Background:​ Ankle fractures with syndesmotic injury treated via standard trans-syndesmotic fixation have a high percentage of syndesmotic malreduction.10 We established a protocol involving both direct syndesmosis visualization and meticulous tibial incisura reconstruction via the posterior malleolus fracture fragment, when present, via the attached, intact PITFL, then compared this with historic controls to assess improvement after this type of syndesmosis reconstruction.

Materials and Methods:​ One hundred forty-nine consecutive direct visualization patients were treated prospectively with either open posterior malleolus reduction and fixation, regardless of fragment size (“PM”:​ 38 patients), or, with no posterior malleolar fracture, open fixation with locked syndesmotic screws (“S”:​ 97 patients);​ fracture-dislocations combined both fixation types (“C”:​ 16 patients). The syndesmosis was opened and debrided in all. All patients had preoperative MRI and postoperative CT. Distances between the fibula and anterior and posterior incisura facets were measured on axial CT. An incongruent joint was defined as an A-P difference greater than 2 mm. Our historic controls were 25 patients previously fixed via indirect, fluoro-scopic reduction and syndesmotic screws.

Results:​ In the direct visualization group, 24 ankles (16%) had incongruity, compared with 13 controls (52%). The average difference between anterior and posterior colliculi measurements between PM and C was significant (p = 0.017).

Conclusion:​ Malreductions were significantly decreased in the direct visualization group. However, our reduction sometimes remains imprecise, even with direct visualization and attention to detail. Also, posterior malleolar reconstruction was more accurate than syndesmotic screw fixa-tion in our study.

Level of Evidence:​ III, Case Control