El conocimiento acerca del manejo de las fracturas de tobillo ha tenido un gran crecimiento los últimos años. La tomografía axial computarizada y el mejor entendimiento biomecánico han renovado conceptos tanto del diagnóstico como del tratamiento. Pese a ello, actualmente existen consideraciones sobre el manejo de fracturas maleolares sin consenso. Esta revisión pretende actualizar conceptos sobre el estudio y manejo de las fracturas de tobillo. Serán discutidos los conceptos de estabilidad, estudios radiológicos, uso de tomografía axial computarizada, manejo de lesiones ligamentarias asociadas (ligamento deltoideo y sindesmosis) y manejo de fracturas del maléolo posterior. Se planteará la opinión de los autores y la evidencia en la literatura para cada pregunta propuesta.

Authors: Pablo Ruiz Riquelme[1,2], Jorge Filippi[3,4]

Affiliation:
[1] Equipo de Cirugía de Pierna, Tobillo y Pie, Departamento de Ortopedia y Traumatología, Hospital Clínico La Florida, Santiago, Chile
[2] Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
[3] Equipo de Cirugía de Pierna, Tobillo y Pie, Departamento de Ortopedia y Traumatología, Clínica Las Condes, Santiago, Chile
[4] Equipo de Cirugía Tobillo y Pie, Departamento de Ortopedia y Traumatología, Hospital del Trabajador, Santiago, Chile

E-mail: pabloruiz@gmail.com

Author address:
[1] Francisco Bilbao 2140, departamento 611A
Providencia, Santiago, Chile
Código postal: 7510947

Citation: Ruiz Riquelme P, Filippi J. An update on the work-up and management of ankle fractures: A literature review. Medwave 2021;21(03):e8130 doi: 10.5867/medwave.2021.03.8130

