Patient-Reported Outcomes,Patient Satisfaction,and Return to Play After Surgical Treatment of Syndesmosis Injuries in Competitive Athletes

Introduction

“The purpose of this study was to evaluate patient-reported outcomes, patient satisfaction, and return to play after surgical repair of syndesmosis injuries in competitive athletes.”

Syndesmotic ankle injuries, often referred to as high ankle sprains, commonly occur among high-level athletes engaging in contact sports such as football, soccer, and lacrosse. High ankle sprains account for 7% to 25% of total ankle sprains ¹ and have been associated with longer recovery than lateral ankle sprains. ²

Management of isolated syndesmotic injuries in athletes is controversial, particularly regarding diagnosis and treatment of intermediate-grade unstable injuries without gross tibiofibular diastasis. ³ There has been recent interest in surgical management of syndesmotic injuries to allow for earlier return to play, ⁴ and a high rate of return to sport has been demonstrated by multiple systematic reviews.^4-6 However, there are few published clinical studies of outcomes after surgical repair of the syndesmosis in athletes,^7-11and only 2 of these studies reported any patient-reported outcome measures (PROMs).^9,11 Both of these studies were limited to a single scoring questionnaire, and none have reported patient satisfaction, subjective assessment of function, or subjective timing of return to unrestricted play.

The aim of this study was to explore return to play and PROMs, including satisfaction and subjective assessment of function, of competitive athletes who underwent surgical treatment of unstable syndesmotic injury without associated fracture.

Methods

Institutional review board (IRB) approval for the study was obtained. A retrospective chart review using a single institution’s electronic medical record was performed using Current Procedural Terminology (CPT) code 27829, Ankle/Lower leg, and Open Reduction and Internal Fixation (ORIF) distal tibiofibular joint disruption (syndesmosis). Inclusion criteria included competitive athletes (high school, collegiate, or professional level) above age 14 who underwent surgery for acute, primary syndesmosis injuries between January 2017 and April 2024, with minimum a follow-up of 9 months. All patients underwent surgical repair by one of 2 fellowship-trained foot and ankle surgeons, using trans-syndesmotic stabilization with suture button constructs or direct anterior inferior tibiofibular ligament (AITFL) reconstruction, with ankle arthroscopy prior to syndesmotic stabilization/repair. Surgical technique was selected at the surgeon’s discretion based on instability/injury pattern. Exclusion criteria included recreational athletes (those not participating at high school, collegiate, or professional level) and concomitant lateral, medial, or posterior malleolus fracture. Patients undergoing other ligamentous repairs at the time of syndesmotic stabilization (ie, lateral ligament reconstruction, deltoid ligament repair, etc) were included in the study. There was no comparison group utilized.

Syndesmotic injuries were classified as either West Point grade ¹² 2B (partial syndesmosis injury with instability) or 3 (complete syndesmotic disruption with frank diastasis), as modified by Calder et al ⁷ based on stress or weight-bearing radiographs, magnetic resonance imaging (MRI), clinical examinations, and findings under arthroscopy. The IRB approval was obtained for the telephone survey process including the questionnaire that was administered. No patients were under 18 years old at the time of the telephone survey. All requirements under the Health Insurance Portability and Accountability Act (HIPAA) were followed. All patients were contacted via telephone to complete a questionnaire at the time of chart review, and informed consent was obtained to participate in a research study. This included the Foot and Ankle Ability Measure (FAAM)-sports subscale-questionnaire ¹³ with an additional 7 questions regarding return to play and patient satisfaction. Twenty-five of 28 (89.3%) patients completed the survey over the phone; 3 of 28 (11.7%) patients were lost to follow-up.

Results

Demographics

A total of 29 ankles in 28 patients were included in the analysis, as 1 patient had surgery for a contralateral syndesmosis injury 3 years after the index procedure (Table 1). The average age of the athletes at the time of surgery was 20.7 ± 2.4 (range = 15-24). Of the patients who completed telephone surveys (N = 25 patients), the average age at the time of survey completion was 24.4 ± 3.3 (range = 19-32). Twenty-four of 28 (86%) patients were male, and 4 of 28 patients were female (14%). Specific sports at the time of injury (Table 2) included collegiate American football (18), professional American football (1), collegiate soccer (4), collegiate lacrosse (1), high school soccer (1), high school baseball (1), high school lacrosse (1), and high school gymnastics (1). One collegiate football player underwent contralateral surgery for a syndesmosis injury while playing professional football 3 years after the index procedure. Two of 4 high school athletes ultimately progressed to a collegiate career in their respective sports.

