title: Delayed operative treatment of syndesmotic instability. Current concepts review.
abstract: OBJECTIVE
  To review the literature concerning articles evaluating the delayed operative treatment of isolated syndesmotic instability.
  
  
  METHODS
  The main databases Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, Current Controlled Trials and Embase were searched from 1988 to September 2008 to identify studies relating to the late reconstruction of the distal tibiofibular syndesmosis after isolated syndesmotic injury. The level of evidence of the included articles was scored.
  
  
  RESULTS
  Fifteen articles were identified, involving 94 ankles with a delayed reconstruction for isolated syndesmotic instability.
  
  
  CONCLUSIONS
  In subacute (6 weeks to 6 months) total ruptures the focus is to restore the normal anatomy by repair of the ruptured ligament with placement of a syndesmotic screw. On base of the literature in combination with experience in clinical practice some guidelines are formulated. If inadequate remnants of the anterior inferior tibiofibular ligament (AITFL) are present, a tendon graft can be used. The insertion of the AITFL on the tibia can be medialised with a bone block and fixed with a screw. For the treatment of persistent widening and late instability these reconstruction techniques have to be used combined with debridement and placement of a syndesmotic screw to protect the reconstruction. Most adequate treatment for chronic syndesmotic instability (>6 months) is the creation of a synostosis to stabilise the distal tibiofibular joint. Late repairs give satisfactory but less favourable outcome as compared to properly treated acute injuries. It is not easy to regain complete stability by means of these secondary procedures.
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands. Bekerom@gmail.com
authors.forename: Michel P J
authors.initials: MP
authors.lastname: van den Bekerom
authors.forename: Peter A J
authors.initials: PA
authors.lastname: de Leeuw
authors.forename: C Niek
authors.initials: CN
authors.lastname: van Dijk
mesh_terms: D016512:Ankle Injuries / Q000601:surgery*; D001863:Bone Screws; D002908:Chronic Disease; D003646:Debridement; D005260:Female; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D007593:Joint Instability / Q000601:surgery*; D008023:Ligaments, Articular / Q000293:injuries / Q000601:surgery*; D008297:Male; D010146:Pain / Q000209:etiology / Q000601:surgery; D019919:Prosthesis Implantation / Q000379:methods; D016059:Range of Motion, Articular; D019651:Plastic Surgery Procedures / Q000379:methods*; D020127:Recovery of Function; D012421:Rupture / Q000601:surgery; D013580:Synostosis / Q000601:surgery; D013997:Time Factors