We analyzed the operative measures that may be used to reduce the likelihood of sagittal syndesmotic malreduction. Hence, we propose a simple technical tip to avoid sagittal plane malreduction of the fibula within the syndesmosis in ankle fractures. Supporting the leg under the heel should be avoided when performing syndesmotic reduction for unstable malleolar fractures, and support under the calf should be used instead. Our observations have been confirmed in 6 cadaver specimens. We observed that there was a significant anterior subluxation of the fibula when the leg was supported under the heel. No significant difference between the intact and unstable state was present when the leg was supported under the calf. In conclusion, during syndesmotic reduction and fixation in supine position, supporting the foot under the heel should be avoided.
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