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Forceps Reduction of the Syndesmosis in Rotational Ankle FracturesA Cadaveric Study
Phinit Phisitkul, MD1; Thomas Ebinger, MD1; Jessica Goetz, PhD2; Tanawat Vaseenon, MD3; J. Lawrence Marsh, MD1
1 Department of Orthopaedics and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242. E-mail address for P. Phisitkul: phinit-phisitkul@uiowa.edu. E-mail address for T. Ebinger: thomas-ebinger@uiowa.edu. E-mail address for J.L. Marsh: j-marsh@uiowa.edu
2 Department of Orthopaedics Biomechanics Lab, University of Iowa Hospitals and Clinics, 2181 Westlawn, Iowa City, IA 52242. E-mail address: jessica-goetz@uiowa.edu
3 Orthopaedic Department, Chiang Mai University, 110 Intawaroros Road, T. Sripoom, A. Muang, Chiang Mai, Thailand 50200. E-mail address tvaseenon@yahoo.com
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Investigation performed at the University of Iowa Hospitals and Clinics, Iowa City, Iowa

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Dec 19;94(24):2256-2261. doi: 10.2106/JBJS.K.01726
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Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement.


Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan.


In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability.


Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis.

Clinical Relevance: 

Clamp placement in the neutral anatomical axis appears to be preferred in the syndesmosis reduction.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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