Review Article

Technical Considerations in the

Treatment of Syndesmotic Injuries
Associated With Ankle Fractures

Abstract
Michael J. Gardner, MD Malleolar ankle fractures associated with syndesmotic injuries are
Matthew L. Graves, MD common. Diagnosis of the syndesmotic injury can be difficult and often
requires intraoperative fluoroscopic stress testing. Accurate reduction
Thomas F. Higgins, MD
and stable fixation of the syndesmosis are critical to maximize patient
Sean E. Nork, MD
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outcomes. Recent literature has demonstrated that the unstable

syndesmosis is particularly prone to iatrogenic malreduction. Multiple
types of malreduction can occur, including translational, rotational,
and overcompression. Knowledge of the technical details regarding
intraoperative reduction methods and reduction assessment
can minimize the risk of syndesmotic malreduction and improve
patient outcomes.

From the Department of Orthopaedic
Surgery, Washington University
School of Medicine, St. Louis, MO
(Dr. Gardner), the Department of
Orthopaedic Surgery, University of
Mississippi Medical Center, Jackson,
MS (Dr. Graves), the Department of
Orthopaedic Surgery, University of
Utah, Salt Lake City, UT (Dr. Higgins),
and the Department of Orthopaedic
Surgery, University of Washington,
Seattle, WA (Dr. Nork).
J Am Acad Orthop Surg 2015;23:
510-518
http://dx.doi.org/10.5435/
JAAOS-D-14-00233
Copyright 2015 by the American
Academy of Orthopaedic Surgeons.
T he syndesmosis is a complex of
ligaments that joins the distal fib-
ula to the distal tibia at the level of the
ankle joint. Four main ligaments con-
tribute to the syndesmotic complex:
the anterior-inferior tibiofibular liga-
ment (AITFL), the posterior-inferior
tibiofibular ligament (PITFL), the
transverse ligament, and the interos-
seous ligament. The AITFL is situated
obliquely between the anterolateral
tibial (Chaput) tubercle and the an-
teromedial distal fibula. The PITFL
connects the posterolateral tibial
(Volkmann) tubercle to the postero-
medial distal fibula. The transverse
ligament represents a deep, thickened
zone of the distal-most portion of the
PITFL and functions like a labrum,
deepening and stabilizing the tibiotalar
joint. The PITFL and associated
transverse ligament provide nearly half
of the overall syndesmotic strength.1
The interosseous ligament is the distal
aspect of the tibiofibular interosseous
membrane and joins the tibia to the
fibula several centimeters above the
articular surface.2
A concavity of variable depth and
shape known as the incisura fibularis
is located at the posterolateral aspect
of the distal tibia.3 The distal fibula
fits into this structure, which pro-
vides a small amount of bony sup-
port to this articulation. However,
without the ligamentous stability
provided by the syndesmosis, the
articulation is rendered unstable to
physiologic stresses.
In the normal ankle, the stabilizing
ligaments of the syndesmosis provide
a small amount of elasticity, allowing
physiologic motion at the distal tib-
iofibular joint. With ankle dorsi-
flexion, the wider anterior talar body
rotates into the mortise, requiring
posterolateral and proximal trans-
lation of the fibula, as well as external
rotation.4 Overall fibular displace-
ment is normally approximately 1 to
2 mm through the entire ankle range
of motion.
The position of the fibula within the
incisura and its relative stability are
critical for maintenance of ankle mor-
tise congruity and normal distribution

510 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
 Michael J. Gardner, MD, et al

