Drill a 2.5 mm hole through the fibula and the lateral cortex of the tibia, just proximal to the inferior tibiofibular joint, 30 degrees from posterior to anterior, parallel to the tibial plafond, with the ankle joint in neutral position.
If the fibular fracture was treated with a plate at this level, the screw may be placed through a hole in the plate.
Use a depth gauge to determine the length of the screw.
As this screw is not intended to act as a compressive lag screw, the thread must be tapped in both ﬁbula and tibia.
Tap the thread and insert a 3.5 mm or 4.5 mm cortex screw.
The foot position during positioning screw placement should be in neutral.
Check position and reduction under image intensification and compare with corresponding images of the uninjured ankle.
Some surgeons prefer two small fragment screws as syndesmotic screws, especially in high fibular fractures, such as the Maisonneuve injury.
Prepare and insert the second positioning screw as described above, parallel to, and 1.5–2 cm proximal to, the first screw.
Once satisfactory reduction and hold with screws has been confirmed, the K-wire is removed.
Intraoperative x-rays or image intensification are advised, to conﬁrm the position of the screw and the distal tibiofibular joint.
Following plating of a multifragmentary fracture, or when a high fibular fracture has not been fixed, postoperative CT or MRI, to assess the rotation of the fibula at the level of the syndesmosis of both ankles, is strongly advised.