Three-Cortex Syndesmotic Fixation for Weber Type B/C Lateral Malleolus Fractures with Syndesmotic Disruption: Clinical and Radiologic Results

Abstract

Background: Despite the frequent occurrence of ankle injuries, there is no consensus among orthopedic surgeons regarding the diagnosis and treatment of syndesmotic injuries. This study evaluates the clinical and radiological outcomes of three-cortex syndesmotic fixation in Weber type B/C lateral malleolus fractures (with or without medial malleolus involvement) associated with syndesmotic injury. Material and Method: This study analyzed thirty-six (36) patients with Weber type B/C lateral malleolus fractures treated between 2011 and 2022. All underwent open reduction and fixation with plates and screws for malleolar fractures, along with a 3.5 mm cortical syndesmosis fixation using three cortical engagements. Preoperative and postoperative radiological findings and final functional ankle assessments were reviewed. Intraclass correlation coefficients (ICC) were used to assess inter- and intra-observer agreement for tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and anterior tibiofibular ratio (ATFR) measurements. The functional status of the ankle has been assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scale. Results: The mean age of the patients was 50.56 ± 16.23 years, and the mean follow-up duration was 20.89 ± 24.93 months. Postoperative AOFAS scores averaged 91.08 ± 9.90. The inter-observer agreement for preoperative assessments was excellent across all parameters (ICC > 0.9). However, in the postoperative period, inter-observer agreement for ATFR measurement was poor (ICC < 0.5), while agreement for all other parameters remained excellent (ICC > 0.9). Intra-observer comparisons of preoperative (pre-op) and postoperative (post-op) measurements were poor across all parameters (ICC < 0.5); this can be attributed to the success of reduction, reflecting the positive directional change on all parameters. After an average follow-up of 20 months, four radiological parameters showed significant differences, indicating enhanced stability and reduced diastasis. Conclusions: Three-cortex syndesmotic screw fixation in Weber type B/C lateral malleolus fractures with syndesmotic injuries yielded excellent mid-term radiological and functional outcomes.

1. Introduction

The tibiofibular syndesmosis consists of the anterior tibiofibular ligament, posterior tibiofibular ligament, transverse tibiofibular ligament, interosseous ligament, and interosseous membrane [1]. These structures provide stability to the mortise, along with resistance to rotational and axial translation forces [2].

Danis and Weber [3] demonstrated that infra-syndesmotic fractures do not result in syndesmosis damage. Trans-syndesmotic fractures exhibit syndesmosis damage in 50% of cases, whereas suprasyndesmal injuries result in complete syndesmosis damage in all cases [3]. All Weber type C fractures involve syndesmosis rupture, irrespective of observable radiographic alterations [4].

Numerous studies have addressed ankle fractures associated with syndesmotic injuries and their treatment. However, the lack of consensus among orthopedic surgeons regarding treatment methods persists. Restoration of syndesmotic separation is essential, yet no standardized method has been universally adopted, despite the wealth of literature on this subject.

Computed tomography (CT) has demonstrated superiority over standard radiographs in detecting subtle mal-reductions in the syndesmosis, particularly posterior translation or malrotation of the fibula [5]. However, routine use of CT in the postoperative setting is limited by concerns regarding cost, radiation exposure, and metal artifact interference. As a result, conventional anteroposterior and lateral radiographs remain the standard method for postoperative radiological evaluation in most clinical settings.

Three-cortex syndesmotic fixation has been proposed as a biomechanically sound technique that provides adequate rotational stability while minimizing the risk of over-compression and hardware failure. Nevertheless, the literature describing the clinical and radiological outcomes of this technique remains scarce.

The primary goal of the study was to evaluate the clinical and radiologic outcomes, along with the reliability of the radiographic parameters, in 36 patients who underwent open reduction and fixation with plates and screws for malleolar fractures, in conjunction with syndesmosis fixation utilizing a 3.5 mm cortical screw engaging three cortices.

2. Material and Method

This retrospective study was approved by the ethics committee of our institution and was registered under protocol.

The present study was conducted in accordance with the Declaration of Helsinki and other applicable international ethical guidelines for human research.