of tibiotalar cartilage forces, minimiz-
ing the risk of posttraumatic arthrosis.
Because multiple individual structures
contribute to distal tibiofibular joint
stability, pathological instability pre-
sents along a spectrum, depending on
the number and severity of structures
injured.
An untreated syndesmotic injury can
adversely affect functional outcomes.
Additionally, applying unstable fixa-
tion to a reduced syndesmosis or stable
fixation to a malreduced syndesmosis
can lead to poor function. Weening
and Bhandari5 evaluated 51 syn-
desmotic injuries treated with screw
fixation and 16% had syndesmotic
malreduction on radiography. At an
average of 18 months, syndesmotic
malreduction was the only significant
predictor of functional outcome. In
a study of 68 patients with syn-
desmotic injuries, Sagi et al6 evaluated
outcomes at a minimum of 2 years
using functional outcome ques-
tionnaires and bilateral CT scans. The
authors found that 27 syndesmoses
(39%) were malreduced, and these
patients had significantly worse out-
comes than did those who had an
anatomic reduction. Both of these
studies demonstrate that accurate
reduction of the syndesmosis after
injury is a critical goal of surgical
management and a major factor in the
resulting outcome. Egol et al7 exam-
ined outcomes in patients with
unstable ankle fractures treated with
syndesmotic stabilization. The au-
thors found that patients with ankle
fractures and a syndesmotic injury
had worse outcomes at 12 months
postoperatively than did those with-
out syndesmotic injury. Whether
impaired function was caused by the
intact syndesmotic screw, higher
injury severity, or syndesmotic mal-
reduction is unclear.
Recent studies have demonstrated
that the rate of syndesmotic malre-
duction is extremely high. One report
demonstrated a 52% malreduction rate
on unilateral CT scans.8 The intra-
operative use of three-dimensional CT
to assess reduction was recommended
by Franke et al,9 who found a lower
rate of malreduction (25.5%) on uni-
lateral scans. However, Davidovitch
et al10 compared the accuracy of re-
ductions with standard fluoroscopy or
intraoperative three-dimensional CT in
36 patients and reported similar and
relatively high malreduction rates with
both modalities (30% and 38%,
respectively).
Preoperative Assessment
Accurate preoperative diagnosis of
a syndesmotic injury is important
when the associated malleolar injuries
alone do not mandate surgical inter-
vention. Much work has been done to
determine the best indications for
surgical management, and care must
be taken when interpreting this body
of work to distinguish between in-
dicators of deltoid incompetence
concomitant with a distal fibula frac-
ture and actual disruption of the syn-
desmosis complex.
Several signs found on physical
examination are potential indicators
of syndesmotic injury, including del-
toid ligament tenderness, anterior
syndesmotic ligament tenderness,
a positive squeeze test (ie, manual
compression of the tibia and fibula
above the level of the joint), and pain
with dorsiflexion and external rota-
tion. A recent study compared the
accuracy of physical examination
with MRI findings for diagnosis of
isolated ligamentous syndesmotic
injury; the squeeze test was shown to
be the most specific test (88%), and
anterior syndesmotic ligament ten-
derness was the most sensitive
(92%).11 However, these tests and
others that have been proposed (eg,
ability to hop on the injured leg) may
not be practical in the setting of
a malleolar ankle fracture.
Plain radiographs of the ankle and
tibia should be evaluated for the
presence of an ankle fracture,
a proximal fibula fracture, and dis-
ruption of the normal relationship
between the distal tibia and distal
fibula. Three radiographic findings
have been identified as indicators of
syndesmotic injury: increased tibio-
fibular clear space, decreased tibio-
fibular overlap, and increased medial
clear space.12 Tibiofibular clear
space is the distance between the
medial border of the fibula and the
lateral border of the posterior tibia at
the incisura. At 1 cm above the joint,
the tibiofibular clear space should
be ,6 mm on both the AP and mortise
radiographic views. Tibiofibular over-
lap is the radiographic projection of
overlap of the lateral malleolus and the
anterior tibial tubercle at 1 cm above
the joint. On the AP view, the overlap
should be .6 mm and, on a true
mortise view, it should be .1 mm. On
the mortise view, the medial clear
space is the distance between the lat-
eral border of the medial malleolus and
the medial border of the talus, with the
ankle at 90° of flexion. The medial
clear space should be less than or equal

Dr. Gardner or an immediate family member serves as a paid consultant to Depuy-Synthes, BoneSupport AB, Pacira Pharmaceuticals,
Synthes, Stryker, and RTI Biologics; has received research or institutional support from Synthes; and serves as a board member, owner,
officer, or committee member of the Orthopaedic Trauma Association. Dr. Graves or an immediate family member is a member of
a speakers’ bureau or has made paid presentations on behalf of and serves as a paid consultant to Synthes and has received research or
institutional support from Synthes and Stryker. Dr. Higgins or an immediate family member has stock or stock options held in Summit
Medical Ventures and serves as a board member, owner, officer, or committee member of the Orthopaedic Trauma Association. Dr. Nork or
an immediate family member serves as a paid consultant to Amgen, AO North America, and Synthes and has received research or
institutional support from AO North America, the Orthopaedic Trauma Association, and Synthes.

