Jacob W McDevitt, Eric H Durudogan, Frederic J Washburn, Milap S Patel, Muhammad Y Mutawakkil, Anish R Kadakia
The available evidence, although limited to low-level retrospective studies, suggests that chronic distal tibiofibular syndesmotic instability may be surgically treatable across a range of clinical presentations, and functional improvement has been reported even in longstanding cases. The evidence is consistent with a phenotype-driven treatment approach, though prospective comparative data are lacking: ligament reconstruction or dynamic stabilization for patients without significant arthritis, and distal tibiofibular arthrodesis as a joint-sparing option for those with post-traumatic degenerative changes or fibular malunion. Severity of instability at the time of surgery appears to influence the ceiling of functional recovery, suggesting that earlier operative intervention in appropriate candidates may be beneficial, although this remains to be confirmed in prospective studies. Standardized classification and outcome reporting remain the primary barriers to advancing evidence-based care for this condition.
BACKGROUND: Chronic distal tibiofibular syndesmotic instability is a diagnostically challenging condition associated with persistent pain, functional limitation, and progressive tibiotalar arthritis. Despite a growing range of surgical options, no consensus exists regarding optimal technique, patient selection, or expected outcomes, and no validated classification system has been established to guide treatment.
METHODS: A scoping review was conducted in accordance with PRISMA-ScR guidelines and the Arksey and O'Malley methodologic framework. PubMed/MEDLINE, Embase, and the Cochrane Library were searched through February 2026 with no date restrictions. Eligible studies included skeletally mature patients undergoing surgical treatment for chronic syndesmotic instability, defined as 6 or more months from injury to intervention, with a minimum 6-month follow-up.
RESULTS: Twelve studies encompassing 122 patients met inclusion criteria. All were Level IV or V evidence. Surgical techniques included tendon graft reconstruction (n = 42), arthroscopic-assisted stabilization (n = 44), suture-button or suture anchor fixation (n = 25), and distal tibiofibular arthrodesis (n = 11). AOFAS scores improved by 20 to 50 points across technique categories. Complication and unplanned reoperation rates were low. Return to sport was achieved in all athletic cohorts. Arthroscopic instability grade influenced the ceiling of functional recovery. Complication and reoperation rates were low.
CONCLUSION: The available evidence, although limited to low-level retrospective studies, suggests that chronic distal tibiofibular syndesmotic instability may be surgically treatable across a range of clinical presentations, and functional improvement has been reported even in longstanding cases. The evidence is consistent with a phenotype-driven treatment approach, though prospective comparative data are lacking: ligament reconstruction or dynamic stabilization for patients without significant arthritis, and distal tibiofibular arthrodesis as a joint-sparing option for those with post-traumatic degenerative changes or fibular malunion. Severity of instability at the time of surgery appears to influence the ceiling of functional recovery, suggesting that earlier operative intervention in appropriate candidates may be beneficial, although this remains to be confirmed in prospective studies. Standardized classification and outcome reporting remain the primary barriers to advancing evidence-based care for this condition.