After the patient was anesthetized and placed supine on the operative table, the leg was sterilely prepped. Contralateral fluoroscopic imaging was obtained as a guide for syndesmotic reduction.

Attention was paid first to the medial malleolus fracture. A standard medial approach was generated, and the medial malleolus was reduced under direct vision. Surgical stabilization was achieved with partially threaded cancellous lag screws (Fig. 7.5). The wound was closed in standard fashion.

Next, attention was paid to the fibula. Because the fibula was not significantly shortened and rotated (as compared to the contralateral fluoroscopic imaging), the fibula fracture proximally did not undergo open reduction and internal fixation. A collinear clamp was utilized to help obtain and maintain syndesmotic reduction. Adequacy of syndesmotic reduction was based on comparisons to the contralateral fluoroscopic imaging, utilizing the position of the fibula along the tibial plafond laterally as the primary gauge for reduction. With the reduction held, two 3.5-mm cortex screws were applied in tricortical fashion (Fig. 7.6). After the clamp was removed, fluoroscopic imaging verified adequacy of implant position, maintenance of acceptable reduction, and mortise stability (with Cotton stress tests). The wound was closed in standard fashion.

The patient was kept nonweight bearing for approximately 8 weeks. He was permitted to perform range of motion as tolerated. He was allowed to progress with partial weight bearing after 9–12 weeks. At his 12-week post-op mark, he was permitted to be full weight bearing with a CAM walking boot.

Discussions were held with the patient regarding the risks and benefits of syndesmotic screw removal versus retention, and the patient elected to retain the screws.

At the last follow-up at 9 months, the patient had returned to activities and sports without limitations (Figs. 7.7 and 7.8).