Syndesmotic Malreduction Prevention, Assessment, and Treatment.

Syndesmotic instability or malreduction is an independent risk factor for an impaired patient-rated outcome. If a syndesmotic injury is suspected, a stepwise diagnostic approach including plane radiographs, MRI, and bilateral stress radiographs should be conducted to differentiate stable from latent unstable and frank diastasis cases. The basic requirement for any surgical treatment approach is a stable and anatomically reduced distal tibio-fibula joint. The best treatment approach for a 2-ligament injury (anterior inferior tibio-fibular ligament [AiTFL] + interosseous ligament [IOL]) seems to be the suture-button system, for a 3-ligament injury (AiTFL + IOL + posterior inferior tibio-fibular ligament), 2 fixation devices.