Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury: A comment.

Sir,

We read with great interest the manuscript by Muhammed et al.1 entitled “Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury”. I must congratulate the authors for this study. However, I would like to draw attention of authors and readers to the following:

The authors confirmed syndesmotic disruption with Cotton hook test. Rather than pulling the fibula laterally, stressing the fibula anteriorly and posteriorly in the sagittal plane is more reliable. Disruption of the syndesmosis will produce significant instability of the fibula that may be best appreciated in the sagittal plane. The improved sensitivity of this testing method was described in a cadaveric study.2

The need for syndesmotic internal fixation is closely tied to the integrity of the medial malleolar osteoligamentous complex (MMOLC). Biomechanical studies have shown that when the MMOLC is intact, disruption of the syndesmosis does not lead to widening of the mortise.34 This implies that in cases when the medial malleolus is fixed, syndesmotic fixation is not indicated.

Authors removed syndesmotic screw at an average of eight weeks. Removing the screw too early may allow recurrent diastasis of the syndesmosis, as evident in one case of the author's series. Late diastasis of the syndesmosis creates a much more difficult clinical problem than broken screws; it is advisable to leave the screw in place for at least 12 weeks.5