title: Evaluation and management of injuries of the tibiofibular syndesmosis.
abstract: BACKGROUND
  Injury to the tibiofibular syndesmosis often arises from external rotation force acting on the foot leading to eversion of the talus within the ankle mortise and increased dorsiflexion or plantar flexion. Such injuries can present in the absence of a fracture. Therefore, diagnosis of these injuries can be challenging, and often stress radiographs are helpful. Magnetic resonance imaging scans can be a useful adjunct in doubtful cases. The management of syndesmotic injuries remains controversial, and there is no consensus on how to optimally fix syndesmosis. This article reviews the mechanism of injury, clinical features and investigations performed for syndesmotic injuries and brings the reader up-to-date with the current evidence in terms of the controversies surrounding the management of these injuries.
  
  
  METHODS
  Embase, Pubmed Medline, Cochrane Library, Elsevier and Google Scholar (January 1950-2014).
  
  
  RESULTS
  The management of syndesmotic injuries remains controversial, and there is no consensus on: (i) which ankle fractures require syndesmotic fixation, (ii) the number or the size and the type of screws that should be used for fixation, (iii) how many cortices to engage for fixation, (iv) the level of screw placement above the ankle plafond, (v) the duration for which the screw needs to remain in situ to allow the tibiofibular syndesmosis to heal and (vi) when should patients weight bear.
  
  
  RESULTS
  (i) A high proportion of syndesmotic fixations demonstrates malreduction of the syndesmosis, (ii) no need to remove screws routinely, (iii) two screws appear to better one alone and (iv) if syndesmosis injury is not detected or not treated long term, it leads to pain and arthritis.
  
  
  CONCLUSIONS
  (i) How to assess the adequacy of syndesmotic reduction using imaging in the peri-operative period, (ii) the use of bio-absorbable materials and Tightrope and (iii) evidence is emerging not to remove syndesmotic screws unless symptomatic.
  (i) A bio-absorbable material that can be used to fix the syndesmosis and allow early weight bearing, and (ii) there is a need for developing a surgical technique for adequately reducing the syndesmosis without the exposure to radiation.
authors.affiliation: Addenbrooke's Cambridge University Hospitals NHS Trust, Cambridge, UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Magan
authors.affiliation: Laboratory of Arthroscopic and Surgical Anatomy, Department of Pathology and Experimental Therapeutics (Human Anatomy Unit), University of Barcelona, Barcelona, Spain.
authors.forename: Pau
authors.initials: P
authors.lastname: Golano
authors.affiliation: Department of Musculoskeletal Surgery, Faculty of Medicine and Surgery, University of Salerno, Salerno, Italy Centre for Sport and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, London, UK.
authors.forename: Nicola
authors.initials: N
authors.lastname: Maffulli
authors.affiliation: Addenbrooke's Cambridge University Hospitals NHS Trust, Cambridge, UK vk279@cam.ac.uk.
authors.forename: Vikas
authors.initials: V
authors.lastname: Khanduja
mesh_terms: D016512:Ankle Injuries / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy*; D000843:Ankle Joint / Q000033:anatomy & histology; D001863:Bone Screws; D005593:Fracture Fixation, Internal / Q000379:methods; D050723:Fractures, Bone / Q000601:surgery; D006801:Humans
keywords: diastasis; injuries; management; tibiofibular syndesmosis