Stabilising the syndesmosis in ankle fractures - It's not just about flexible or rigid

Ankle syndesmotic injuries remain a controversial topic, with few high-level studies and conflicting evidence. Consequently, practice varies widely. We aim to provide a narrative review, based on an extensive analysis of the current literature to inform the authors' management of syndesmosis injuries, in the context of ankle fractures. Management options include indirect stabilisation of the syndesmosis through fixation of malleolar and/or avulsion fractures or, direct trans-syndesmotic stabilisation of the syndesmosis with rigid or flexible implants. The choice between these two types of devices is not binary but nuanced and based on the plane(s) of instability. Accurate diagnosis and accurate reduction of the syndesmosis are much more important factors in determining outcome than the choice between flexible or rigid stabilisation. Further large-scale prospective studies are required to answer controversial issues surrounding this topic.