Ankle Syndesmosis Reduction Pearls: Open Technique, Thumb Reduction, and Endobutton Fixation

February 8, 2026 Dr. Michael Lee – Health Editor Health

Key Takeaways from Clifford B. Jones, MD’s Presentation on Ankle Syndesmosis Malreduction

This article details advice from Clifford B. Jones, MD, on minimizing malreduction and achieving stable fixation in ankle syndesmosis injuries. Here’s a breakdown of the key points:

1. Acceptable Reduction Thresholds:

* Studies suggest that small discrepancies in reduction (1.5-3mm gap, 10-15° rotation) may not substantially impact outcomes at one year.
* However, a better initial open reduction generally leads to better anatomical results.
* A difference of up to 2mm in reduction can be accepted.

2. Avoiding Malreduction – Medial clamp Positioning:

* Clamp Use Caution: Jones advocates for minimizing or even avoiding clamps, suggesting manual reduction with the thumb is preferable.
* Clamp Placement: If clamps are used, position the medial clamp tine in the anterior third of the tibial line (on lateral view) to minimize malreduction risk.
* Over-Compression: be mindful of over-compression (fibular medialization > 1mm compared to uninjured ankle), which is common (52% of patients) and linked to increased clamp forces.

3. Stable Fixation is Crucial:

* Endobutton Technique: For closed reduction, an endobutton technique is favored as it allows for better fibular fit within the incisura.
* Reliable Fixation: Choose a fixation method that is secure, considering patient compliance.
* Suture Button vs. Screws: Studies show no significant difference in outcomes, complication rates, or reoperation rates between suture buttons and syndesmotic screws. “Do what you do best to reduce these, but do it well.”

4. Extensive Reduction:

* Fibula & Colliculus: Reduce both the fibula and collicular components for optimal length, alignment, and rotation.
* Posterior Malleolus: Reducing the posterior malleolus provides stability.
* Anterior Colliculus: Don’t forget the anterior colliculus (anterior portion of the tibiofibular ligament). Reducing both anterior and posterior components can possibly eliminate the need for syndesmotic fixation, but final checking is essential.

Contact information:

* Clifford B. Jones, MD: [email protected]

In essence, Jones emphasizes a careful, anatomical approach to ankle syndesmosis injuries, prioritizing stable fixation and minimizing the risks associated with clamp use and over-compression.