Arch Orthop Trauma Surg (2006) 126: 304–308
DOI 10.1007/s00402-006-0131-8
O R I GI N A L A R T IC L E
Laura Bragonzoni Æ Alessandro Russo
Mauro Girolami Æ Ugo Albisinni Æ Andrea Visani
Nicoletta Mazzotti Æ Maurilio Marcacci
The distal tibiofibular syndesmosis during passive foot flexion. RSA-based
study on intact, ligament injured and screw fixed cadaver specimens
Received: 29 November 2004 / Published online: 28 March 2006
Ó Springer-Verlag 2006
Abstract Introduction: The aim of the study was to
investigate the kinematics of the distal tibiofibular syn-
desmosis in intact and ligament injured ankles and to
assess how effective is the syndesmotic screw in
restraining mortise width variations during passive foot
flexion. Materials and methods: The trials were carried
out on seven fresh frozen cadaver specimens. The distal
tibiofibular syndesmosis widening was investigated using
Roentgen stereophotogrammetric analysis, in intact and
ligament injured ankles and after the fixation of the
syndesmotic screw. The AO-ASIF recommendations
were followed for screw implant. Results: Injury to the
syndesmotic and deltoid ligaments of the ankle did not
result in a significant variation of the syndesmosis
behavior during passive foot flexion. The 4.5-mm
diameter cortical screw used in this study proved effec-
tive in restraining mortise width variation during foot
flexion. The recorded mortise widening in the flexion arc
extending from the neutral to the maximally dorsiflexed
position was negligible in intact and ligament injured
joints. Conclusion: The result does not endorse the
L. Bragonzoni (&) Æ A. Russo Æ A. Visani
N. Mazzotti Æ M. Marcacci
Biomechanics Laboratory,
Centro di Ricerca ‘‘Codivilla-Putti’’,
Istituti Ortopedici Rizzoli, Via di Barbiano 1/10,
40136 Bologna, Italy
E-mail: l.bragonzoni@biomec.ior.it
Tel.: +39-51-6366520
Fax: +39-51-583789
E-mail: a.visani@biomec.ior.it
E-mail: n.mazzotti@biomec.ior.it
E-mail: m.marcacci@biomec.ior.it
M. Girolami
Department of Orthopaedic, Istituti Ortopedici Rizzoli,
Via Pupilli 1, 40136 Bologna, Italy
E-mail: mauro.girolami@ior.it
U. Albisinni
Department of Radiology, Istituti Ortopedici Rizzoli,
Via Pupilli 1, 40136 Bologna, Italy
E-mail: ugo.albisinni@ior.it
recommendation of placing the foot in full dorsal flexion
during screw implantation. The choice of screw fixation
as a treatment for ankle syndesmosis disruption should
be carefully evaluated.
Keywords Syndesmosis Æ Screw Æ RSA Æ
Tibiofibular Æ Ankle
Introduction
Syndesmotic injury with ensuing tibiofibular diastasis is
normally associated with ankle fractures, but can also
occur without bone damage [12, 15, 25, 27, 45]. Screw
fixation following syndesmosis disruption with or with-
out fracture is recommended by many authors [10–13,
18, 19, 31, 32, 39, 43], while others raise doubts as to its
use in several circumstances [4, 6, 7, 24, 29, 42, 47].
When no fracture is present, injury is difficult to assess
radiographically, misdiagnosis is common and the effi-
cacy of the surgical treatment is contradictory [23, 35].
Fixation is aimed at accelerating the healing process of
the syndesmosis structures, but hinders the physiologic
motion between tibia and fibula during foot flexion. This
often results in patient discomfort and pain and occa-
sionally causes implant failure if weight bearing is al-
lowed before screw removal.
Conventional surgical techniques recommend that
the foot be kept in dorsal flexion during screw insertion.
Such recommendation is based on the anatomic obser-
vation that during dorsal flexion the talus glides poste-
riorly and its broader section engages the ankle mortise
[5, 16]. While there seems to be a wide agreement on the
kinematic meaning of the previous assumption, its clin-
ical consequences are still rather unclear.
Roentgen stereophotogrammetric analysis (RSA) is a
radiographic measurement technique [17, 36–38], which
has already been successfully used in biomechanical and
clinical studies concerning the ankle joint [1–3, 20–22,
40]. The use of RSA in this study is motivated by the
high accuracy level [34, 48] it provides.

The aim of this study was to measure the relative
motion occurring between the distal fibula and tibia in
intact ankles during passive foot flexion and to test
whether ankle mortise width variations were affected by
simple ligament disruption without bone fracture and
screw fixation.
Materials and methods
The experimental setup used in this study resembles the
one described by Olerud [28]. The experimental protocol
included no weight bearing simulation through axial
loading or internal–external stress trials, as the AO-
ASIF surgical protocol [26] recommends not to allow
weight bearing before screw removal.
