Treatment of Syndesmotic Instability: Attaining Anatomic Tibiofibular Reduction and Fixation Strategies

Abstract: The syndesmosis is a complex joint and plays a critical role in ankle stability. Disruption of the syndesmosis most commonly occurs when the foot is in a dorsiflexed position, and an external rotation force is applied. Injuries can be obvious or subtle, and appropriate imaging is paramount for diagnosis. Weight-bearing radiographs, stress radiographs, magnetic resonance imaging, and weight-bearing computed tomography scans are used to evaluate the integrity of the syndesmosis. Ankle arthroscopy can also be used for diagnosis; however, it is inherently more invasive. Once the diagnosis is made, reduction and fixation of the syndesmosis should be anatomic to limit any abnormal stresses at the ankle joint. Reduction can be achieved using direct visualization and intraoperative fluoroscopy, including radiographs of the contralateral, uninjured extremity, and ankle arthroscopy. Once appropriately reduced, the syndesmosis is stabilized with flexible fixation, such as a suture button device, or rigid fixation with screws based on surgeon preference. Level of Evidence: Diagnostic level V. See Instructions for authors for a complete description of levels of evidence.