The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Suture fixation of acute disruption of the distal tibiofibular syndesmosis, in June 2015.


Syndesmotic injuries are injuries to the ligaments that connect the tibia and fibula at the ankle joint. They are the most severe ligament injuries to the ankle and occur either in isolation or at the same time as an ankle fracture. Typical fractures associated with syndesmotic instability include pronation external rotation fractures (PER or Weber type C), supination external rotation fractures (SER or Weber type B), and proximal fibular fractures with associated syndesmotic injury (Maisonneuve fractures). The most common mechanisms causing syndesmotic injuries are ankle external rotation and/or hyperdorsiflexion. These injuries can occur during activities such as sports or dancing, and from falls or slipping on ice. Patients with isolated syndesmotic injuries such as acute ankle sprains have acute ankle instability, pain and functional problems.

Isolated syndesmotic injuries can sometimes be treated conservatively with immobilisation, limited weight bearing, ankle exercises, compression and elevation. Distal tibiofibular syndesmosis, syndesmotic injuries with persistent symptoms and all syndesmotic injuries occurring with ankle fractures are normally treated by surgical rigid fixation with syndesmotic screws (single or double screws). The screws are often removed at a subsequent operation. Other fixation methods include bolt fixation and syndesmotic hooks, both of which may also be removed at a subsequent operation, and staples or direct repair.

Anatomical reduction and healing of the syndesmosis is desirable because any abnormal shift of the talus in the ankle mortise causes development of early and progressive osteoarthritis.

Coding recommendations

The OPCS-4 codes for suture fixation tibiofibular syndesmosis are:

W77.8 Other specified stabilising operations on joint

Z85.2 Lower tibiofibular joint

Z94.- Laterality of operation

Any associated fracture of the tibia or fibula which has been internally reduced and fixated will have these procedures coded in addition, and the OPCS-4 codes for reduction and fixation of the fracture will be sequenced before the above codes for suture fixation of the syndesmosis.

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)