August 2015, Vol 23, No 8 511

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures
to the superior clear space between the
talar dome and the tibial plafond.12
The evaluation and interpretation of
these values has been the source of
much investigation to determine if
these numbers are reliable and useful
for making decisions on surgical in-
dications. Pneumaticos et al13 showed
that the tibiofibular clear space does
not change significantly with rotation
of the ankle and should be viewed as
more reliable than other plain radio-
graphic parameters (eg, the tibio-
fibular clear space). However, Beumer
et al14 demonstrated that plain
radiographic views were unlikely to
be replicated accurately between
multiple radiographs, making inter-
pretation of findings based on these
views unreliable. The authors con-
cluded that the usefulness of plain
radiography for the diagnosis of
syndesmotic injury was limited.
Occasionally, preoperative stress ra-
diographs are useful; however, in the
presence of unstable malleolar frac-
tures, specifically stressing the syn-
desmosis is not possible.
Other studies have shown that CT
may demonstrate tibiofibular dias-
tasis that is not evident on plain radi-
ography.15,16 However, CT has
poorer soft-tissue resolution than
MRI, is a static examination, and
may not demonstrate instability if
diastasis is not present. Oae et al17
used preoperative MRI and ankle
arthroscopy to assess 58 patients with
distal fibula fracture or ankle sprain.
MRI had a sensitivity of 100% and
a specificity of 93% for diagnosis of
AITFL rupture, with ankle arthros-
copy considered the standard of care.
Nielson et al18 examined ankle frac-
tures with MRI and found that the
classically described plain radio-
graphic measurements did not cor-
relate with demonstrated soft-tissue
injuries seen on MRI. Although CT
cannot demonstrate instability and
may lead to underdiagnosis of clini-
cally significant injuries, MRI dem-
onstrates even the slightest evidence
512
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
of soft-tissue injury, some of which
may not correlate with clinical
instability. Therefore, the clinical
significance of these diagnostic tools
in the management of syndesmotic
injury remains unclear. Although
preoperative evaluation of syn-
desmotic injury can be useful overall,
the lack of accuracy of preoperative
methods highlights the importance of
intraoperative stress testing to deter-
mine the stability of the syndesmosis
in all surgical ankle fractures.
Intraoperative Injury
Assessment
Syndesmotic stability should be as-
sessed intraoperatively in patients
with ankle fracture. Although there
are injury patterns that should
heighten concern for instability, few
patterns have no risk. According
to the Lauge-Hansen classification
system, pronation external rotation,
supination external rotation, and
pronation abduction fractures hold
the highest risk of syndesmotic
injury. The supination adduction
pattern is the only type with minimal
risk of instability. Based on the Danis-
Weber classification system, type B
and C fibular fractures have the
highest risk of syndesmotic instabil-
ity, and type A fibular fractures
pose minimal risk (note the correla-
tion between the two systems, with
the type A fibular fracture pattern
seen in the supination adduction
fracture pattern). However, many
ankle fracture patterns do not con-
form perfectly to the Lauge-Hansen
system. Similarly, severe capsular and
ligamentous injuries, which destabi-
lize the syndesmosis, can be present
even in Danis-Weber type A fibular
fractures. Because missed syn-
desmotic injuries are associated with
inferior results and the current clas-
sification systems are imperfect in
predicting syndesmotic instability, it
is logical to conclude that the
Journal of the American Academy of Orthopaedic Surgeons
syndesmosis should be evaluated in-
traoperatively in every patient with
an ankle fracture.
The timing of intraoperative syn-
desmotic evaluation is critical. The
tibial Chaput and fibular Wagstaffe
fragments (ie, anterior avulsion off
the fibula) provide attachment points
for the AITFL. The tibial Volkmann
and posterior fibular tubercle provide
attachment points for the PITFL. In
addition to these points of stability,
pathologic talar motion is unlikely to
occur if the deltoid ligament is intact
or has been functionally restored.
Because these osseous fragments con-
tribute to syndesmotic stability, and
syndesmotic reduction and stabiliza-
tion maneuvers have been associated
with complications, the intraoperative
evaluation of syndesmotic stability
should occur after all other points of
instability have been addressed.
Assessment of syndesmotic stability
before stabilization of the lateral
malleolus, medial malleolus, and
posterior malleolus (assuming the
decision has been made to treat these
points of instability) is not effective for
assessing the competence of the syn-
desmotic ligaments.
Manual stress testing and
arthroscopy have been used for
accurate intraoperative identification
of a syndesmotic injury. Prior to
dynamic testing, static radiographic
parameters should be revisited, as
described earlier. It should be noted
that, on radiography, the syndesmosis
may have a nonpathologic appear-
ance because of the variability of the
incisura contour (eg, flat or cupped)19
(Figure 1). Specifically, a tibiofibular
overlap of 0 mm, which has tradi-
tionally been considered to be indic-
ative of an injured syndesmosis, may
be a normal finding in a patient with
a flat incisura; however, it may rep-
resent pathology in a patient with
a cupped incisura. If the contralateral
ankle is uninjured, comparison
radiographic views should be ob-
tained; comparison of the injured and