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Table 1.

Patient Demographics.

Total number of ankles	29
Total number of athletes	28
Age at time of surgery (N = 28)	Mean = 20.7; SD = 2.4 (range = 15-24)
Age at time of survey completion (N = 25)	Mean = 24.4; SD = 3.3 (range = 19-32)
Gender (N = 28)	24/28 male (86%), 4/28 female (14%)

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Table 2.

Sports Represented.

Sport	Number of athletes
Collegiate football	18
Professional football	1
Collegiate soccer	4
Collegiate lacrosse	1
High school soccer	1
High school baseball	1
High school lacrosse	1
High school gymnastics	1

Injury Classifications, Surgical Details, and Complications

Seven of 29 (24.1%) surgeries were for acute injuries (surgery within 4 weeks of injury), 8 of 29 (27.6%) surgeries were for subacute injuries (surgery 4-12 weeks after injury), and 13 of 29 (44.8%) surgeries were for chronic injuries (surgery greater than 12 weeks from injury) (Table 3). Five of 29 ankles (17.2%) were West Point grade 3 (radiographic tibiofibular diastasis with complete injury of syndesmotic ligaments). Twenty-four of 29 ankles (82.8%) were West Point grade 2B (unstable syndesmosis without radiographic tibiofibular diastasis). Eight ankles underwent concomitant deltoid ligament repair (27.6%), 12 ankles underwent lateral ligament reconstruction (41.4%), and 5 of 29 ankles had evidence of chondral injury on routine arthroscopy (17.2%). Eleven of 29 (38%) ankles were true isolated syndesmosis injuries without lateral or deltoid ligament injuries.

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Table 3.

Injury Classifications, Surgical Details, and Complications.

Timing of injury relative to surgery	Acute (<4 weeks) – 7/29 = 24.1% Subacute (4-12 weeks) – 8/29 = 27.6% Chronic (>12 weeks) – 13/29 = 44.8%
West Point grade	2B (24/29 = 82.8%) 3 (5/29 = 17.2%)
Deltoid ligament repair	8/29 = 27.6%
Lateral ligament reconstruction	12/29 = 41.4%
Chondral injury on arthroscopy	5/29 = 17.2%
Repair technique	Trans-syndesmotic suture button – 15/29 = 51.7% AITFL repair – 13/29 = 44.8% Suture button with AITFL augmentation – 1/29 = 3.4%
Complications	2/29 = 6.9%

Fifteen of 29 (51.7%) ankles were treated with trans-syndesmotic flexible fixation with a suture button construct. Thirteen of 29 (44.8%) ankles were treated with direct AITFL repair using suture anchors. One ankle was treated with both techniques.

Complications were seen in 2 of 29 surgeries (6.8%). One patient had post-operative peroneal neuropathy and later underwent common peroneal/superficial peroneal nerve decompression with improvement in symptoms. One patient required removal of the suture button construct due to saphenous neuritis from the medial button. The patient’s symptoms resolved with hardware removal.

Survey Results

Twenty-five of 28 (89.3%) athletes completed telephone surveys post-operatively at a mean follow-up of 41 months (3.4 years) post-operatively, with a minimum follow-up of 9 months (range = 9-88 months) (Table 4). Mean FAAM-sports subscale score was 29.6 ± 3.5 out of 32 (range = 21-32). The mean “Percentage Normal” was 86.6% ± 16.5%.

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Table 4.

Telephone Survey Results.

