Defining reference values for the normal tibiofibular syndesmosis in adults using weight-bearing CT

Bone Joint J. 2019 Mar;101-B(3):348-352. doi: 10.1302/0301-620X.101B3.BJJ-2018-0829.R1.


Aims: Cone beam CT allows cross-sectional imaging of the tibiofibular syndesmosis while the patient bears weight. This may facilitate more accurate and reliable investigation of injuries to, and reconstruction of, the syndesmosis but normal ranges of measurements are required first. The purpose of this study was to establish: 1) the normal reference measurements of the syndesmosis; 2) if side-to-side variations exist in syndesmotic anatomy; 3) if age affects syndesmotic anatomy; and 4) if the syndesmotic anatomy differs between male and female patients in weight-bearing cone beam CT views.

Patients and methods: A retrospective analysis was undertaken of 50 male and 50 female patients (200 feet) aged 18 years or more, who underwent bilateral, simultaneous imaging of their lower legs while standing in an upright, weight-bearing position in a pedCAT machine between June 2013 and July 2017. At the time of imaging, the mean age of male patients was 47.1 years (18 to 72) and the mean age of female patients was 57.8 years (18 to 83). We employed a previously described technique to obtain six lengths and one angle, as well as calculating three further measurements, to provide information on the relationship between the fibula and tibia with respect to translation and rotation.

Results: The upper limit of lateral translation in un-injured patients was 5.27 mm, so values higher than this may be indicative of syndesmotic injury. Anteroposterior translation lay within the ranges 0.31 mm to 2.59 mm, and -1.48 mm to 3.44 mm, respectively. There was no difference between right and left legs. Increasing age was associated with a reduction in lateral translation. The fibulae of men were significantly more laterally translated but data were inconsistent for rotation and anteroposterior translation.

Conclusion: We have established normal ranges for measurements in cross-sectional syndesmotic anatomy during weight-bearing and also established that no differences exist between right and left legs in patients without syndesmotic injury. Age and gender do, however, affect the anatomy of the syndesmosis, which should be taken into account at time of assessment. Cite this article: Bone Joint J 2019;101-B:348-352.

Keywords: Ankle syndesmosis; Distal tibiofibular joint; Syndesmosis; Tibiofibular ankle; Tibiofibular syndesmosis.

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Aged
  • Aged, 80 and over
  • Anatomy, Cross-Sectional
  • Ankle Joint / anatomy & histology
  • Ankle Joint / diagnostic imaging*
  • Ankle Joint / physiology
  • Body Weights and Measures / standards
  • Cone-Beam Computed Tomography*
  • Female
  • Fibula / anatomy & histology
  • Fibula / diagnostic imaging
  • Humans
  • Male
  • Middle Aged
  • Reference Values
  • Retrospective Studies
  • Sex Factors
  • Tibia / anatomy & histology
  • Tibia / diagnostic imaging
  • Weight-Bearing*
  • Young Adult