Figure 1
Axial CT scans of the ankle demonstrating flat (A) and cupped (B) incisura
morphology.
uninjured ankles is more effective
than comparing the injured ankle
with standards based on the general
population.20 These views can be
obtained with fluoroscopy at the
beginning of the surgical procedure,
using standard ankle and C-arm
positioning. In addition to determin-
ing whether an injury is present, these
images aid in the assessment of in-
traoperative reduction.21 The lateral
projection is critical for this
evaluation.
When syndesmotic asymmetry ex-
ists on static imaging, stress views are
typically not required; however, if
doubt exists, diagnoses can be clari-
fied with stress views. Standard intra-
operative stress mechanisms include
an external rotation stress test of the
dorsiflexed ankle or direct translation
of the fibula via a clamp or hook
(modified Cotton test, Figure 2).
Consistency is challenging with re-
gard to the magnitude of force gen-
erated intraoperatively for translation
of the fibula. The amount of insta-
bility (millimeters of displacement
during the stress test) that can
be recognized on radiography has
been questioned. The degree of
instability on stress testing that war-
rants stabilization is unclear.
August 2015, Vol 23, No 8
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Based on the literature on syn-
desmotic imaging, there are several
reasonable, albeit imperfect, recom-
mendations for identifying instability.
First, preoperative plain radiographic
assessment alone is inadequate.
Unrecognized instability can be eluci-
dated intraoperatively with stress test-
ing.22 Second, the position of the ankle
should be standardized during testing,
and the tibiofibular clear space on the
AP view reveals the least amount of
variability attributable to rotation.13
Third, population norms for tibio-
fibular clear space and overlap can be
deceiving based on the two primary
types of incisura morphology. Com-
parison views of the uninjured con-
tralateral ankle should clarify the
patient norm more effectively than
a population average.19 Fourth, the
absolute increase in tibiofibular clear
space is greater for the same injury
pattern when using a laterally directed
translational force with a hook than
with an external rotation stress test.23
This larger absolute increase should be
easier to detect intraoperatively with
the modified Cotton test. Fifth, the
coronal plane is not the only plane
that should be assessed. Sagittal plane
translational stress, as demonstrated
on the lateral view, has been shown to
Michael J. Gardner, MD, et al
Figure 2
AP radiograph of the ankle after
fibular fixation demonstrating
a syndesmotic injury. Translation of
the fibula (ie, Cotton test) produces
demonstrable widening of the medial
clear space (*) and syndesmotic
space (#).
be an effective measure for assessment
of instability.24,25
Although intraoperative manual
stress testing provides the advantages
of simplicity and efficiency, arthro-
scopic evaluation of the syndesmosis
provides other advantages, including
direct visualization of ligaments. First,
direct visualization of the AITFL and
PITFL ligaments provides clearer evi-
dence of injury to these ligaments than
an indirect evaluation of their stability
through stress testing.26 Second,
associated injuries, such as loose
bodies and osteochondral defects,
may be more completely diagnosed
arthroscopically.27 Third, arthros-
copy aids the clinician in defining the
different patterns of syndesmotic
displacement and assessment of
reduction.28 Disadvantages include
the potential for cutaneous nerve
injury,29 overtreatment based on
anatomic findings that do not corre-
late with pathologic instability, and
513
Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures
Figure 3
A and B, Postoperative bilateral axial CT scans of the ankle demonstrating
overcompression in a patient who underwent vigorous clamping of the
syndesmotic component of the injury.
the increased setup time and logistical
complexity of intraoperative fluo-