Telephone survey completed	25/28 = 89.3%
Follow-up time (minimum 9 months for all subjects)	Mean = 41 months (SD = 22)
FAAM-sports score (maximum score = 32)	Mean = 29.6 (SD = 3.5)
Mean “percentage normal” out of 100	86.6 (SD = 16.5)
Patient satisfaction	Very satisfied – 16/25 = 64% Satisfied – 8/25 = 32% Neither satisfied nor dissatisfied – 1/25 = 4%
Subjective assessment of function	Normal – 16/25 = 64% Nearly normal – 8/25 = 32% Severely abnormal – 1/25 = 4%
Return to athletic activity	25/25 = 100%
Return to competition	19/20 = 95.2%
Time to unrestricted play	Mean = 19.9 weeks (SD = 9.8)

Average reported return to unrestricted play was 19.9 weeks ± 9.8 (range = 2-52 weeks). Twenty-five of 25 (100%) patients returned to athletic activity after surgery. Four of 25 patients had surgery after their competitive athletic careers ended or during their senior seasons. Of the 20 patients who were eligible to do so, 19 of 20 (95%) patients returned to competition level. The 1 athlete who did not return to competition level was a high school athlete.

Twenty-four of 25 (96%) patients rated their current level of ankle function as normal (16/25 = 64%) or nearly normal (8/25 = 42%). One of 25 (4%) patients rated the current level of function as severely abnormal. Sixteen of 25 (64%) patients reported that they returned to the pre-injury level of function. Nine of 25 (36%) patients reported they did not return to the pre-injury level of function. Twenty-four of 25 (96%) patients reported they were either very satisfied (16/25 = 64%) or satisfied (8/25 = 32%) with their surgical outcome. One of 25 (4%) patients reported neither satisfied nor dissatisfied with the outcome. Twenty-three of 25 (92%) patients reported that they would have surgery again, with 2 of 25 (8%) patients reporting that they would not undergo surgery again. Two of 25 (8%) patients had a repeat injury of the operative ankle after return to play; the remaining patients reported no further injuries to their ankle.

Discussion

In this cohort of young (age range = 15-24), competitive athletes undergoing surgical repair of the ankle syndesmosis without associated fracture, return to sport was excellent, with 100% of athletes who completed telephone surveys returning to unrestricted athletic activity, and 19 of 20 (95%) athletes eligible to do so returning to collegiate or professional competition level. This is similar to other systematic reviews in the literature. Vancolen et al ⁶ reported a 93.8% return to pre-injury level for athletes after syndesmotic injury; however, that study included recreational athletes as well as injuries managed non-operatively in the analysis. A more recent systematic review by Bolia et al ⁵ reported that 100% of 171 elite athletes (collegiate or professional level) undergoing surgical repair of ankle syndesmosis injuries returned to sport. The majority of the studies included in this review focused solely on timing of return to play rather than subjective assessments of function, which is the strength of our study. Our study included 4 high school athletes, 2 of whom did progress to a collegiate career in their respective sport. The 1 patient in our cohort who did not return to competition level despite being eligible to do so was a high school athlete whose sport was gymnastics. Five patients in our cohort were not eligible to return to competition, as their injury ended their senior season; however, all of these patients reported return to athletic activity. Three of the 5 patients reported a 32/32 on the FAAM-sports score, rated their current ankle function as “normal,” and reported that they returned to pre-injury level of function. Two of the 5 patients reported an FAAM-sports score of 21/32 and that they did not return to pre-injury level.

There are minimal data in the existing literature on PROMs after syndesmosis repair in athletes. Of the studies included in the previously mentioned systematic review, which were athlete-specific studies, only 2 included any PROMs, both of which were limited to a single outcome score. Kim and Shin ⁹ reported on 22 athletes undergoing suture anchor repair of the AITFL and included only the average Foot and Ankle Outcome Scores (FAOS). Taylor et al ¹¹ described a case series of 6 collegiate athletes undergoing screw fixation of syndesmotic injuries and reported scores using the Sports Ankle Rating System. Our study offers a greater breadth of PROMs, including the FAAM-sports subscale, subjective assessment of function, and patient satisfaction, which should assist surgeons who treat athletes in the future with regards to patient counseling. Our cohort was also larger (28 patients) than the previous studies that included any PROMs.

In addition, of the 171 athletes in the Bolia systematic review, ⁵ only 3 played American football. The highest number of patients in these studies were either soccer or rugby players.^7-10 To our knowledge, our study reports return to play and outcomes on the largest cohort of American football players undergoing surgical repair of the syndesmosis in the literature, with 19 patients in our series playing football. This is significant given the prevalence of these injuries in American football as well as recent media attention.

