![]() Between the anterior and posterior margins of the tibia there is a triangular concave notch, named incisura tibialis, where the convex medial margin of the distal fibula rests. Posterior tubercle functions as a fulcrum during external rotation injury, and the fibula spins around its longitudinal axis. These tubercles represent the tibial attachment sites respective of the anterior and posterior syndesmotic ligaments. The lateral ridge of the distal tibia bifurcates into an anterior and posterior margin, forming a larger anterior (Chaput’s tubercle) and a smaller posterior tubercle (Volkman’s tubercle). The bony anatomy of the distal tibia and fibula is important for the osseous stability of the tibiofibular joint, which is a syndesmosis formed by the medial rough convex surface of the distal fibula which articulates with the lateral triangular fibular notch of the distal tibia. The aim of this study is to review anatomical and biomechanical characteristics of DTS, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment. However, there is no unique consensus on whether DF methods are superior to the static ones in terms of functional outcomes, change in range of motion, complication rates and incidence of reoperation. Recently, this technique has become increasingly popular because it allows a more physiological articular movement, early rehabilitation, satisfactory functional outcomes and no requirement for implant removal. An alternative dynamic method of fixation (DF) uses an implanted suture-button device it consists of a nonabsorbable synthetic suture between two metallic buttons implanted across the DTS. Screw loosening, breakage, discomfort, pain related to overcompression, the need for a reoperation for screw removal and the risk of late diastasis after early removal are potential drawbacks of this type of fixation. However, some significant issues should be considered. Static fixation (SF) with one or more cortical screws is the reference standard fixation method. Various fixation techniques have been introduced over recent decades (metallic and bioabsorbable screws, staples, polyester bands, syndesmosis hooks, Kirschner wires and suture-button fixation). Patients with unstable injuries require surgical stabilization. Persistent ankle pain, function disability and early osteoarthritis are potential problems related to misdiagnosed or inadequate treatment, and for this reason it is necessary to acquire an accurate diagnosis and maintain syndesmotic reduction when treating ankle fractures with concomitant syndesmotic disruption. Therefore, it is crucial that surgeons adequately diagnose these lesions, which are present in up to 40% of all type B injuries according to Danis-Weber classification and up to 80% of all type C. About 10% of all are associated to syndesmotic injury, and this percentage is twice as high in patients who require internal fixation. Ankle fractures occur with an incidence of 107-100 in the adult population. They are consequent to an external rotation force applied to the foot that leads to eversion of the talus within the ankle mortise. DTS injuries of sufficient severity can disrupt the normal stability of the ankle and they may occur in many forms, commonly classified into isolated or, more frequently, with an associated malleolar fracture. The distal tibiofibular syndesmosis (DTS) complex is critical for maintaining the congruency of the ankle mortise and is the most important supporter of this joint. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint.
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