If the syndesmosis is disrupted, the anatomical relationship between the fibula and tibia must be maintained while the ligaments heal.
The syndesmosis may be stabilized with screw transfixation or suture-button (suspensory) fixation. The latter should be used with caution in length unstable fibular fractures.
Ensure that insertion does not damage the distal tibial physis.
The syndesmotic screws are typically removed after 2–3 months to avoid breakage.
Associated high fibular fractures
A fracture of the middle or proximal third of the fibular shaft may be part of a more complex injury and is often underestimated.
High fibular fractures may be associated with instability of the syndesmotic complex.
Restoration of length, axis, and rotation of the fibula at the level of the ankle joint is of primary concern.
The proximal fibular fracture is usually indirectly reduced and rarely requires separate fixation to increase the overall stability.
After transfixation of the syndesmosis, ankle joint stability should be assessed.
2. Instruments and implants
A 3.5 mm fully threaded screw (ideally self-tapping) may be used as a syndesmotic positioning screw.
The following equipment is needed:
Although insertion of a suture and button can be performed with standard instrumentation, specialized implant inserters are available and facilitate minimally invasive placement of sutures (refer to the manufacturer’s technical guide).
3. Skin incision
Use an image intensifier to determine the correct level.
Incise the skin slightly posterior and lateral to the fibula, proximal to the tibial physis at the level of the planned suture or screw insertion.