Syndesmotic Instability after ankle fracture?


Description of patient (type of occupation, indication of age, intensity of sport):

A 40-year-old man. Gustillo II open fracture luxation bi-maleolar weber C. ORIF at day 1.

History and previous treatment:

ORIF with good reduction. Then at 2 month take out of trans syndesmotic screw. At 4 months follow-up there is widening of/open syndesmosis on weight bearing X-ray.

Current complaints:

No complaints. He can walk without pain.

Physical examination:

Almost normal range of motion of the ankle, minimal pain on external rotation, sqeeze test is negative and a little A-P hypermobility of the fibula.


[Picture 1 + 2]
At 4 months follow-up thereĀ  is widening of/open syndesmosis on weight bearing X-ray.


Case summary:

Persistent syndesmotic instability 4 months after surgery, after removal of the trans syndesmotic screw. Patient with minimal complaints and already returned to sport.

Question(s) to this case:

Even if the patient is not painful, would you go for surgery? What would your treatment be?

A) Open procedure with medial malleolar gutter examination and a tight rope?

B) OR syndesmotic stabilization with cerclage?

C) OR syndesmotic reconstruction with gracilis?

D) Or anterior as, evaluate deltoid incarceration, cleaning medial and lateral gutter, abrasion of anterior tibiofibular ligament insertion to stimulate healing and a tight rope?

E) Or other fixation method?


This is a malunion. The malunion can only be corrected in the fracture or by correction osteotomy: derotate, lengthen and close the syndesmosis. Debride the medial joint and also the syndesmotic area. Anatomy must be restored . Add a positioning screw.