Submission date: 1/7/2020

Acceptance date: 26/1/2021

Publication date: 19/3/2021

Origin: Not commissioned

Type of review: Externally peer-reviewed by three reviewers, double-blind

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1. Singh R, Kamal T, Roulohamin N, Maoharan G, Ahmed B, Theobald P. Ankle Fractures: A Literature Review of Current Treatment Methods. Open J Orthop. 2014;04(11):292–303. | CrossRef |
2. Ortiz CA, Wagner P, Wagner E. State-of-the-Art in Ankle Fracture Management in Chile. Foot Ankle Clin. 2016 Jun;21(2):367-89. | CrossRef | PubMed |
3. Flynn JM, Rodriguez-del Rio F, Pizá PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int. 2000 Apr;21(4):311-9. | CrossRef | PubMed |
4. Vega J, Malagelada F, Manzanares Céspedes MC, Dalmau-Pastor M. The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surg Sports Traumatol Arthrosc. 2020 Jan;28(1):8-17. | CrossRef | PubMed |
5. Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69. | CrossRef | PubMed |
6. Amaha K, Nimura A, Yamaguchi R, Kampan N, Tasaki A, Yamaguchi K, et al. Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament. J Exp Orthop. 2019 Jan 28;6(1):2. | CrossRef | PubMed |
7. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976 Apr;58(3):356-7. | PubMed |
8. Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am. 1997 Dec;79(12):1809-15. | CrossRef | PubMed |
9. Stufkens SA, van den Bekerom MP, Kerkhoffs GM, Hintermann B, van Dijk CN. Long-term outcome after 1822 operatively treated ankle fractures: a systematic review of the literature. Injury. 2011 Feb;42(2):119-27. | CrossRef | PubMed |
10. Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strategies Trauma Limb Reconstr. 2012 Aug;7(2):73-85. | CrossRef | PubMed |
11. Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? how to assess stability, which ones to fix and the role of the deltoid ligament. Bone Joint J. 2017 Jul;99-B(7):851-855. | CrossRef | PubMed |
12. Saltzman C, Anderson RB. Mann’s Surgery of the Foot and Ankle, 2-Volume Set - 9th Edition. 9th Editio. Coughlin M, editor. Elsevier; 2013. 2336 p. [On line] | Link |
13. Aiyer AA, Zachwieja EC, Lawrie CM, Kaplan JRM. Management of Isolated Lateral Malleolus Fractures. J Am Acad Orthop Surg. 2019 Jan 15;27(2):50-59. | CrossRef | PubMed |
14. Ashraf A, Murphree J, Wait E, Winston T, Wooldridge A, Meriwether M, et al. Gravity Stress Radiographs and the Effect of Ankle Position on Deltoid Ligament Integrity and Medial Clear Space Measurements. J Orthop Trauma. 2017 May;31(5):270-274. | CrossRef | PubMed |
15. Jeong BO, Kim TY, Baek JH, Song SH, Park JS. Assessment of Ankle Mortise Instability After Isolated Supination-External Rotation Lateral Malleolar Fractures. J Bone Joint Surg Am. 2018 Sep 19;100(18):1557-1562. | CrossRef | PubMed |
16. Seidel A, Krause F, Weber M. Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle. Foot Ankle Int. 2017 Jul;38(7):736-744. | CrossRef | PubMed |
17. van Leeuwen C, Haak T, Kop M, Weil N, Zijta F, Hoogendoorn J. The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures. Eur J Trauma Emerg Surg. 2019 Aug;45(4):727-735. | CrossRef | PubMed |
18. Dawe EJ, Shafafy R, Quayle J, Gougoulias N, Wee A, Sakellariou A. The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures. Foot Ankle Surg. 2015 Jun;21(2):86-90. | CrossRef | PubMed |
19. Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int. 2012 Feb;33(2):92-8. | CrossRef | PubMed |
20. Marzo JM, Kluczynski MA, Clyde C, Anders MJ, Mutty CE, Ritter CA. Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle. Quant Imaging Med Surg. 2017 Dec;7(6):678-684. | CrossRef | PubMed |
21. Lawlor MC, Kluczynski MA, Marzo JM. Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model. Foot Ankle Int. 2018 Jul;39(7):850-857. | CrossRef | PubMed |
22. Kumar A, Mishra P, Tandon A, Arora R, Chadha M. Effect of CT on Management Plan in Malleolar Ankle Fractures. Foot Ankle Int. 2018 Jan;39(1):59-66. | CrossRef | PubMed |
23. Rammelt S, Boszczyk A. Computed Tomography in the Diagnosis and Treatment of Ankle Fractures: A Critical Analysis Review. JBJS Rev. 2018 Dec;6(12):e7. | CrossRef | PubMed |
24. Bartoníček J, Rammelt S, Kašper Š, Malík J, Tuček M. Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg. 2019 Apr;139(4):497-506. | CrossRef | PubMed |
25. Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994 Oct;10(5):558-60. | CrossRef | PubMed |
26. Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg. 2018 Sep;138(9):1213-1222. | CrossRef | PubMed |
27. Fitzpatrick E, Goetz JE, Sittapairoj T, Hosuru Siddappa V, Femino JE, Phisitkul P. Effect of Posterior Malleolus Fracture on Syndesmotic Reduction: A Cadaveric Study. J Bone Joint Surg Am. 2018 Feb 7;100(3):243-248. | CrossRef | PubMed |
28. Mangnus L, Meijer DT, Stufkens SA, Mellema JJ, Steller EP, Kerkhoffs GM, et al. Posterior Malleolar Fracture Patterns. J Orthop Trauma. 2015 Sep;29(9):428-35. | CrossRef | PubMed |
29. Blom RP, Meijer DT, de Muinck Keizer RO, Stufkens SAS, Sierevelt IN, Schepers T, et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury. 2019 Jul;50(7):1392-1397. | CrossRef | PubMed |
30. Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg. 2015 Dec;41(6):587-600. | CrossRef | PubMed |
31. Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006 May;88(5):1085-92. | CrossRef | PubMed |
32. Assal M, Dalmau-Pastor M, Ray A, Stern R. How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches. J Orthop Trauma. 2017 Apr;31(4):e127-e129. | CrossRef | PubMed |
33. Lee S, Lin J, Hamid KS, Bohl DD. Deltoid Ligament Rupture in Ankle Fracture: Diagnosis and Management. J Am Acad Orthop Surg. 2019 Jul 15;27(14):e648-e658. | CrossRef | PubMed |
34. Dabash S, Elabd A, Potter E, Fernandez I, Gerzina C, Thabet AM, et al. Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review. Foot Ankle Surg. 2019 Dec;25(6):714-720. | CrossRef | PubMed |
35. Woo SH, Bae SY, Chung HJ. Short-Term Results of a Ruptured Deltoid Ligament Repair During an Acute Ankle Fracture Fixation. Foot Ankle Int. 2018 Jan;39(1):35-45. | CrossRef | PubMed |
36. Strömsöe K, Höqevold HE, Skjeldal S, Alho A. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg Br. 1995 Nov;77(6):920-1. | PubMed |
37. Zhao HM, Lu J, Zhang F, Wen XD, Li Y, Hao DJ, et al. Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study. BMC Musculoskelet Disord. 2017 Dec 21;18(1):543. | CrossRef | PubMed |
38. Fort NM, Aiyer AA, Kaplan JR, Smyth NA, Kadakia AR. Management of acute injuries of the tibiofibular syndesmosis. Eur J Orthop Surg Traumatol. 2017 May;27(4):449-459. | CrossRef | PubMed |
39. Pakarinen H, Flinkkilä T, Ohtonen P, Hyvönen P, Lakovaara M, Leppilahti J, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. | CrossRef | PubMed |
40. Onggo JR, Nambiar M, Phan K, Hickey B, Ambikaipalan A, Hau R, et al. Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials. Foot Ankle Surg. 2020 Jan;26(1):54-60. | CrossRef | PubMed |
41. Hak DJ, Egol KA, Gardner MJ, Haskell A. The "not so simple" ankle fracture: avoiding problems and pitfalls to improve patient outcomes. Instr Course Lect. 2011;60:73-88. | PubMed |
42. Kukreti S, Faraj A, Miles JNV. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury [Internet]. 2005 Sep;36(9):1121–4. | CrossRef |
43. Walley KC, Hofmann KJ, Velasco BT, Kwon JY. Removal of Hardware After Syndesmotic Screw Fixation: A Systematic Literature Review. Foot Ankle Spec. 2017 Jun;10(3):252-257. | CrossRef | PubMed |
44. Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2019 Sep;47(11):2764-2771. | CrossRef | PubMed |
45. Pang EQ, Bedigrew K, Palanca A, Behn AW, Hunt KJ, Chou L. Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model. Injury. 2019 Nov;50(11):1901-1907. | CrossRef | PubMed |
46. Schon JM, Williams BT, Venderley MB, Dornan GJ, Backus JD, Turnbull TL, LaPrade RF, Clanton TO. A 3-D CT Analysis of Screw and Suture-Button Fixation of the Syndesmosis. Foot Ankle Int. 2017 Feb;38(2):208-214. | CrossRef | PubMed |
47. Clanton TO, Whitlow SR, Williams BT, Liechti DJ, Backus JD, Dornan GJ, et al. Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques. Foot Ankle Int. 2017 Feb;38(2):200-207. | CrossRef | PubMed |
48. Coetzee JC, Ebeling P. Treatment of Syndesmosis Disruptions With TightRope Fixation. Tech Foot Ankle Surg. 2008 Sep;7(3):196–202. | CrossRef |
49. Neary KC, Mormino MA, Wang H. Suture Button Fixation Versus Syndesmotic Screws in Supination-External Rotation Type 4 Injuries: A Cost-Effectiveness Analysis. Am J Sports Med. 2017 Jan;45(1):210-217. | CrossRef | PubMed |
50. Cosgrove CT, Spraggs-Hughes AG, Putnam SM, Ricci WM, Miller AN, McAndrew CM, et al. A Novel Indirect Reduction Technique in Ankle Syndesmotic Injuries: A Cadaveric Study. J Orthop Trauma. 2018 Jul;32(7):361-367. | CrossRef | PubMed |

