Alice Chu, MD and Lon Weiner, MD J Am Acad Orthop Surg, Vol 17, No 4, April 2009,
Anatomic reduction and fixation of unstable ankle fractures is necessary to prevent posttraumatic arthritis. Malunion of the distal fibula in unstable ankle fractures may lead to progressive talar instability. Ankle fracture malunions often present with concomitant syndesmotic widening, which can cause surgeons to overlook changes in fibula length and rotation. The decision to proceed with surgery should be made only after a careful diagnostic workup and detailed preoperative discussion with the patient. Considerations for surgical management include location and orientation of a corrective osteotomy, use of structural graft, widening of the syndesmosis, assessment of reduction, and the need for medial exposure. Good and excellent clinical results after fibular reconstruction have been reported in 67% to 92% of ankles. Proper patient selection is critical, because ankle malunions can be complicated, with coexisting fibular, syndesmotic, medial, and posterior malleolar malalignment, along with degenerative joint disease. Understanding the indications and surgical technique for revising fibular malunions may obviate a future salvage procedure.