Table 2.

Technical Pearls

The patient is positioned supine with the ipsilateral hip elevated using a bump to provide easier access to the lateral fibula.

A tourniquet is placed around the thigh.

Manual distraction is applied to the ankle, which is usually already quite lax in the setting of an unstable fracture.

A 30° arthroscope is inserted into the anterolateral portal. During arthroscopy, the surgeon should evaluate for cartilage injuries and loose bodies that may prevent adequate reduction.

The drive-through test is performed by attempting to pass the 2.9-mm shaver from the anteromedial portal between the medial malleolus and the medial talar dome. The test is usually positive at this point because of the fibula fracture, but performing the test now establishes a base case to compare with after the fibula is repaired.

Open reduction–internal fixation is performed.

The surgeon returns to arthroscopy and performs the drive-through sign again. If the shaver passes easily, the drive-through sign is positive, and further fixation of the syndesmosis is then performed.

After syndesmosis fixation, the arthroscope and shaver are again reinserted and the drive-through test is performed. A negative test indicates that the syndesmosis has been adequately reduced and fixed, whereas a test that continues to be positive should raise suspicion for inadequate reduction and/or fixation of the fibula and syndesmosis.