

Setting: One Level 1 and 1 Level 3 Trauma Center.

Patients: Ninety-seven patients with syndesmosis injury.

Intervention: Stabilization of syndesmosis injury. Open reduction and internal fixation of malleolar fracture, if present.

Main Outcome Measurements: Anterior, central, and posterior measures of syndesmosis width on computed tomography scans, Olerud–Molander Ankle score, American Orthopaedic Foot and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, and range of motion measurements.

Results: Eighty-seven patients completed 2 years of follow-up. The difference in anterior tibiofibular distance (aTFD) between the injured and noninjured ankle postoperatively had a significant effect on the Olerud-Molander Ankle score after 6 weeks [b = −2.6, 95% confidence interval (CI), −4.8 to −0.4; P = 0.02], 1 year (b = −2.7, 95% CI, −4.7 to −0.8; P < 0.001), and 2 years (b = −2.6, 95% CI, −4.6 to −0.6; P = 0.009) and on American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score after 6 weeks (b = −2.2, 95% CI, −3.7 to −0.7; P = 0.004), 1 year (b = −1.7, 95% CI, −3.0 to −0.4; P = 0.04), and 2 years (b = −1.9, 95% CI, −3.2 to −0.5; P = 0.006). The effect of computed tomography measurements on range of motion was inconsistent. Receiver operating characteristic (ROC) curves demonstrated that aTFD had adequate discriminatory performance (area under the ROC curve ≥ 0.7) 1 and 2 years after surgery and the central measurement at only 2 years after surgery. ROC analyses indicate a cutoff value for syndesmosis malreduction of 2 mm. The postoperative rate of malreduction was 32%.

Conclusions: The aTFD correlated with clinical outcome. A 2-mm difference in aTFD seems to predict poorer clinical outcome.

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

*Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Trust, Baerum, Norway;

Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway;

Oslo Centre for Biostatistics and Epidemiology (OCBE), Oslo University Hospital, Oslo, Norway;

§Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; and

Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.

Reprints: Mette R. Andersen, MD, PhD, Department of Orthopaedic Surgery, Baerum Hospital, Vestre Viken Hospital Thrust, 3004 Drammen, Norway (e-mail:

Presented in part at the Annual Meeting of the Norwegian Orthopaedic Association, Oslo, Norway, October 26, 2017.

The authors report no conflict of interest.

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Accepted March 15, 2019

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