Restoring length, axis and rotation of the fibula
If the fibula is displaced, make sure it is properly reduced.
Use a small bone hook to pull the lateral malleolus distally if necessary, until perfect congruence of the distal tibiofibular joint is achieved.
Check rotation, length and antero-posterior translation of the fibula, by intraoperative radiology and/or direct visual inspection of the syndesmosis. Fix the reduction with a K-wire, if necessary.
Preliminary fixation with a K-wire
Fix the reduction with a 2.0 mm K-wire, inserted from the lateral side, distal to the planned distal screw and 1-2 cm above the joint line. The position of the ankle joint during this maneuver should be in neutral.
Confirm reduction under image intensification in both planes. Reduction must be anatomical. Compare with the uninjured ankle.
If reduction in the anterior-posterior direction is not anatomical, the congruity of the tibio-talar joint in the lateral view is not perfect, ie, the joint lines are not perfectly aligned.