Technical Tip: The Use of Arthroscopic Portals to Safeguard Medial Neurovascular Structures During Suture Button Fixation

IntroductionAnkle fractures with concurrent syndesmotic instability are commonly encountered orthopaedic injuries. Suture button syndesmotic fixation has emerged as a favorable alternative to traditional screw fixation due to its comparable biomechanical stability and reduced hardware removal rates. However, concerns persist regarding potential injury to medial neurovascular structures during tibial cortical button deployment and a medial incision is often recommended for verification.TechniqueThis paper describes a safe and reproducible technique for suture button fixation that offers an alternative to a medial incision. Using an anteromedial arthroscopy portal, indirect visualization, and palpation ensure safe tibial button placement, avoiding neurovascular structure impingement or soft tissue entrapment.DiscussionVia cadavers, we confirmed the absence of neurovascular or soft tissue injury. Anecdotally, this approach has been successfully implemented in multiple clinical cases without observed intraoperative complications or immediate post-operative neurovascular injuries. However, further studies with more rigorous follow-up are needed to confirm its safety and efficacy in a clinical setting. By utilizing an anteromedial arthroscopic portal, this technique offers a potential alternative for confirming button placement without requiring an additional medial incision. Avoiding a medial incision may reduce risks associated with wound healing, infection, and morbidity in the medial ankle-an area prone to soft tissue breakdown. Further research is necessary to assess long-term clinical outcomes and validate the broader applicability of this approach.ConclusionThe described arthroscopic-assisted technique provides a safe, efficient method for suture button fixation in syndesmotic injuries without requiring a medial incision. By utilizing indirect visualization and palpation, it minimizes risks of neurovascular injury and surgical morbidity while preserving the benefits of suture button constructs. This technique provides a reproducible and efficient alternate approach to managing syndesmotic instability in ankle fractures.Level of Evidence:V.