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However, current diagnostic imaging modalities are impeded by a two\u2010dimensional assessment, without considering ligamentous stabilizers. Therefore, our aim is threefold: (1) to construct an articulated statistical shape model of the normal DTFJ with the inclusion of ligamentous morphometry, (2) to investigate the effect of weight\u2010bearing on the DTFJ alignment, and (3) to detect differences in predicted syndesmotic ligament length of patients with syndesmotic lesions with respect to normative data. Training data comprised non\u2010weight\u2010bearing CT scans from asymptomatic controls (<jats:italic>N<\/jats:italic>\u2009=\u200976), weight\u2010bearing CT scans from patients with syndesmotic ankle injury (<jats:italic>N<\/jats:italic>\u2009=\u200913), and their weight\u2010bearing healthy contralateral side (<jats:italic>N<\/jats:italic>\u2009=\u200913). Path and length of the syndesmotic ligaments were predicted using a discrete element model, wrapped around bony contours. Statistical shape model evaluation was based on accuracy, generalization, and compactness. The predicted ligament length in patients with syndesmotic lesions was compared with healthy controls. With respect to the first aim, our presented skeletal shape model described the training data with an accuracy of 0.23\u2009\u00b1\u20090.028\u2009mm. Mean prediction accuracy of ligament insertions was 0.53\u2009\u00b1\u20090.12\u2009mm. In accordance with the second aim, our results showed an increased tibiofibular diastasis in healthy ankles after weight\u2010bearing. Concerning our third aim, a statistically significant difference in anterior syndesmotic ligament length was found between ankles with syndesmotic lesions and healthy controls (<jats:italic>p<\/jats:italic>\u2009=\u20090.017). There was a significant correlation between the presence of syndesmotic injury and the positional alignment between the distal tibia and fibula (<jats:italic>r<\/jats:italic>\u2009=\u20090.873, <jats:italic>p<\/jats:italic>\u2009&lt;\u20090,001). Clinical Significance: Statistical shape modeling combined with patient\u2010specific ligament wrapping techniques can facilitate the diagnostic workup of syndesmosic ankle lesions under weight\u2010bearing conditions. In doing so, an increased anterior tibiofibular distance was detected, corresponding to an \u201canterior open\u2010book injury\u201d of the ankle syndesmosis as a result of anterior inferior tibiofibular ligament elongation\/rupture.<\/jats:p>","DOI":"10.1002\/jor.25318","type":"journal-article","created":{"date-parts":[[2022,3,6]],"date-time":"2022-03-06T15:33:50Z","timestamp":1646580830000},"page":"2873-2884","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":30,"title":["Statistical shape model\u2010based tibiofibular assessment of syndesmotic ankle lesions using weight\u2010bearing CT"],"prefix":"10.1002","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2333-5386","authenticated-orcid":false,"given":"Matthias","family":"Peiffer","sequence":"first","affiliation":[{"name":"Department of Orthopaedics and Traumatology Ghent University Hospital Ghent Belgium"},{"name":"Department of Human Structure and Repair 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