roscopy and arthroscopy equipment
in the same surgical field.
Syndesmotic Reduction
and Assessment
Following the intraoperative deter-
mination or confirmation of a syn-
desmotic disruption, reduction must
be achieved. There are several syn-
desmotic reduction techniques. An
indirect reduction involves the appli-
cation of a clamp between the distal
fibula and tibia without direct visu-
alization of the syndesmotic rela-
tionship. Alternatively, a direct
reduction can be performed by visu-
alizing and palpating the anterior
syndesmotic reduction.30
When planning the reduction, it is
important to consider the variables
that can lead to malreduction of the
syndesmosis. These variables fall into
several categories, including length
(typically fibular shortening), rota-
tion (either internal or external rota-
tion), sagittal plane translation, or
overcompression of the syndesmosis
(Figure 3).
514
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
If an associated fibular fracture is
present, the surgeon should strongly
consider anatomic fibular reduction
to accurately reduce the length and
rotation of the fibula relative to the
tibia. Additionally, if the fibula is
anatomically reduced, the sagittal
plane reduction can be more accu-
rately accomplished and assessed. A
fibular malreduction will likely trans-
late into a syndesmotic malreduction
regardless of the reduction method
used. Although anatomic restoration
of the fibula does not guarantee an
accurate syndesmotic reduction, the
length will be correct, provided the
proximal tibiofibular joint is intact.
The rotation and translation can then
be more easily addressed.
When the fibular fracture is not
directly reduced, intraoperative
assessment of fibular length is largely
based on fluoroscopy. Contralateral
ankle radiographs are invaluable. The
relationship between the fibula and
the talus on the mortise view should
demonstrate symmetry between the
lateral talus and the medial fibula.
Furthermore, restoration of the Shen-
ton line at the ankle (ie, the confluence
of the cortical line between the medial
Journal of the American Academy of Orthopaedic Surgeons
distal fibula and lateral distal tibia)
produces a qualitative assessment of
the fibular length.21
Intraoperative fluoroscopic assess-
ment of the rotation of the fibula rela-
tive to the tibia is difficult. In a cadaver
study, Marmor et al31 found that the
typical radiographic indices used to
judge syndesmotic reduction could
not detect rotational abnormalities of
as much as 30° in external rotation.
However, internal rotational deform-
ities of the fibula could be detected
with as little as 10° of malreduction.
The authors hypothesized that, with
internal rotation, the fibula impinges
at the talus distally, leading to
a detectable decrease in the tibio-
fibular overlap and a detectable
increase in the tibiofibular clear space.
Conversely, with external rotation of
the fibula, there is a decrease in the
tibiofibular clear space and a slight
increase in the tibiofibular overlap.
This may be of clinical relevance given
the common association between
external rotation ankle injuries and
syndesmotic disruptions.
Syndesmotic reduction most com-
monly involves placing a clamp
between the fibula and the tibia.
However, the clamp vector and
location and the applied force need
to be considered. Given that the
estimated frequency of syndesmotic
malreduction is as high as 50%,8 the
need for technical accuracy during
this portion of the procedure cannot
be overemphasized. The clamp
position is critical and should be
applied at the level of the syndes-
mosis; proximal or distal clamp po-
sitions can introduce a coronal plane
deformity in the fibula. Additionally,
the location of the clamp on both the
fibula and the tibia will determine
the force vector for compression. In
a recent cadaveric study,32 a clamp
applied from the lateral malleolar
ridge of the fibula to the center of
the AP width of the tibia resulted in
the most consistent and accurate
reduction of the syndesmosis.