Singh R, Kamal T, Roulohamin N, Maoharan G, Ahmed B, Theobald P. Ankle Fractures: A Literature Review of Current Treatment Methods. Open J Orthop. 2014;04(11):292–303. | CrossRef |

Ortiz CA, Wagner P, Wagner E. State-of-the-Art in Ankle Fracture Management in Chile. Foot Ankle Clin. 2016 Jun;21(2):367-89. | CrossRef | PubMed |

Flynn JM, Rodriguez-del Rio F, Pizá PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int. 2000 Apr;21(4):311-9. | CrossRef | PubMed |

Vega J, Malagelada F, Manzanares Céspedes MC, Dalmau-Pastor M. The lateral fibulotalocalcaneal ligament complex: an ankle stabilizing isometric structure. Knee Surg Sports Traumatol Arthrosc. 2020 Jan;28(1):8-17. | CrossRef | PubMed |

Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69. | CrossRef | PubMed |

Amaha K, Nimura A, Yamaguchi R, Kampan N, Tasaki A, Yamaguchi K, et al. Anatomic study of the medial side of the ankle base on the joint capsule: an alternative description of the deltoid and spring ligament. J Exp Orthop. 2019 Jan 28;6(1):2. | CrossRef | PubMed |

Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976 Apr;58(3):356-7. | PubMed |

Thordarson DB, Motamed S, Hedman T, Ebramzadeh E, Bakshian S. The effect of fibular malreduction on contact pressures in an ankle fracture malunion model. J Bone Joint Surg Am. 1997 Dec;79(12):1809-15. | CrossRef | PubMed |

Stufkens SA, van den Bekerom MP, Kerkhoffs GM, Hintermann B, van Dijk CN. Long-term outcome after 1822 operatively treated ankle fractures: a systematic review of the literature. Injury. 2011 Feb;42(2):119-27. | CrossRef | PubMed |

Stufkens SA, van den Bekerom MP, Knupp M, Hintermann B, van Dijk CN. The diagnosis and treatment of deltoid ligament lesions in supination-external rotation ankle fractures: a review. Strategies Trauma Limb Reconstr. 2012 Aug;7(2):73-85. | CrossRef | PubMed |

Gougoulias N, Sakellariou A. When is a simple fracture of the lateral malleolus not so simple? how to assess stability, which ones to fix and the role of the deltoid ligament. Bone Joint J. 2017 Jul;99-B(7):851-855. | CrossRef | PubMed |

Saltzman C, Anderson RB. Mann’s Surgery of the Foot and Ankle, 2-Volume Set - 9th Edition. 9th Editio. Coughlin M, editor. Elsevier; 2013. 2336 p. [On line] | Link |

Aiyer AA, Zachwieja EC, Lawrie CM, Kaplan JRM. Management of Isolated Lateral Malleolus Fractures. J Am Acad Orthop Surg. 2019 Jan 15;27(2):50-59. | CrossRef | PubMed |

Ashraf A, Murphree J, Wait E, Winston T, Wooldridge A, Meriwether M, et al. Gravity Stress Radiographs and the Effect of Ankle Position on Deltoid Ligament Integrity and Medial Clear Space Measurements. J Orthop Trauma. 2017 May;31(5):270-274. | CrossRef | PubMed |

Jeong BO, Kim TY, Baek JH, Song SH, Park JS. Assessment of Ankle Mortise Instability After Isolated Supination-External Rotation Lateral Malleolar Fractures. J Bone Joint Surg Am. 2018 Sep 19;100(18):1557-1562. | CrossRef | PubMed |

Seidel A, Krause F, Weber M. Weightbearing vs Gravity Stress Radiographs for Stability Evaluation of Supination-External Rotation Fractures of the Ankle. Foot Ankle Int. 2017 Jul;38(7):736-744. | CrossRef | PubMed |

van Leeuwen C, Haak T, Kop M, Weil N, Zijta F, Hoogendoorn J. The additional value of gravity stress radiographs in predicting deep deltoid ligament integrity in supination external rotation ankle fractures. Eur J Trauma Emerg Surg. 2019 Aug;45(4):727-735. | CrossRef | PubMed |

