Arthroscopically assisted reduction of ankle syndesmotic injuries associated with malleolar fractures: Our experience

Federico  Liuni; Francesco Pogliacomi; Salvatore  Battaglia; Luna  Ponzi; Luca  Berni; Filippo Calderazzi; Riccardo Cepparulo

doi:10.23750/abm.2026.18465

Authors

Federico Liuni Orthopedics and Traumatology Department, Santa Maria Hospital, Borgo Val di Taro (Parma), Italy
Francesco Pogliacomi Orthopedic and Traumatology Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
Salvatore Battaglia Orthopedic and Traumatology Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
Luna Ponzi Orthopedics and Traumatology Department, Santa Maria Hospital, Borgo Val di Taro (Parma), Italy
Luca Berni Orthopedics and Traumatology Department, Santa Maria Hospital, Borgo Val di Taro (Parma), Italy
Filippo Calderazzi Orthopedic and Traumatology Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
Riccardo Cepparulo Orthopedics and Traumatology Department, Santa Maria Hospital, Borgo Val di Taro (Parma), Italy

Keywords:

Malleolar fractures; syndesmosis; Arthroscopy; Arthroscopically assisted reduction; Computed tomography

Abstract

Background and aim of the work: Malleolar fractures are associated with syndesmotic lesions in up to 40% of cases. Accurate reduction and stabilization of the syndesmosis is crucial to prevent chronic instability, persistent pain and post-traumatic osteoarthritis. Ankle arthroscopy allows direct three-dimensional visualization of the distal tibiofibular joint and might improve the accuracy of reduction. The aim of this study was to evaluate the effectiveness of arthroscopically assisted reduction and fixation in ankle fractures with syndesmosis disruption.

Research design and Methods: Prospective monocentric case–control study including 48 patients with AO/OTA 44B–44C malleolar fractures associated with syndesmotic injury. Group A (n=24) underwent arthroscopically assisted reduction and fixation; Group B (n=24) received conventional reduction and fixation. At a mean follow-up of 30 months, clinical outcomes (AOFAS, OMAS, VAS), specific syndesmotic tests (Squeeze test, External Rotation Stress Test, Cotton test, anterior tibiofibular tenderness) and CT-based measurements (tibio-fibular clear space, fibular rotation angle) were assessed. Non-parametric statistics were applied.

Results: Significantly higher functional scores were recorded in Group A (AOFAS 91.7±9.9 vs 81.8±14.2, p=0.016; OMAS 86.0±14.2 vs 70.6±20.7, p=0.0019) and a significantly lower difference in fibular rotation angle compared with the contralateral ankle (2.71°±3.44 vs 7.41°±4.80, p<0.001). The Squeeze test was positive in 12.5% of Group A vs 45.8% of Group B (p=0.029).

Conclusions: Arthroscopically assisted surgery is associated with more accurate anatomical and rotational reduction and significantly better functional outcomes at mid-term follow-up. Arthroscopy represents a valuable adjunct in the surgical management of ankle fractures associated with syndesmotic injury.

References

1. Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supination–external rotation ankle fractures: stability a key issue. Clin Orthop Relat Res. 2010;468(1):243-51. doi: 10.1007/s11999-009-0988-2.

2. van Dijk CN, Longo UG, Loppini M et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016 Apr;24(4):1217-27. doi: 10.1007/s00167-016-4017-1.

3. Bartoníček J. Anatomy of the tibiofibular syndesmosis and its clinical relevance. Surg Radiol Anat. 2003;25(5-6):379-86. doi: 10.1007/s00276-003-0156-4..

4. Beumer A, Valstar ER, Garling EH, et al. Kinematics of the distal tibiofibular syndesmosis: radiostereometry in 11 normal ankles. Acta Orthop Scand. 2003;74(3):337-43. doi: 10.1080/00016470310014283.

5. Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27(10):788-92. doi: 10.1177/107110070602701005.

6. Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthop Trauma. 2012;26(7):439-43. doi: 10.1097/BOT.0b013e31822a526a.

7. Warner SJ, Fabricant PD, Garner MR, Schottel PC, Helfet DL, Lorich DG. The measurement and clinical importance of syndesmotic reduction after operative fixation of rotational ankle fractures. J Bone Joint Surg Am. 2015;97(23):1935-44. doi: 10.2106/JBJS.O.00016.

8. Lepojärvi S, Pakarinen H, Savola O, Haapea M, Sequeiros RB, Niinimäki J. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthop Trauma. 2014 Apr;28(4):205-9. doi: 10.1097/BOT.0b013e3182a59b3c.

9. Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults: a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633-45. doi:10.1111/j.1469-7580.2010.01302.x.

10. Beumer A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM. A biomechanical evaluation of clinical stress tests for syndesmotic ankle instability. Foot Ankle Int. 2003 Apr;24(4):358-63. doi: 10.1177/107110070302400410.

11. Spindler Ft, Herterich V, Holzapfel BM, Böcker W, Polzer H, Baumbach SF. A systematic review and meta-analysis on the value of the external rotation stress test under fluoroscopy to detect syndesmotic injuries. EFORT Open Rev. 2022 Oct 26;7(10):671-679. doi: 10.1530/EOR-22-0037.

12. Sikka RS, Fetzer GB, Sugarman E, Boyd JL, Saluan P. Correlation of arthroscopic and magnetic resonance imaging findings in acute syndesmotic injuries. Arthroscopy. 2012;28(4):575-82. doi:10.1016/j.arthro.2011.10.013.

13. Leontaritis N, Hinojosa L, Panchbhavi VK. Arthroscopically detected intra-articular lesions associated with acute ankle fractures. J Bone Joint Surg Am. 2009 Feb;91(2):333-9. doi: 10.2106/JBJS.H.00584.

14. Takao M, Ochi M, Naito K, Uchio Y, Matsusaki M, Oae K. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy. 2001 Oct;17(8):836-43. doi: 10.1016/s0749-8063(01)90007-6.

15. Miksch RC, Spindler FT, Bocker W, Polzer H, Baumbach SF. Arthroscopically assisted (AORIF) ankle fracture treatment seems to lead to superior results when compared to open reduction and internal fixation (ORIF) only: results of a systematic review. Arch Orthop Trauma Surg. 2025 Sep 18;145(1):451. doi: 10.1007/s00402-025-06030-4.

16. Tourné Y, Molinier F, Andrieu M, Porta J, Barbier G. Diagnosis and treatment of tibiofibular syndesmosis lesions. Orthop Traumatol Surg Res. 2019 Dec;105(8S):S275-S286. doi: 10.1016/j.otsr.2019.09.014.

17. Zambelli R, Fagundes AO, Arêas TS, et al. Ankle arthroscopy does not elevate complication rates in ankle fractures. Foot Ankle Surg. 2024 Jun;30(4):309-312. doi: 10.1016/j.fas.2024.01.004.

18. Leigheb M, Rusconi M, De Consoli A, et al. Arthroscopically-assisted Reduction and Internal Fixation (ARIF) of tibial plateau fractures: clinical and radiographic medium-term follow-up. Acta Biomed. 2020 May 30;91(4-S):152-159. doi: 10.23750/abm.v91i4-S.9500.

19. Pogliacomi F, De Filippo M, Casalini D, et al. Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts. World J Orthop. 2021 May 18;12(5):270-291. doi: 10.5312/wjo.v12.i5.270.

20. Pogliacomi F, Artoni C, Riccoboni S, Calderazzi F, Vaienti E, Ceccarelli F. The management of syndesmotic screw in ankle fractures. Acta Biomed. 2018 Dec 20;90(1-S):146-149. doi: 10.23750/abm.v90i1-S.8015.