Syndesmotic reduction: What technique is most accurate?

The purpose of the present study was to assess the reliability of three syndesmotic reduction methods (Indirect clamp reduction, direct reduction with palpation of the incisura congruence, direct reduction with articular surface visualization) across various syndesmotic injury conditions (ventral disruption; AITFL, 2-ligament injury; AITFL/IOL, and 3-ligament injury; AITFL/IOL/PITFL) in an in-vitro model. It was hypothesized that indirect clamp reduction would be the least reliable method, with a higher mal-reduction rate. A cadaveric model of syndesmotic injury in eight through the knee specimens was employed. Sagittal plane translation following reduction was recorded using a digital caliper. Malreduction was defined as a difference of > 2 mm from the intact condition. Overall, direct reduction with articular surface visualization was the most accurate method, irrespective of the injury state across all specimens (p > 0.01). Direct reduction with palpation of the incisura was reliable for 2 and 3-ligament injury conditions (p = 0.518); while indirect clamp reduction was least reliable (p = 585). As the injury condition progressed, the incidence of malreduction increased for direct palpation, and clamp reduction. No malreductions were recorded using direct visualization of the articular surface. In the present cadaveric model, indirect clamp reduction was the least reliable method for syndesmotic realignment, with the highest incidence of malreduction. Surgeons should be cognizant of the inherent subjectivity, and limited reliability of the historically popularized clamp reduction method. LEVEL OF EVIDENCE: Level V, cadaveric.