Needle Arthroscopy-Guided Anatomic Reduction and Suture Button Fixation of the Distal Tibiofibular Syndesmosis

Syndesmotic malreduction remains a major contributor to poor outcomes after ankle injuries, yet conventional fixation methods rely primarily on fluoroscopic assessment and may not fully reveal rotational or subtle translational malalignment. Needle arthroscopy offers direct visualization of the distal tibiofibular interval, enabling precise assessment of the injury and real-time confirmation of reduction. This surgical technique describes a fully arthroscopic approach to anatomic reduction and dynamic stabilization of the syndesmosis using a suture button device. After arthroscopic identification of the pathological widening, a four-cortex trans-syndesmotic tunnel is created under fluoroscopic control, the medial button is deployed, and final reduction is achieved through symmetric tensioning while monitoring the syndesmosis with needle arthroscopy. This method allows accurate restoration of the fibular position within the incisura with minimal soft-tissue disruption and may reduce the risk of malreduction associated with traditional techniques.