Seven fresh frozen cadaver specimens (six right and
one left limbs) were used for this study. No information
was available on the donors, but none of the specimens
showed signs of injury or disease which could invalidate
the study. Specimens were thawed for 18 h at room
temperature and disarticulated at the knee. The syn-
desmosis and deltoid ligaments and the interosseous
membrane were exposed. Great care was taken to limit
soft tissue damage. Joint capsules were not dissected.
Each specimen was firmly secured to a testing device
which held it in horizontal position without restricting
Fig. 1 Experimental setup
305
foot flexion. Fixation was obtained with K-wires im-
planted through the proximal tibia. The foot was
strapped to a wooden board on which a 14.7 N force
was exerted to achieve flexion. Forces were applied by
means of a weight hung on a string-and-pulley mecha-
nism. The experimental setup is shown in Fig. 1.
Tantalum beads (0.8-mm diameter) were implanted
into distal tibia, distal fibula and talus, to be used as
reference markers for the RSA. Four to six beads were
implanted in each bone. Markers were inserted spread as
far apart as possible, as their geometric distribution is
strongly correlated to measurement accuracy [8, 34, 41].
Figure 2 provides an illustrative representation of mar-
ker configuration in the specimens.
Two simultaneous orthogonal radiographs were ta-
ken for each specimen using a standard bi-planar RSA
setup [33]. All marker coordinates were used to measure
accurately the range of flexion obtained for each speci-
men. The coordinates of tibial and fibular markers were
also used to measure the variation of ankle mortise
width during the passive movement. Such variation
arises from the abduction–adduction motion of the
distal end of fibula with respect to tibia. The distance
between the distal ends of tibia and fibula was calculated
as the distance between the centers of the tibia and fibula
marker sets. It was assumed that mortise width varia-
tions were equal to the variations of the above-defined
distance.
The exam was reiterated with the foot in a neutral
position, in dorsal flexion and in plantar flexion for each
of the following conditions: (1) with the joint still intact;
(2) after resection of the anterior tibiofibular ligament,
the distal 3 cm of the interosseous ligament/membrane,
the posterior tibiofibular ligament and the deltoid liga-
ment; (3) after implantation of a 4.5-mm diameter cor-
tical screw (SynthesÒ, Mathys Medical Ltd, Bettlach,
Fig. 2 Representative marker distribution in a specimen
306

Switzerland). The screw was placed 2 cm above the an-

kle joint at an angle of about 30° in a posterolateral to
anteromedial direction, and during screw insertion the
foot was kept in maximal dorsal flexion as prescribed by
AO-ASIF [26].
Radiographs were digitized (D-9000 digitizer table,
Tilly Medical Products AB, Lund, Sweden) and the 2-D
marker coordinates measured were processed (WinRSA
3.0, Tilly Medical Products AB, Lund, Sweden) in order
to obtain 3-D coordinates. Such coordinates are ex-
pressed in a unique reference frame and this allows for
measurement of small movements between the marker-
equipped rigid bodies.
Statistical tests were performed to assess whether:
– Variations were significant in intact joints. The re-
corded data were tested (t test) against zero to assess
statistical significance;
– Variations in intact joints differ significantly from
those recorded after ligament resection. Data con- Fig. 3 Mean values and standard deviations of ankle mortise width
cerning intact joints were compared to those collected variations following foot dorsal flexion
after ligament disruption using the Wilcoxon (non-
parametric) test; ligament resection, whereas the syndesmosis behavior
– Variations in intact joints differ significantly from was significantly different after screw fixation (P=0.04).
those recorded after screw fixation. The Wilcoxon Mortise width variations during plantar flexion ex-
(non-parametric) test was used to compare data per- ceeded the system accuracy in intact joint and the liga-
taining to intact joints with those collected after screw ment resection (Fig. 4). Mortise width showed a mean
fixation; decrease of 0.73 mm (s=0.34 mm) in intact specimens, a
– The implanted cortical screw blocked the syndesmosis mean decrease of 0.56 mm (s=0.18 mm) after ligament
during passive foot flexion. The absolute mortise cutting, whereas width variations recorded after syn-
width variations recorded after screw fixation were desmotic screw implantation were negligible ( x ¼ 0:02
tested (t test) against our accuracy threshold of mm, s=0.09 mm; Table 2).
0.20 mm. This test was conceived to check whether The width decrease during plantar flexion in intact
values lay within the accuracy interval of ±0.20 mm joints was significant (P=0.002). As in the previous
centered around zero. case, no statistically significant change in mortise
behavior was evident after ligament resection, whereas
mortise width variations showed a significant decrease
Results following screw implantation (P=0.03) and, in addition,
they lay within the accuracy interval of ±0.20 mm
The evaluation of the ankle range of motion in intact centered around zero (P=0.002).
specimens highlighted that the plantar flexion was Statistical power analysis performed on the previous
greater than the dorsal flexion. Starting from neutral significant findings showed that the sample size was
position an average of 12.1° (standard deviation 4.8°) of adequate (power >0.9 for all tests).
maximum dorsal flexion and an average of 34.6° (stan-
dard deviation 4.3°) of maximal plantar flexion were
measured. Discussion
Mortise width variations during dorsal flexion of the
foot were always below the system accuracy (Fig. 3). The first objective of this study was to assess the
Intact specimens showed a mean width increase of effectiveness of a syndesmotic screw in restraining
0.09 mm (sample standard deviation s=0.26 mm). The ankle mortise width variations during passive foot
mean width variation after ligament resection was null flexion. Moreover, we tried to measure the tibiofibular
(sample mean x ¼ 0:00 mm, s=0.20 mm). A mean
width increase of 0.12 mm (s=0.33 mm) was recorded Table 1 Mortise width variation in dorsal flexion
after implanting the syndesmotic screw (Table 1).
