Reconstruction of chronic injury of the distal tibiofibular syndesmosis by peroneus longus tendon

Abstract

Objective: The dynamic stability and congruence of the ankle joint have direct relationship with the integrity of distal tibiofibular syndesmosis ligament complex, especially if associated with fracture and/or dislocation in the ankle. The acute injury has systematic classification and treatment, but in chronic injuries the literature is scarce and still does not have a standardization of its treatment. The main change is anatomical talar translation under the tibia, mainly if the foot was in eversion force and rotating the ankle. Clinically, the patients with chronic syndesmotic lesion complain of pain and instability with more than 3 months from the initial trauma. The objective of this paper was to evaluate patients submitted to ligamentoplasty in accord with the Grass et al. method, seeking to rebuild the normal anatomical relations of syndesmosis complex. Methods: We have done the ligamentoplasty in seven patients who presented with pain and chronic instability of the syndesmosis and whose X ray showed syndesmosis joint clear space >1cm, after trauma in external rotation of the foot and pronation ankle joint, associated or not with fracture. Other injuries were present in cases with osteochondral lesion of the talus and in three cases with fibula fracture type AO-44C3. Results: The mean follow-up was 62 months (ranging from 26 to 110 months). Six patients returned their activities prior to injury and were satisfied with the surgery’s outcome. Two patients had decreased the ankle mobility between 10 and 30o of dorsi-flexed, probably due to advance aspect of the osteoarthritis of ankle, being that a patient was unhappy due to preoperative osteoarthritis of the ankle, and one patient was dissatisfied because of functional limitation resulting from the tibiofibular synostosis. In the postoperative period, there was no case of infection but there was a case of neuropraxia of the common fibular nerve with remission. Six patients had improvement in edema and instability, with gain of strength and skill in daily activities. In the latest assessment, all patients had improvement according to the American Orthopaedic Foot and Ankle Society (AOFAS) score, with an average of points ranging from 79.71 (58 to 92 points), being that the lower results had a direct relationship with the overweight patients and preoperatively cartilaginous injury stage at the ankle joint.(Conclusion: retirar)In conjecture, the ligamentoplasty with flap of peroneus longus tendon proved to be effective in reconstruction and stabilization of the syndesmosis ligament complex of the distal tibia with improved function and decrease pain. We believe that larger studies must be conducted to standardization of treatment of chronic injury of the syndesmosis.