Translating the tibial clamp tine 10
mm anteriorly resulted in anterior
fibular translation and abutment of
the anterior incisura. With a posteri-
orly directed clamp vector, fibular
displacement was posterior and
increased with progressive levels of
syndesmotic destabilization. Miller
et al33 applied a clamp to one of
three locations on the medial tibia
over a 30° arc. Fibular external
rotation and anterior fibular dis-
placement were observed. The re-
sults of these two studies suggest
that the clamp orientation can
have significant effects on trans-
lational malreduction. Additionally, as
noted, the internal contour of the in-
cisura is variable, ranging from rela-
tively flat to more cupped19 (Figure 1).
Flat incisurae do not contain the fibula
well and are likely more prone to
translational malreductions.
The influence of foot position on
reduction is currently unknown. In
a study by Tornetta et al,34 no loss of
maximum ankle dorsiflexion was
observed despite placement of lag
screws across the syndesmosis with the
foot in plantar flexion. The authors
concluded that foot position does not
have a clinical effect with regard to
passive ankle dorsiflexion. However,
no ligament injury was created in this
model, and CT scans were not used for
evaluation. More recently, several
studies have suggested that over-
compression of the syndesmosis is
possible.32,33 In one study, all cadaver
specimens had overcompression of the
syndesmosis (by an average of 0.9 mm,
based on CT measurements).32 In
another cadaver study, Miller et al33
similarly demonstrated significant
overcompression almost universally.
The optimal force that should be
applied with a clamp to reduce the
syndesmosis is currently unknown, but
overcompression is possible (Figures 3
and 4). Thus, consideration should be
given to confirming the reduction
(with direct visualization, fluoroscopy,
or both) rather than clamping more
August 2015, Vol 23, No 8
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Michael J. Gardner, MD, et al
Figure 4
Sagittal (A) and coronal (B) CT reconstructions of the ankle in the patient shown
in Figure 3 demonstrating anterior and distal extrusion of the talus caused by the
narrowing of the intermalleolar distance. Revision with hardware removal,
manual reduction, and careful fluoroscopic scrutiny was performed.
C, Postoperative lateral radiograph of the ankle after revision. The patient had
an uneventful recovery.
vigorously in clinical instances where Summers et al21 recently introduced
the reduction of the syndesmosis does a new method for intraoperative
not occur easily. Clinical data corre- evaluation of the syndesmotic reduc-
lating syndesmotic overcompression to tion using fluoroscopy. Given the
functional outcomes are currently frequency of malreduction in the
unavailable. sagittal plane, a careful analysis of the
Fluoroscopy is typically used for lateral view was felt to be an impor-
intraoperative assessment of the tant component of intraoperative
reduction of the syndesmosis. How- assessment. The authors recom-
ever, the use of other intraoperative mended obtaining intraoperative
imaging studies has been evaluated. mortise and perfect lateral fluoro-
Intraoperative three-dimensional CT scopic views of the talar dome of the
has been used as an adjunct to uninjured ankle before fixation of the
improve the accuracy of syndesmotic injured extremity. The mortise view
reduction, with conflicting results was used to evaluate fibular length
reported. In a study of 251 consecu- and rotation. The lateral view of the
tive ankle fractures with syndesmotic talar dome was used to assess the
injuries, intraoperative three- anterior to posterior relationship of
dimensional CT altered the surgical the fibula and the tibia. On the lateral
outcome in 33% of ankles.9 The most view, the distance from the point at
common malpositions were anterior which the posterior border of the
displacement and internal rotation of fibula crosses the posterior tibial
the fibula. In contrast, a study that articular surface to the tip of the
compared the accuracy of reduction posterior malleolus was measured
assessment with intraoperative three- and used to compare the injured and
dimensional CT or standard fluoro- uninjured ankles (Figure 5). This
scopic imaging at two trauma centers method led to highly accurate reduc-
found that the addition of three- tions confirmed by intraoperative
dimensional CT imaging did not three-dimensional CT scans. Alterna-
decrease the malreduction rate.10 tively, an anterior ratio can be
515
Technical Considerations in the Treatment of Syndesmotic Injuries Associated With Ankle Fractures