A total of 112 cases of Weber type B/C lateral malleolus and bimalleolar fractures with syndesmotic injury were included in this study. Cases involving patients we could not contact (mostly tourists), distal tibial fractures (pilon fractures), calcaneal and open fractures associated with lateral malleolus fractures, and pediatric patients were excluded from the study. After exclusions, 36 patients underwent open reduction and fixation with plates and screws for malleolar fractures, along with a 3.5 mm cortical syndesmosis fixation engaging three cortices from October 2012 to December 2021 were included.

2.1. Surgical Technique

The standard lateral approach was used for lateral malleolus fractures. Dissection was performed anteriorly between the peroneus tertius and posteriorly between the peroneus longus and brevis. In cases of uncertainty, an intraoperative hook test was used to confirm syndesmotic disruption. The fracture site was exposed, and after achieving satisfactory reduction, fixation was performed using distal fibula anatomical plate and screws specifically designed for the lateral malleolus. The syndesmotic diastasis was reduced using a large reduction clamp under fluoroscopic guidance (See Figure 1—case sample with weber type c lateral malleoli fracture associated with medial malleoli fracture). A syndesmotic screw was inserted through the plate hole located approximately 2–3 cm above the plafond. For any associated medial malleolus fractures, a conventional medial incision was made, followed by the stabilization of the fracture using a lag screw(s).

Preoperative, postoperative, and final follow-up standard AP and lateral radiographs of the ankle were obtained.

The postoperative follow-up protocol included dressing changes within the first three days following surgery, and suture removal at approximately 15 days. Patients were maintained as non-weight-bearing for 6 to 8 weeks, using a range-of-motion (ROM) walker. In the absence of symptoms, routine removal of the syndesmotic screw was not performed. Polyclinic follow-up visits were scheduled within the first three months postoperatively and continued throughout the first year. Thereafter, a yearly follow-up protocol was implemented.

Radiographs were obtained using a UT 2000 X-ray machine (Konica Minolta, 2018, Tokyo, Japan) with a source-to-image distance of ~100 cm and the patient positioned in both supine and lateral positions. The radiological measurements were performed by two independent radiologists, and functional evaluations were conducted using the AOFAS scoring system at the last follow-up.

Tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and anterior tibiofibular ratio (ATR) measurements were performed preoperatively and postoperatively at the latest follow-up. Measurements were conducted 1 cm above the tibia plafond, as described by Harper and Keller (Figure 2A,B) [6]. MCS was defined as the widest distance between the medial border of the talus and the lateral border of the medial malleolus on the AP views (Figure 2A,B) [7]. The ATFR was calculated as the ratio of the distance between the anterior tibial cortex and the anterior fibular cortex to the distance between the anterior tibial cortex and the posterior tibial cortex, as described by Croft et al. (Figure 3A,B and Figure 4) [8].

Statistical analyses were performed using SPSS version 25.0. Variables were assessed for normal distribution using the Shapiro–Wilk test. The descriptive statistics included the mean, standard deviation, median, minimum, and maximum values for quantitative variables and frequency and percentage for categorical variables. The Wilcoxon sign rank test was used to evaluate inter-observer and intra-observer differences for dependent variables that did not show a normal distribution. Intraclass correlation coefficient (ICC) statistics were used to assess the intra-observer and interobserver agreement for the TFCS, TFO, MCS, and ATFR measurements.

The intraclass correlation is an index comparing the variability within a group to the variability across groups. In this study, ICC was used for assessing the consistency or reproducibility of quantitative measurements made by different observers measuring the same quantity. ICC values range from 0 and 1, with values below 0.5 indicating poor reliability, values between 0.5 and 0.75 indicating moderate reliability, values between 0.75 and 0.9 indicating good reliability, and values above 0.9 indicating excellent reliability.

2.2. Sample Size and Power Analysis

To address the concern regarding sample size adequacy, a priori power analysis was conducted using G*Power software (version 3.1.9.7). For quantitative variables, assuming a medium effect size (Cohen’s d = 0.5), two-tailed t-test, α = 0.05, and power (1 − β) = 0.80, the required sample size was determined to be 34. For categorical variables, with an effect size (g) of 0.3, α = 0.05, and a desired power of 0.95, the required sample size was calculated as 35. Our final sample of 36 patients satisfied both conditions, confirming adequate statistical power for the study.

