Anterior Subluxation of the Talus: A Complication of Malreduction of the Ankle Syndesmosis

The goal of operative treatment of unstable ankle fractures is to obtain an anatomic reduction of the ankle mortise and provide stable fixation until osseous union and ligamentous healing occur1. The syndesmosis, an important secondary stabilizer of the ankle joint, may be injured in rotational ankle fractures and require stabilization. However, placement of a transsyndesmotic screw is an independent risk factor for inferior outcomes2, which may be caused by the high incidence of syndesmosis malreduction when a closed reduction is attempted3,4. The tibiotalar joint is highly conforming, bearing more weight per unit area than any other joint. Therefore, small changes in the relationship between the tibia and the talus may lead to posttraumatic arthritis5,6. The literature has focused on reduction of the mortise in the coronal plane since l mm of lateral talar translation decreases the tibiotalar contact area by 42%, consequently increasing cartilage pressures7. The clinical relevance of lateral talar shift is corroborated by studies demonstrating poor outcomes in patients with widening of the mortise after an ankle fracture1,8. We report a series of three patients with malreduction of the tibiotalar joint in the sagittal plane after closed reduction of the syndesmosis and placement of transsyndesmotic screws. In all three of these cases, the talus subluxated anteriorly after placement of a syndesmotic screw and was rigidly fixed in the malreduced position. This complication results from avoidable technical errors that result in malreduction of the syndesmosis and secondarily affect the tibiotalar joint. The patients were all informed that data concerning the cases would be submitted for publication, and they all provided consent. We reviewed 364 consecutive cases of operatively treated ankle fractures that included fixation of the syndesmosis. Based on postoperative radiographs …