3 The procedure
3.1 Suture fixation of acute disruption of the distal tibiofibular syndesmosis is done with the patient in the supine position, either under general or spinal anaesthesia, with antibiotic prophylaxis and tourniquet control. An incision is made on the lateral aspect of the ankle to access the joint. If there is any associated fracture of the tibia or fibula, this is first reduced and internally fixed using standard ankle fixation techniques. After fracture fixation, syndesmosis integrity is evaluated using either a hook test or an external rotation test under intraoperative fluoroscopy. The syndesmosis is reduced to obtain precise anatomical alignment, and maintained in position using a clamp with the ankle in a neutral position.
3.2 A small tunnel is drilled through the fibula and the tibia under image guidance. A polyethylene‑based suture loop, threaded with an oblong metal button, is then inserted through the tunnel (and the vacant hole in a fracture fixation plate, if used) using a needle. After it has passed through the tibia, the button is pulled back so that it lies flat against the medial cortex of the tibia. The ends of the suture loop on the lateral side of the fibula are pulled tight against the fibula (or the fracture fixation plate) and secured by drawing a second metal button onto the surface of the fibula or the plate. Once both buttons are flush with the bone, a small knot is made with the free ends of the loop to secure the system and stabilise the joint. If additional stability is needed, a second suture loop can be inserted through the same or another tunnel.
3.3 The incisions are closed and the ankle is placed in a below‑the‑knee cast. The ankle should be non‑weight bearing for the first 2 weeks, partial weight bearing from 2 weeks to 6 weeks, and full weight bearing after 6 weeks. Rehabilitation is provided once the ankle has healed. The polyethylene‑based suture loop is usually left in place. The potential advantages of this procedure include a more rapid return to weight bearing, maintenance of physiological micro‑motion between the tibia and the fibula, and avoiding further surgery to remove the device.