3. Results

Data from 36 patients (13 females, 36.11%; 23 males, 63.89%) were analyzed (

Table 1. Age and gender demographics.

	Mean ± SD	Median (Min–Max)
Age	50.56 ± 16.23	50.50 (23.00–82.00)
		N	%
Gender	Female	13	36.11%
	Male	23	63.89%
Total		36	100%

). The fracture type distribution was as follows: Weber type B, 23 patients (63.88%); Weber type B/C, 2 patients (5.56%); and Weber type C, 11 patients (30.56%) (

Table 2. Distribution of fracture pattern.

		n	%
Fracture pattern as per the Dennis Weber classification	B	23	63.88
	B-C	2	5.56
	C	11	30.56
Total		36	100%

). The mean follow-up period was 21.81 ± 24.51 months, with a median of9 months (range: 2.00–84.00). The mean AOFAS score was 91.08 ± 9.90, with a median score of 90.00 (range: 47.00–100.00) (

Table 3. The mean and median postoperative follow-up time and AOFAS score.

	Mean ± SD	Median (Min–Max)
Postoperative follow-up (month)	20.89 ± 24.93	8.50 (1.00–84.00)
Day	1757.42 ± 7104.58	229.00 (0.00–42,917)
AOFAS score	91.08 ± 9.90	90.00 (47.00–100.00)

).

Intra-observer and inter-observer agreement for TFCS, TFO, MCS, and ATFR were assessed using ICC values. Descriptive statistics, including mean ± standard deviation (SD), median (minimum–maximum), and ICC values were calculated for both Observer 1 and Observer 2.

Significant differences were observed for TFCS, TFO and MCS preoperatively between observers (p < 0.001). However, ATFR showed no significant difference (p = 0.132). ICC values ranged from0.983 to 0.999, indicating excellent inter-observer agreement across all preoperative parameters (

Table 4. Comparison of inter-rate agreement pre-operative and post-operative measurements.

		Observer	Mean ± SD	Median (Min–Max)	p *	ICC ** İnter Rater Agreement
Pre-op	TF_CS	1	0.61 ± 0.31	0.60 (0.00–1.19)	<0.001	0.998
		2	0.59 ± 0.30	0.58 (0.00–1.17)
Pre-op	TF- OVELP	1	0.40 ± 0.21	0.41 (0.02–0.88)	<0.001	0.996
		2	0.39 ± 0.24	0.40 (0.00–0.96)
Pre-op	MCS	1	0.79 ± 0.58	0.59 (0.44–2.75)	0.014	0.999
		2	0.78 ± 0.61	0.57 (0.39–2.88)
Pre-op	ATFR	1	0.31 ± 0.18	0.31 (0.00–0.67)	0.132	0.999
		2	0.35 ± 0.14	0.34 (0.11–0.65)
Post-op	TF_CS	1	0.41 ± 0.12	0.38 (0.18–0.70)	0.792	0.983
		2	0.40 ± 0.12	0.38 (0.19–0.64)
Post-op	TF- OVELP	1	0.68 ± 0.22	0.68 (0.09–1.24)	0.993	0.993
		2	0.68 ± 0.22	0.68 (0.10–1.10)
Post-op	MCS	1	0.31 ± 0.10	0.32 (0.00–0.56)	0.584	0.918
		2	0.33 ± 0.08	0.31 (0.19–0.55)
Post-op	ATFR	1	0.39 ± 0.07	0.39 (0.24–0.57)	0.494	0.473
		2	0.41 ± 0.10	0.41 (0.26–0.65)

*: p < 0.05 significant, Wilcoxon Sign Rank test and **: ICC; intraclass correlation coefficient, interrater agreement.

).

Postoperative Measurements

Most postoperative comparisons showed no significant inter-observer differences (p > 0.05). The ICC values remained high for TFCS, TFO and MCS. However, the inter-observer agreement for ATFR in the postoperative period was poor (ICC = 0.473) (Table 4). The findings indicate that inter-observer agreement was consistently high across both preoperative and postoperative measurements, with statistically significant differences in some preoperative parameters. Despite this, ATFR showed poor inter-observer reliability postoperatively.