A review of National Football League (NFL) athletes participating in the NFL combine from 2009 to 2015 reported that 1216 of 2285 (53.2%) had a history of ankle injury, with high ankle sprains representing 417 of 1242 (33.6%) ankle sprains. ¹⁴ Another study reported 533 high ankle sprains in 498 NFL players between 2009 and 2020. ¹⁵ In collegiate football, Hunt et al ¹⁶ reported 573 high ankle sprains over a 5-year period, accounting for 24.6% of all ankle sprains; however, only 2.7% required surgical intervention. Our study adds important data to the existing literature on surgical syndesmosis repair in football players, as relatively small numbers of athletes require surgical intervention in comparison with the total number of high ankle sprains sustained. This is particularly true as the indications for surgery in intermediate-grade injuries evolve.

The average patient-reported return to play in our cohort was 19.9 weeks (139 days). The most comprehensive study on return to play after surgical treatment was done by D’Hooghe et al. ⁸ They followed 110 professional soccer players after surgery for West Point grade 2B and 3 injuries without fracture and found a mean time to return to team training of 72 days post-operatively and a mean time to first official match of 103 days post-operatively. This is a faster return to play than the averages seen in our cohort. It is, however, important to note that all athletes in their study were professional-level athletes and did not include the higher-energy injuries often sustained during American football participation. The majority of athletes in this study were collegiate level; thus, the timing of surgery in relation to in-season or off-season status may have had more influence on return to play. We also based our return-to-play information on patient-reported data, which may contribute to differences.

Eleven of the 29 (38%) ankles in this study were true isolated syndesmosis injuries without lateral or deltoid ligament injuries. Five of the 29 (17.2%) ankles demonstrated chondral injury on arthroscopy. There are growing data to suggest that isolated syndesmosis injuries are rare, and risk factors for prolonged returned to play should be evaluated. A recent analysis of 83 syndesmosis injuries in the NFL found that only 11 of 83 (13%) injuries were isolated to the syndesmosis, with 65 of 83 (78%) associated with other ligamentous injuries. ¹⁷ That study found a significantly longer return to play if there was the presence of an associated deltoid injury or fracture. Calder et al ⁷ similarly found prolonged return to play with associated deltoid ligament injury, and the previously discussed D’Hooghe study ⁸ found prolonged returned to play with chondral injury. We did not find worse FAAM scores or differences in return to play with concomitant injury in our cohort; however, this could have been limited by sample size. Interestingly, patients with chondral injury had a significantly higher FAAM score in our cohort than those without. While these data are difficult to interpret, it underscores the importance of routine arthroscopy and suggests that even with chondral injury, return to play and outcomes can be predictable. There was no significant impact on the timing of surgery in relation to injury, and this may indicate that even those athletes with delayed presentation may do well once an appropriate diagnosis and treatment plan is established.

This study is not without limitations. This was a retrospective study, which comes with inherent limitations in data collection. This was a single-arm case series without a comparison group. This was also a relatively small sample size with 29 surgeries completed by only 2 surgeons, which may limit generalizability. Return-to-play data are difficult to standardize, as there are different definitions on return to play. This is particularly true in high school and collegiate athletics, as several players had surgery in the off-season or after their careers ended, unrelated to their injury. In addition, there may be differences from when a player is cleared to return to play by their surgeon or athletic trainer compared with when he or she actually felt comfortable to return to sport. We therefore focused on subjective return to unrestricted play data reported by the individual athletes as a PROM; however, timing of return to play was still influenced by whether the athlete was in or out of season at the time of injury. Three patients were lost to follow-up and did not complete telephone surveys. The telephone surveys were also administered at the time of chart review rather than at standardized time post-operative points with variable follow-up. The information included is thus subject to recall bias, in particular for patients with longer follow-up. The study participants were obviously made aware that they were participating in a research study, which could influence responses. We also did not compare non-operative to operative treatment in grade II injuries; thus, we are unable to comment on differences in return to play or outcomes.

Conclusion

In this review of competitive athletes who underwent surgical repair of an unstable ankle syndesmosis injury without associated fracture, nearly all were able to return to their previous level of participation, with high patient satisfaction and outcomes scores, and few complications. Severity of injury, presence of concomitant injury, and repair technique were not found to have an effect on patient-reported outcome scores or timing of return to play.