The two bones in the lower leg are the tibia and the fibula. The place just above the ankle where these two bones meet is called the syndesmosis. At the syndesmosis, the tibia and fibula are connected to each other with several strong ligaments. While technically a joint, the syndesmosis does not function like most joints as there is very little motion between the two bones. Its main functions are to provide stability to the ankle joint and to allow the ankle joint to move.
In rare cases, ankle sprains can injure the syndesmosis. The ligaments also can be injured when the ankle is broken. High ankle sprains refer to ankle sprains in which the syndesmotic ligaments are torn. These more severe ankle sprains are commonly seen in running/jumping sports like football, basketball, and soccer.
Surgery to stabilize the syndesmosis is sometimes but not always necessary for these types of injuries. The goal of surgery is to properly align and stabilize the syndesmosis so the ligaments can heal in the correct position.
Your foot and ankle orthopaedic surgeon will examine your ankle. X-rays will be taken and may include a stress X-ray. This is an X-ray that is taken while your doctor carefully twists or stresses your ankle to test the stability of the syndesmosis. If there is an unstable joint, surgery is typically necessary to provide stability.
If the syndesmosis is found to be stable, it usually will not require surgical management. If you have other medical conditions that make surgery too risky for your health, your surgeon may recommend non-surgical treatment. Surgery should also be avoided if you have any active infections or chronic wounds around your ankle.
Surgery usually is done on an outpatient basis, meaning you go home the same day. In rare cases, an overnight stay is required. Spinal or general anesthesia is used during the surgery, and your surgeon may also recommend a nerve block for pain relief after surgery.
Your surgeon will put the syndesmosis into its proper position and secure it in place with screws or suture implants. A plate also may be used. Some foot and ankle orthopaedic surgeons also look inside the ankle joint with an arthroscope to see if the cartilage is injured.
After making an incision over the outside of the ankle, your surgeon will identify and expose the fibula bone and syndesmosis. Using direct vision and live X-ray techniques, your surgeon will place the syndesmosis into the correct position and set it with an implant. This typically involves one or two screws that go from the fibula bone into the tibia bone. The screws may be placed through a plate that sits on the fibula bone. Alternatively, your surgeon may use a suture device instead of screws.
A stress X-ray is performed to confirm that the syndesmosis is stable. Any additional injuries (e.g., fractures) are repaired if necessary. Your surgeon will close the incision(s) with stitches and then place your let in a splint, cast, or boot.
After surgery, you may be immobilized in a splint for the first 10-14 days. You will typically be kept non-weightbearing for 6-8 weeks and then allowed to put weight on your foot in a cast or boot.
Swelling persists for many months after this surgery. The time to return to sports depends on the severity of the injury and the sport. Return to running sports typically does not occur until at least 3 months after surgery, and often longer. Stiffness can be a problem, and physical therapy often is necessary.
All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.
The main complications that can occur after this surgery include irritation or failure of the hardware, the development of arthritis in the syndesmosis or the ankle joint, and failure of the syndesmosis to heal properly.
Most of the time, orthopaedic hardware does not need to be removed. In the case of syndesmosis surgery, your surgeon may recommend removing the screws that go from the fibula to the tibia. Because
there normally is motion between these two bones, the screws may cause pain, limit motion, or even break. You do not need to worry if the screws break, but they may be more difficult to remove if needed. The hardware is not removed until after the syndesmosis is healed. You and your surgeon will discuss what is best for you.
Original article by Brian Clowers, MD
Last reviewed by David Porter, MD; Elizabeth Cody, MD
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