Figure 5 to be the most common malreduction.

This led the authors to recommend
anatomic reconstruction of the poste-
rior malleolus in ankles that have an
associated syndesmotic injury and
a posterior malleolus fracture. In
a study of 15 patients with posterior
malleolar fractures, Gardner et al36
reported that the PITFL remained
attached to the fractured posterior
malleolus in all patients, and that fix-
ation of the posterior malleolus led to
restoration of 70% of native syn-
desmotic strength versus 40% with
a syndesmotic screw.

A, True lateral fluoroscopic image of the talar dome demonstrating the profile of
the posterior malleolus posterior to the fibula (oval). This fluoroscopic view can Postoperative Reduction
then be compared with the preoperative true lateral image of the contralateral Assessment
ankle (B), focusing on the amount of posterior malleolus visible behind the fibular
cortex (arrowheads).
Much of the focus on scrutinizing
postoperative syndesmotic reduc-
tion began with a 2006 study that
Figure 6
reported that 13 of 25 ankle frac-
tures (52%) with syndesmotic fixa-
tion demonstrated malreduction of
the fibula within the incisura.8 Fur-
thermore, this article demonstrated
that postoperative plain radiogra-
phy had only a 31% sensitivity and
83% specificity for detecting mal-
reduction compared with that of
CT. These findings highlighted that
accurate postoperative assessment
could only be made with CT; sub-
sequently, there has been further
examination of the parameters
Bilateral postoperative axial CT scans of a normal (A) and injured (B) ankle measured on CT for syndesmotic
demonstrating a treated syndesmotic injury in a patient with a concomitant and assessment.
posterior malleolar fracture that was untreated. The posterior incisura Nault et al37 showed reasonable
incompetence likely contributed to the slight posterior translation and
overcompression of the fibula.
consistency in CT measurements
among the normal population and
good interobserver reliability. They
determined on the lateral view, which prone to malreduction because the noted that the mean ratio of ante-
may be particularly useful in the set- tibial incisura is often involved rior tibiofibular distance to poste-
ting of a posterior malleolus (Figure 6). Reduction of the posterior rior tibiofibular distance was 0.54
fracture.35 malleolus reconstructs the tibial (greater distance posteriorly) and, at
The incidence of an associated pos- incisura and reestablishes the rela- the midpoint of the incisura, the
terior malleolus fracture as a compo- tionship between the fibula and mean width of the distal tibiofibular
nent of an unstable ankle injury with an the tibia by effectively repairing the joint was 2.8 mm. Mendelsohn
associated syndesmotic disruption has PITFL attachments.30 Interestingly, et al38 also showed the fibula to be
been reported in 36% of cases.30 These either internal rotation or anterior closest to the tibia anteriorly and
injury patterns may be particularly translation of the fibula was observed progressively further away more

516 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

posterior in the incisura. In a study of
107 CT scans of normal ankles,
Lepojärvi et al39 noted that the fibula
either sits centrally or anterior in the
incisura in 97% of uninjured ankles,
such that posterior translation of
the fibula seen on CT should raise
the index of suspicion for malre-
duction. Interestingly, a recent study
by Song et al40 demonstrated that 8
of 9 syndesmotic malreductions
(89%) spontaneously reduced fol-
lowing screw removal at 3 months
postoperatively.
Although population norms may be
used for ankle measurements, some
investigators have advocated match-
ing CT measurements of the injured
ankle to those of the contralateral
ankle. Mukhopadhyay et al41 exam-
ined anatomic variation in a small
series of patients with normal ankles
or injured ankles treated with syn-
desmotic fixation. The authors found
that there was enough variation
between all measurement parameters
that caution must be exercised in
concluding that the upper limit of
side-to-side variation is 2 mm.
However, Dikos et al42 examined the
bilateral ankle CT scans of 30 normal
volunteers and found that they had
good symmetry side to side. The
authors also reported excellent in-
traobserver and interobserver reli-
ability, and the mean variance in
anterior tibiofibular space was only
0.8 mm, with a calculated maximum
variance of 2.3 mm side to side. The
authors concluded that the contra-
lateral ankle was a reliable standard
for comparison. Finally, Knops
et al43 looked specifically at how to
determine rotational malreduction
on CT, comparing the accuracy and
reliability of four methods of mea-
surement. The authors determined
that the best method to assess rota-
tion was the angle between the tan-
gent of the anterior tibial surface and
the bisection of the vertical midline
of the fibula at the level of the
incisura.
August 2015, Vol 23, No 8
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Summary
The use of a clamp to reduce the
syndesmosis frequently leads to
inaccurate reduction. Avoiding mal-
rotation, overcompression, and sag-
ittal plane translation can be difficult.
The anatomic reconstruction of the
fibula (in length and rotation) and
reconstruction of the incisura (if
either the anterolateral distal tibia or
posterior malleolus is fractured)
should be prioritized. Following res-
toration of lateral malleolar length
and articulation with a stable syn-
desmotic incisura, ankle mortise re-
lationships can be restored with the
application of a clamp. Syndesmotic
reduction is highly sensitive to clamp
and screw positioning. A clamp angle
of zero leads to the least amount of
fibular rotation,33 but substantial
posterior translation and all clamp
vectors can lead to overcompression.
Intraoperatively, assessment of
direct reduction or meticulous fluo-
roscopic comparison of the injured
and contralateral ankles can be
helpful to determine the accuracy of
the reduction. Restoring the fibula to
an anatomic position within the in-
cisura has repeatedly correlated with
functional outcomes.
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