X-ray scan showing internal fixation of a leg fractureTreatment of a<unk>  aims to: * Reduce the proximal fibula and medial malleolus to achieve stabilisation * Repair the distal tibiofibular syndesmosis and deltoid ligament * Restore ankle mortise stability Treatment can be achieved by either non-operative (or conservative) or operative means. The main operative treatments for a<unk>  are open-reduction surgery and closed-reduction surgery, both of which usually preceding internal fixation of the injury. These procedures are known as Open Reduction Internal Fixation (ORIF) and Closed Reduction Internal Fixation (CRIF). Internal fixators Syndesmotic screws are the main, internal fixators used in surgeries for a<unk> . Two main types of syndesmotic screws are used: trans-syndesmotic screws (positioned at the level of the syndesmosis) and supra-syndesmotic screws (positioned above the syndesmosis). Based on several clinical results, syndesmotic screws are recommended to be fixed at least 1 centimetre proximal to the tibiofibular syndesmosis or 4 to 6 centimetres proximal to the tibiotalar joint line. Cadaveric analyses, from a comparative study published in Foot & Ankle International in 1997, suggest that screw fixation at 2 centimetres proximal to the tibiotalar joint line is also adequate. Biodegradable implants such as bioabsorbable screws, which do not require postoperative removal, may be used as an alternative to metallic hardware. However, biodegradable implants still limit rotation of the ankle and dorsiflexion of the foot. Non-operative treatment In cases where only the posterior ligaments of the tibiofibular syndesmosis are partially damaged, non-operative treatment such as long-leg casting for at least 6 weeks is recommended. Immobilisation techniques such as casting are often paired with non-weight bearing precautions. Gradually, physiotherapy rehabilitation programs allow patients to weight-bear after at least 8 weeks of postoperative casting. Orthopaedic surgeons also administer these non-operative treatments for cases where the medial malleolus remains intact. Operative treatment Open Reduction Internal Fixation (ORIF) Distraction osteogenesis Open-reduction surgery is typically not performed at the level of the proximal fibula, as dissection near the proximal end may risk severing the common peroneal nerve. Instead, reducing the proximal fibula at the level of the distal tibiofibular syndesmosis is recommended. A hook test is performed, using a curved hook, to assess the stability of the fibula. If instability is detected, further distraction of the fibula can be done to repair the full bone. The fibula can then be guided into the fibular notch located on the tibia, effectively restoring its length. Internal rotation of the foot may then be used to correct anatomical alignment. Following open-reduction, internal fixation is usually performed to stabilise the ankle mortise. To account for the distal fibula being slightly posterior to the distal tibia, drill holes are angled at 30° from the anteromedial aspect of the tibia to the posterolateral aspect of the fibula. Trans-syndesmotic screws can be inserted in this way to ensure tibia fixation. Additional supra-syndesmotic screws may be temporarily inserted, for approximately 3 to 6 months, if instability is still present after fibular reduction. To reduce the fibula and restore the ankle mortise to its proper anatomical configuration, partial dorsiflexion of the foot is maintained prior to intraoperative screw fixation. This is because, in a neutral or maximally dorsiflexed position of the foot, the trochlear surface of the talus may reduce maximal postoperative dorsiflexion due to rigidity after screw fixation. Assessing the severity of syndesmotic lesions can be performed with fluoroscopic screening. Guidance under fluoroscopy can also assist with syndesmotic screw fixation. Restoration of the anteromedial joint capsule of the ankle can be achieved with suturing techniques. Closed Reduction Internal Fixation (CRIF) Short-leg cast Closed-reduction surgery requires no dissection or incisions being made into the leg to operate. It is most commonly applied in cases where the<unk>  has only extensively damaged the anterior portion of the syndesmotic ligaments. That is, the posterior hinge of the ankle is still stable, and the foot can be internally rotated using traction to restore fibular bone length. Long-leg casting or short-leg casting is applied postoperatively to maintain this alignment. It is generally recommended that medial malleolar fractures do not require surgical intervention if closed reduction is sufficient enough for the restoration of bone length. Otherwise, large medial malleolar fractures can be fixed using trans-syndesmotic screws, figure-of-8 wires, or Kirschner wires. For smaller medial malleolar fractures, repair with a wire-tension band is sufficient enough. Complications Delaying diagnosis and treatment can result in intraoperative complications. In one case of a clinical study, conducted in 2000 and published in Orthopedics, the insertion of a super-syndesmotic screw caused the lateral malleolus to be further shifted laterally; subsequent removal of the screw was necessary. Complications that may postoperatively occur include: * the development of osteoarthritis around the ankle joint. * the development of peroneal nerve palsy following damage to the common peroneal nerve. * extra-osseous ("outside of the bone") calcification of vessels or tissues surrounding the tibiofibular joint. Surgical hardware complications Incorrectly positioned screws can potentially make contact with articular surfaces, which can cause calcification around the affected area. Screw breakage can also cause pain in these areas. Postoperative hardware removal can cause problems such as infection, joint rigidity, or diastasis if fixation was not sufficiently long enough. In areas where residual stiffness has persisted, patients may report feeling pain or a mild aching sensation. Generally, it is recommended that hardware removal should be done anywhere from 6 weeks to 12 weeks after internal fixation to allow the tibiofibular syndesmosis to properly heal. Syndesmotic screws should be removed prior to rehabilitative training; bearing weight without prior hardware removal may result in ankle stiffness due to reduced dorsiflexion of the foot and potential screw breakage. Postoperative follow-ups Postoperative follow-ups are done to ensure that treatment has produced satisfactory results, such as checking if malreduction of any of the associated structures in a<unk>  has occurred. Follow-ups may be performed from 6 months to 2 years after the surgery and are applicable for both non-operative and operative treatments.
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