The surgical repair of transmalleolar fractures commonly involves reduction and internal fixation of the boney injuries. In the absence of extreme syndesmotic disruptions, little attention has been given in the recent literature to the role of the syndesmosis in general or to the anterior inferior tibiofibular ligament (AITFL) in particular in preserving the stability of the ankle mortise. In this paper, the author describes a surgical approach to evaluate and repair AITFL ligament injuries in transmalleolar ankle fractures. A significant portion of these injuries are associated with an avulsion of the tibial or fibular insertion resulting in an intra-articular fracture in the distal tibiofibular joint which may not be apparent on plain x-rays. Direct visualization of the injury allows accurate assessment of the injury pattern and obviates the need for more costly imaging studies such as computed tomography and magnetic resonance imaging scans. Anatomic repair of the AITFL injury restores the stability of the ankle mortise and improves the stability of the bone repair, allowing for early return to functional exercises and activities. Syndesmotic screw fixation of transmalleolar ankle fractures was not necessary when the AITFL was repaired directly by the techniques described.

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Background: Surgical treatment of unstable syndesmotic injuries is not trivial, and there are no generally accepted treatment guidelines. The most common controversies regarding surgical treatment are related to screw fixation versus dynamic fixation, the use of reduction clamps, open versus closed reduction, and the role of the posterior malleolus and of the anterior inferior tibiofibular ligament (AITFL). Our aim was to draw important conclusions from the pertinent literature concerning surgical treatment of unstable syndesmotic injuries, to transform these conclusions into surgical principles supported by the literature, and finally to fuse these principles into an evidence-based surgical treatment algorithm. Methods: PubMed, Embase, Google Scholar, The Cochrane Database of Systematic Reviews, and the reference lists of systematic reviews of relevant studies dealing with the surgical treatment of unstable syndesmotic injuries were searched independently by two reviewers using specific terms and limits. Surgical principles supported by the literature were fused into an evidence-based surgical treatment algorithm. Results: A total of 171 articles were included for further considerations. Among them, 47 articles concerned syndesmotic screw fixation and 41 flexible dynamic fixations of the syndesmosis. Twenty-five studies compared screw fixation with dynamic fixations, and seven out of these comparisons were randomized controlled trials. Nineteen articles addressed the posterior malleolus, 14 the role of the AITFL, and eight the use of reduction clamps. Anatomic reduction is crucial to prevent posttraumatic osteoarthritis. Therefore, flexible dynamic stabilization techniques should be preferred whenever possible. An unstable AITFL should be repaired and augmented, as it represents an important stabilizer of external rotation of the distal fibula. Conclusions: The current literature provides sufficient arguments for the development of an evidence-based surgical treatment algorithm for unstable syndesmotic injuries.