All mean values were contained within the accuracy Specimen #1 #2 #3 #4 #5 #6 #7
interval of ±0.20 mm centered around zero. No mortise
width variation during foot dorsiflexion was statistically Intact 0.13 0.05 0.28
0.22 0.56
0.23 0.05
No ligaments
0.07
0.29
0.11 0.34 0.23
0.05
0.07
significant in intact joints. No significant difference was Screw 0.89 0.16
0.01
0.17
0.07 0.01 0.05
observable comparing data collected before and after

Fig. 4 Mean values and standard deviations of ankle mortise width
variations following foot plantar flexion
syndesmosis width variation after ligament disruption.
Several authors have reported significant diastasis of the
tibiofibular syndesmosis after ankle ligament resection in
their experimental studies [9, 46]. Yet, no quantitative
data are available in the literature on the kinematic
behavior of the tibiofibular syndesmosis in ligament
injured joints.
Although all specimens showed an acceptable range
of flexion on visual inspection, the degree of flexion
obtained during the experiment was accurately mea-
sured to ascertain its adequacy. Our measurements are
comparable to those reported by Tornetta et al. [44].
That we did not measure any statistically significant
flexion-induced mortise widening in ligament injured
joints could be due to the fact that, following ligament
resection, the mortise was already in a diastasized con-
figuration and therefore no longer sensitive to the width
of the articulating segment of talus.
The results of our experiments showed that a syn-
desmotic screw implant might prevent variations of an-
kle mortise width. To the authors’ knowledge only a few
reports are available in the literature which are focused
specifically on this topic and report accurate measure-
ments of foot-flexion-induced mortise width variations
after screw fixation. Peter et al. [30], though, measured
mortise width during foot dorsiflexion in eight cadaver
specimens using electromechanical transducers and
concluded that screw fixation did not limit syndesmosis
widening.
Conventional surgical techniques prescribe that the
foot be kept in dorsal flexion during screw insertion, as
in this position the ankle mortise embraces the widest
portion of talus [5, 16]. Disregarding this recommenda-
tion could lead to an overtightening of the mortise,
which would in turn restrict foot dorsal flexion [26].
Experimental studies on cadavers have yielded conflict-
ing results in this respect, showing that compression of
307
Table 2 Mortise width variation in plantar flexion
Specimen #1 #2 #3 #4 #5 #6 #7
Intact
0.88
0.89
0.83
0.92
0.89 0.09
0.79
No ligaments
0.57
0.74
0.64
0.55
0.79
0.31
0.31
Screw 0.20 0.02
0.01
0.02
0.10
0.02 0.04
the syndesmosis by means of an overtightened screw can
either restrain [28] or have no measurable effect [44] on
foot dorsal flexion. Our measurements in intact joints
indicate that the ankle mortise undergoes non-negligible
tightening when the foot is moved from the neutral to
maximally plantarflexed position, but no significant
mortise enlargement is detectable when the foot is
brought from the neutral to the maximally dorsiflexed
position.
Several experimental studies showed that the ankle
syndesmosis widens when the foot moves from the fully
plantarflexed to the fully dorsiflexed position [1, 9, 14,
30] in healthy limbs. Authors agree in stating that such
widening is unevenly distributed along the flexion arc,
being larger when passing from the fully plantarflexed to
the neutral position and smaller when passing from the
neutral to the fully dorsiflexed position. Our results
match those reported in the cited papers from both a
qualitative and a quantitative standpoint. Our observa-
tions suggest that blocking the syndesmosis with the foot
in neutral position might not restrict foot dorsal flexion
capacity and, consequently, the aforementioned surgical
recommendation might not be essential [44].
The syndesmotic screw proved effective at restraining
mortise width variation during foot flexion. Implanting
cortical screws is therefore advisable when the target is
keeping the syndesmosis blocked. The recorded mortise
widening in the flexion arc extending from the neutral to
the maximally dorsiflexed position is negligible in intact
joints. Such finding does not agree with the assumption
on which the recommendation of placing the foot in
dorsal flexion during screw implantation is based.
Acknowledgments The authors wish to thank Vito Amabile, Luci-
ano Ussia and Valentina Matti of the Radiology Department for
their essential cooperation, Elettra Pignotti for her help with sta-
tistical data processing, Carmelo Carcasio for the technical sup-
port, and Silvia Bassini for her assistance with graphics.
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