Ankle fractures are among the most common operatively treated lower extremity injuries. Displaced fractures require anatomic reduction to ensure restoration of joint surfaces and normalization of tibiotalar contact forces to minimize the risk of posttraumatic arthritis.^{10, 18} Although AO Weber type C ankle fractures have traditionally been associated with syndesmotic injuries, injury to the syndesmosis may occur with other fibular fracture patterns.^{10, 19} Complete disruption of this complex often manifests in diastasis that is visible on plain radiographs; however, more subtle injuries can go undetected. Increasing evidence exists that the traditional radiographic parameters for determining the status of the syndesmosis may be inaccurate.^{10, 20} None of the specific syndesmotic stress tests was uniformly positive in the presence of a syndesmotic rupture.⁶ No definite diagnosis should be made based on the medical history and the physical examination alone.⁶

Arthroscopic evaluation of ankle fractures has the advantage of being minimally invasive while providing excellent visualization of the ankle joint intraoperatively.²¹ When, based on medical history and physical examination, syndesmotic injury is suspected, but standard radiographs of the ankle show no indication that syndesmotic injury is present or the diagnosis is still open to debate, additional evaluation of the syndesmosis can be desirable. During arthroscopy of the ankle, injury of the anterior syndesmosis can be confirmed with more certainty.^{6, 11, 15, 22, 23, 24} The arthroscopic stress test is useful for evaluating the stability of the tibiofibular articulation.²⁴ By means of ankle arthroscopy, the pattern of syndesmosis disruption can be assessed in three planes (coronal, sagittal, and frontal).¹⁴

An accurate initial reduction of a disrupted syndesmosis is crucial to the long-term stability and function of the ankle.²⁵ Failure to reduce and stabilize a disruption of the syndesmosis that occurs in association with some rotational ankle fractures is associated with poor outcomes. A recent study of human cadaver specimens concluded that no optimal radiographic measurement exists to assess syndesmotic integrity, and that repeated radiographs of the ankle are of little value because of the inability to reproduce ankle positioning even under optimal laboratory conditions.⁷ In the setting of ankle fractures with syndesmosis disruption, fixing the fibula in as much as 30 degrees of external rotation may go undetected using intraoperative fluoroscopy alone. These findings are clinically relevant since in both supination-external rotation and pronation-external rotation injuries of the ankle, which constitute the majority of ankle fractures, the distal fibula is displaced in external rotation²⁶ and may therefore be subject to malreduction and fixation in this position. As it may be difficult to obtain an accurate lateral fluoroscopic view and there is no definition of the anatomic location of the syndesmosis on the lateral view, the integrity of the syndesmosis in the sagittal plane is difficult to assess radiographically.¹⁵ Assessment of the three-dimensional position of the distal fibula within the incisura is difficult when relying on two-dimensional imaging. The incidence of incongruity of the distal tibiofibular joint after operative reduction and internal fixation for syndesmotic injury was higher than previously reported the literature.¹⁰ The prevalence of postoperative syndesmotic malreduction has been reported to be between 0% and 16%.^{8, 16, 21, 27}