Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines

Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1217-27. doi: 10.1007/s00167-016-4017-1. Epub 2016 Feb 4.


Purpose: Correct management of syndesmotic injuries is mandatory to avoid scar tissue impingement, chronic instability, heterotopic ossification, or deformity of the ankle. The aim of the present study was to perform a systematic review of the current treatments of these injuries to identify the best non-surgical and surgical management for patients with acute isolated syndesmotic injuries.

Methods: A review of the literature was performed according to the PRISMA guidelines. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases was performed using the following keywords: "ankle injury", "syndesmotic injury", "chronic", "acute", "treatment", "conservative", "non-operative" "operative", "fixation", "osteosynthesis", "screw", "synostosis", "ligamentoplasties" over the years 1962-2015.

Results: The literature search and cross-referencing resulted in a total of 345 references, of which 283 were rejected due to off-topic abstract and/or failure to fulfil the inclusion criteria. After reading the remaining full-text articles, we included four studies, describing non-surgical management, and only two studies investigating surgical management of acute isolated injuries.

Conclusions: The ESSKA-AFAS consensus panel provided recommendations to improve the management of patients with isolated acute syndesmotic injury in clinical practice. Non-surgical management is recommended for stable ankle lesions and includes: 3-week non-weight bearing, a below-the-knee cast, rest and ice, followed by proprioceptive exercises. Surgery is recommended for unstable lesions. Syndesmotic screw is recommended to achieve a temporary fixation of the mortise. Suture-button device can be considered a viable alternative to a positioning screw. Partial weight bearing is allowed 6 weeks after surgery.

Level of evidence: IV.

Keywords: Acute; Internal fixation; Non-surgical management; Surgery; Syndesmotic injury.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Ankle Injuries / therapy*
  • Casts, Surgical
  • Conservative Treatment
  • Humans
  • Orthopedic Fixation Devices
  • Orthopedic Procedures
  • Physical Therapy Modalities
  • Practice Guidelines as Topic