Dawe EJ, Shafafy R, Quayle J, Gougoulias N, Wee A, Sakellariou A. The effect of different methods of stability assessment on fixation rate and complications in supination external rotation (SER) 2/4 ankle fractures. Foot Ankle Surg. 2015 Jun;21(2):86-90. | CrossRef | PubMed |

Hoshino CM, Nomoto EK, Norheim EP, Harris TG. Correlation of weightbearing radiographs and stability of stress positive ankle fractures. Foot Ankle Int. 2012 Feb;33(2):92-8. | CrossRef | PubMed |

Marzo JM, Kluczynski MA, Clyde C, Anders MJ, Mutty CE, Ritter CA. Weight bearing cone beam CT scan versus gravity stress radiography for analysis of supination external rotation injuries of the ankle. Quant Imaging Med Surg. 2017 Dec;7(6):678-684. | CrossRef | PubMed |

Lawlor MC, Kluczynski MA, Marzo JM. Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model. Foot Ankle Int. 2018 Jul;39(7):850-857. | CrossRef | PubMed |

Kumar A, Mishra P, Tandon A, Arora R, Chadha M. Effect of CT on Management Plan in Malleolar Ankle Fractures. Foot Ankle Int. 2018 Jan;39(1):59-66. | CrossRef | PubMed |

Rammelt S, Boszczyk A. Computed Tomography in the Diagnosis and Treatment of Ankle Fractures: A Critical Analysis Review. JBJS Rev. 2018 Dec;6(12):e7. | CrossRef | PubMed |

Bartoníček J, Rammelt S, Kašper Š, Malík J, Tuček M. Pathoanatomy of Maisonneuve fracture based on radiologic and CT examination. Arch Orthop Trauma Surg. 2019 Apr;139(4):497-506. | CrossRef | PubMed |

Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994 Oct;10(5):558-60. | CrossRef | PubMed |

Verhage SM, Hoogendoorn JM, Krijnen P, Schipper IB. When and how to operate the posterior malleolus fragment in trimalleolar fractures: a systematic literature review. Arch Orthop Trauma Surg. 2018 Sep;138(9):1213-1222. | CrossRef | PubMed |

Fitzpatrick E, Goetz JE, Sittapairoj T, Hosuru Siddappa V, Femino JE, Phisitkul P. Effect of Posterior Malleolus Fracture on Syndesmotic Reduction: A Cadaveric Study. J Bone Joint Surg Am. 2018 Feb 7;100(3):243-248. | CrossRef | PubMed |

Mangnus L, Meijer DT, Stufkens SA, Mellema JJ, Steller EP, Kerkhoffs GM, et al. Posterior Malleolar Fracture Patterns. J Orthop Trauma. 2015 Sep;29(9):428-35. | CrossRef | PubMed |

Blom RP, Meijer DT, de Muinck Keizer RO, Stufkens SAS, Sierevelt IN, Schepers T, et al. Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures. Injury. 2019 Jul;50(7):1392-1397. | CrossRef | PubMed |

Bartoníček J, Rammelt S, Tuček M, Naňka O. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg. 2015 Dec;41(6):587-600. | CrossRef | PubMed |

Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006 May;88(5):1085-92. | CrossRef | PubMed |

Assal M, Dalmau-Pastor M, Ray A, Stern R. How to Get to the Distal Posterior Tibial Malleolus? A Cadaveric Anatomic Study Defining the Access Corridors Through 3 Different Approaches. J Orthop Trauma. 2017 Apr;31(4):e127-e129. | CrossRef | PubMed |

Lee S, Lin J, Hamid KS, Bohl DD. Deltoid Ligament Rupture in Ankle Fracture: Diagnosis and Management. J Am Acad Orthop Surg. 2019 Jul 15;27(14):e648-e658. | CrossRef | PubMed |

Dabash S, Elabd A, Potter E, Fernandez I, Gerzina C, Thabet AM, et al. Adding deltoid ligament repair in ankle fracture treatment: Is it necessary? A systematic review. Foot Ankle Surg. 2019 Dec;25(6):714-720. | CrossRef | PubMed |

