Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis

Abstract

Background: Syndesmotic ankle sprains are common and challenging injuries for athletes. The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury. The present study seeks to review and report the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in the athletic population. Methods: PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcomes were the rate and time to return to play after syndesmotic ankle sprains for both surgical and nonsurgical treatment. Secondary outcomes included short-term complications and recurrence. Results: Eighteen articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85), whereas it was 39.33 days (95% CI 28.78, 49.88) for nonsurgically treated cases. A low incidence of recurrence and complications were reported. Conclusion: This article reports a high rate of RTP after syndesmotic sprains. Grade of injury and surgical vs conservative management can affect the time to RTP in high-level athletes. Level of Evidence: Level IV, systematic review and meta-analysis.

Postoperative Return to Play and the Role of Imaging

“…55 Because syndesmotic injuries represent a heterogeneous group with varying grades of syndesmotic ligament injury, possible concomitant osseous and/or other ligamentous injuries, and potential syndesmotic instability, it is not surprising that optimal treatment is controversial. 50,52,58 Nonoperative management is generally considered an appropriate treatment strategy for patients with a stable syndesmosis. 53,55,59 However, multiple degrees of variation exist within nonoperative management of such injuries, including the weight-bearing regimen and immobilization options, with reported lengths of immobilization ranging from 1 to 6 weeks.…”

“…55 In a meta-analysis of syndesmotic injuries, overall return to sport was 71 days among a cohort of patients undergoing operative management, compared with 39 days for patients who were managed nonoperatively, likely in part reflecting the inherently increased injury grade associated with surgical management. 50 Among postoperative patients who experience pain during the rehabilitation process, imaging is a likely step in the diagnostic algorithm. Familiarity with possible complications and expected findings following syndesmotic fixation is essential to direct appropriate treatment, if necessary.…”

“…General complications of syndesmotic fixation include heterotopic ossification, implant failure, and infection. 50 A specific complication with implications for clinical outcomes is malreduction, or malalignment of the syndesmosis, reported in fewer cases with suture button construct fixation compared with screw fixation. 55,63 Intraoperative imaging aims to limit the risk of malreduction, but careful attention to alignment on postoperative imaging is essential.…”

“…Traumatic injuries of the ankle are extremely common in the general population, and one of the most common locations of injury in sport, accounting for ∼ 40% of all sports-related injuries. 50 The ankle is a complex joint, including the tibiotalar, distal tibiofibular, and subtalar articulations. The ankle relies on multiple ligamentous structures for stabilization, including the medial collateral ligament, or deltoid ligament; the lateral collateral ligaments, including the anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament; the spring ligament; and the tibiofibular syndesmosis.…”

“…55 In a meta-analysis of syndesmotic injuries, overall return to sport was 71 days among a cohort of patients undergoing operative management, compared with 39 days for patients who were managed nonoperatively, likely in part reflecting the inherently increased injury grade associated with surgical management. 50…”