There is little question that these patients require anatomic reduction of the syndesmosis with operative fixation. There is some discussion over the exact method with which to fix them. The standard teaching is to reduce the syndesmosis closed, using a large clamp with the ankle dorsiflexed. This is viewed on anteroposterior and lateral projection to ensure anatomic reduction. After reduction, the screws are placed percutaneously from the fibula to the tibia at a 20-degree angle posteriorly to anteriorly to ensure placement of the screw into the tibia. The postoperative course is then non-weight bearing for 6 to 8 weeks, followed by weight bearing as tolerated for a few weeks, followed by screw removal at 10 to 12 weeks.
Some authors recommend open reduction with direct ligament repair of the syndesmosis. Certainly, if a significant amount of force is required or if the syndesmosis will not reduce, open reduction is indicated, but this is rarely necessary. There is controversy over the size of screws and how many to place. Most recommend either two 3.5-mm cortical screws 1 cm apart, with the inferior screw 1 cm above the plafond, or one 4.5-mm cortical screw. The length of the screw is also debated, with some recommending three cortices and others recommending four. Controversy also exists over whether to remove screws. Screws limit the ability of the fibula to rotate normally. The screws often eventually break, but broken screws rarely cause any sequelae. They are more difficult to remove after they have broken. Regardless of the fixation used, anatomic reduction and maintenance of fixation until the syndesmotic ligaments have healed are the mainstays of treatment.
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