Syndesmosis preserving osteotomy of the fibula for access to the lateral talar dome

Open surgical access to the postero-lateral talar dome for the treatment of osteochondral lesions is challenging, often requiring a segmental osteotomy of the fibula (fibular window) and division of the anterior inferior tibiofibular ligament (AITFL) or a fibular osteotomy with division of the AITFL and the anterior talofibular ligament (ATFL) (fibular door). Alternatively, to preserve the tibiofibular syndesmosis both the fibula and the lateral tibial plafond can be osteotomised to expose the entire lateral talar dome. All of these techniques involve extensive surgical exposures and a significant amount of internal fixation of the osteotomy to achieve surgical access.

A trapezoidal fibular osteotomy which hinges on the AITFL thus preserving the syndesmotic and lateral ligamentous complex was developed to permit perpendicular access to the lateral talar dome. The remaining posterior column of fibula allows keying in of the osteotomy requiring minimal internal fixation.

A 43 year old male with a displaced osteochondral fracture of the superolateral talar dome underwent the osteotomy to provide perpendicular fixation with two Herbert's screws. The osteotomy was reduced and fixed with a single 3.5mm lag screw. At 3 month follow up the osteotomy had healed both clinically and radiographically.

Our technique utilizes a novel trapezoidal fibular osteotomy with preservation of key syndesmotic and ligamentous structures and requires minimal internal fixation.