During the different steps of the operation, the reduction has to be assessed repeatedly using visual and fluoroscopic control. Angulation, length of both tibia and fibula, and rotation need to be considered, as does the integrity of the ankle mortise.
Rotation is difficult to assess radiographically. By physical exam, one should confirm rotational symmetry with the opposite side.
There is a considerable variation of anatomy in the ankle region, regarding tibial shaft alignment, length of the fibula in relation to the medial malleolus, and width of the syndesmosis. Therefore, reference should be made to radiographs of the intact opposite side. Intraoperative fluoroscopy of the opposite (uninjured) leg may also be helpful.
Axial alignment: <5º of varus or valgus and <10º of anterior or posterior angulation. Malrotation of more than 5 or 10º may significantly interfere with certain pursuits (alpine skiing), but interferes minimally with usual activities of daily living.
Fibular length and width of syndesmosis: <2 mm difference to the opposite, uninjured side.