Patient is placed in the supine position on the radiolucent operating room table. A bump may be placed beneath the hip of the surgical limb to internally rotate the ankle allowing surgical access to the lateral ankle and proper positioning of fluoroscopic C-arm imaging. Folded blankets are used to elevate the surgical limb to avoid obstruction of contralateral limb during lateral imaging.

The tips of the medial and lateral malleoli of the ankle are identified. The syndesmosis is reduced by placing a reduction clamp across the medial and lateral malleoli matching the biomechanical axis of the ankle. This axis is approximately 25° from posterolateral to anteromedial direction (Fig. 10.4). Once clamp is tightened, reduction is verified with mortise and anterior-posterior views under fluoroscopy (Fig. 10.5).

Under fluoroscopic imaging, a 2.5-mm drill hole is made from the fibula to the tibia approximately 1.5–2.0 cm superior as well as parallel to the tibiotalar joint line and angulated 25° from posterolateral to anteromedial trajectory. The cortices are tapped to avoid distraction of the fibula from the tibia when engaging the 3.5-mm screw through the third cortex and to achieve non-lag technique. The hole is measured and a 3.5-mm fully threaded cortical screw is placed tricortically maintaining the reduction of the tibiofibular syndesmosis. Two 3.5-mm fully threaded cortical screws with tricortical purchase or one ­4.5-mm fully threaded cortical screw tetracortical have equivocal purchase strength.19

Screw fixation through a one-third tubular plate can increase stability of fixation by distributing the stress of screw head purchase to the fibula.20 For an isolated ­syndesmotic disruption without distal fibula fracture or syndesmotic disruptions with a Maison­neuve fracture, a 2-hole one-third tubular plate may be incorporated with transsyndesmotic fixation (Fig. 10.6).

A proposed advantage of tensioned suture button fixation of the syndesmosis was that it did not require removal. Though mechanical studies comparing the stability of suture versus screw fixation reveal that screw fixation better resists syndesmotic widening and external rotation compared to suture, there are no significance differences with ­clinical outcomes of either technique.21–23

Using the same drill hole orientation as described for transsyndesmotic screw fixation and with the reduction clamp in place, all four cortices are drilled. The straight needle attached to the suture-button fixation is passed from lateral to medial through the drill hole and out of the intact medial skin while avoiding injury of the saphenous nerve and vein. The oblong button is advanced through the drill hole of the medial tibial cortex. The two medial lead sutures are pulled in opposite directions to seat the oblong button flush to the medial tibial cortex. Both lead sutures are cut and removed. The suture attached to the trailing lateral ­button is tensioned by pulling on either free end of the suture tightening the syndesmosis. Once the lateral button is flush to the fibula, the suture ends are secured with 4–5 ties and cut 1 cm long to allow the knot to lay flush, reducing suture prominence. Position of the ­buttons is confirmed with fluoroscopy. A second tightrope may be placed 1 cm proximal using the same method but divergent angle to improve rotational ­stability (Fig. 10.7).