Woo SH, Bae SY, Chung HJ. Short-Term Results of a Ruptured Deltoid Ligament Repair During an Acute Ankle Fracture Fixation. Foot Ankle Int. 2018 Jan;39(1):35-45. | CrossRef | PubMed |

Strömsöe K, Höqevold HE, Skjeldal S, Alho A. The repair of a ruptured deltoid ligament is not necessary in ankle fractures. J Bone Joint Surg Br. 1995 Nov;77(6):920-1. | PubMed |

Zhao HM, Lu J, Zhang F, Wen XD, Li Y, Hao DJ, et al. Surgical treatment of ankle fracture with or without deltoid ligament repair: a comparative study. BMC Musculoskelet Disord. 2017 Dec 21;18(1):543. | CrossRef | PubMed |

Fort NM, Aiyer AA, Kaplan JR, Smyth NA, Kadakia AR. Management of acute injuries of the tibiofibular syndesmosis. Eur J Orthop Surg Traumatol. 2017 May;27(4):449-459. | CrossRef | PubMed |

Pakarinen H, Flinkkilä T, Ohtonen P, Hyvönen P, Lakovaara M, Leppilahti J, et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. | CrossRef | PubMed |

Onggo JR, Nambiar M, Phan K, Hickey B, Ambikaipalan A, Hau R, et al. Suture button versus syndesmosis screw constructs for acute ankle diastasis injuries: A meta-analysis and systematic review of randomised controlled trials. Foot Ankle Surg. 2020 Jan;26(1):54-60. | CrossRef | PubMed |

Hak DJ, Egol KA, Gardner MJ, Haskell A. The "not so simple" ankle fracture: avoiding problems and pitfalls to improve patient outcomes. Instr Course Lect. 2011;60:73-88. | PubMed |

Kukreti S, Faraj A, Miles JNV. Does position of syndesmotic screw affect functional and radiological outcome in ankle fractures? Injury [Internet]. 2005 Sep;36(9):1121–4. | CrossRef |

Walley KC, Hofmann KJ, Velasco BT, Kwon JY. Removal of Hardware After Syndesmotic Screw Fixation: A Systematic Literature Review. Foot Ankle Spec. 2017 Jun;10(3):252-257. | CrossRef | PubMed |

Shimozono Y, Hurley ET, Myerson CL, Murawski CD, Kennedy JG. Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2019 Sep;47(11):2764-2771. | CrossRef | PubMed |

Pang EQ, Bedigrew K, Palanca A, Behn AW, Hunt KJ, Chou L. Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model. Injury. 2019 Nov;50(11):1901-1907. | CrossRef | PubMed |

Schon JM, Williams BT, Venderley MB, Dornan GJ, Backus JD, Turnbull TL, LaPrade RF, Clanton TO. A 3-D CT Analysis of Screw and Suture-Button Fixation of the Syndesmosis. Foot Ankle Int. 2017 Feb;38(2):208-214. | CrossRef | PubMed |

Clanton TO, Whitlow SR, Williams BT, Liechti DJ, Backus JD, Dornan GJ, et al. Biomechanical Comparison of 3 Current Ankle Syndesmosis Repair Techniques. Foot Ankle Int. 2017 Feb;38(2):200-207. | CrossRef | PubMed |

Coetzee JC, Ebeling P. Treatment of Syndesmosis Disruptions With TightRope Fixation. Tech Foot Ankle Surg. 2008 Sep;7(3):196–202. | CrossRef |

Neary KC, Mormino MA, Wang H. Suture Button Fixation Versus Syndesmotic Screws in Supination-External Rotation Type 4 Injuries: A Cost-Effectiveness Analysis. Am J Sports Med. 2017 Jan;45(1):210-217. | CrossRef | PubMed |

Cosgrove CT, Spraggs-Hughes AG, Putnam SM, Ricci WM, Miller AN, McAndrew CM, et al. A Novel Indirect Reduction Technique in Ankle Syndesmotic Injuries: A Cadaveric Study. J Orthop Trauma. 2018 Jul;32(7):361-367. | CrossRef | PubMed |