Significant differences in TFCS, TFO, MCS, and ATFR were noted between preoperative and postoperative measurements for both observers (

Table 5. Comparison of intra-observer pre-operative and postoperative measurements.

		Observer	Mean ± SD	Median (Min–Max)	p *	ICC **
						Intra-Observer
Pre-op	TF_CS	1	0.61 ± 0.31	0.60 (0.00–1.19)	0.003	−0.051 a
Post-op			0.41 ± 0.12	0.38 (0.18–0.70)
Pre-op	TF- OVELP	1	0.40 ± 0.21	0.41 (0.02–0.88)	<0.001	0.355
Post-op			0.68 ± 0.22	0.68 (0.09–1.24)
Pre-op	MCS	1	0.79 ± 0.58	0.59 (0.44–2.75)	<0.001	0.07
Post-op			0.31 ± 0.10	0.32 (0.00–0.56)
Pre-op	ATFR	1	0.31 ± 0.18	0.31 (0.00–0.67)	0.017	0.142
Post-op			0.39 ± 0.07	0.39 (0.24–0.57)
Pre-op	TF_CS	2	0.59 ± 0.30	0.58 (0.00–1.17)	0.004	−0.178
Post-op			0.40 ± 0.12	0.38 (0.19–0.64)
Pre-op	TF- OVELP	2	0.39 ± 0.24	0.40 (0.00–0.96)	<0.001	0.482
Post-op			0.68 ± 0.22	0.68 (0.10–1.10)
Pre-op	MCS	2	0.78 ± 0.61	0.57 (0.39–2.88)	<0.001	0.048
Post-op			0.33 ± 0.08	0.31 (0.19–0.55)
Pre-op	ATFR	2	0.35 ± 0.14	0.34 (0.11–0.65)	0.035	0.389
Post-op			0.41 ± 0.10	0.41 (0.26–0.65)

*: p <0.05 significant, Wilcoxon Sign Rank test; **: ICC; intraclass correlation coefficient, intra-observer A. ICC can become negative when the within-groups variance exceeds the between-groups variance; it can be accepted as poor reliability.

). However, the ICC values for TFCS were negative, and those for TFO, MCS, and ATFR were poor. While preoperative and postoperative measurements exhibited statistically significant differences across most parameters, the ICC values indicate varying degrees of intra-observer reliability, ranging from poor to moderate. In particular, TFCS and MCS had negative or near-zero ICC values (Table 5).

It is important to note that ICC values comparing pre- and postoperative measurements may inherently appear low due to the expected directional changes resulting from successful syndesmotic reduction.

Across all observers and outcome measures—TFCS, tibiofibular overlap, MCS, ATFR, and AOFAS score—there were no statistically significant differences between Weber Type B and Type C fractures.

There is no statistically significant difference in AOFAS scores between Weber Type B and Weber Type C fractures (p = 0.780) (See

Table 6. Postoperative changes in key radiologic measurements.

Parameter	Test Used	p-Value
AOFAS_Score	Mann–Whitney U	0.7802
ΔTFCS_1	Mann–Whitney U	0.5531
ΔTFCS_2	Mann–Whitney U	0.6466
ΔTbFO_1	Mann–Whitney U	0.8329
ΔTbFO_2	Mann–Whitney U	0.7516
ΔMCS_1	Mann–Whitney U	0.4358
ΔMCS_2	Mann–Whitney U	0.456
ΔATFR_1	T-test	0.1822
ΔATFR_2	T-test	0.6022
ΔMCS_1	Mann–Whitney U	0.4358
ΔMCS_2	Mann–Whitney U	0.456
ΔATFR_1	T-test	0.1822
ΔATFR_2	T-test	0.6022

TFCS: Tibiofibular clear space, TbFO: tibiofibular overlap, MCS: medial clear space, ATFR: anteroposterior tibiofibular ratio. Statistical significance was assessed using the Mann–Whitney U test or independent T-test where appropriate (α = 0.05).

).

This suggests that despite radiographic differences, functional outcomes (AOFAS) were comparable between the two fracture types in our patient cohort.

The table presents a comprehensive statistical evaluation of postoperative changes in key radiologic measurements (TFCS, tibiofibular overlap, MCS, ATFR) and the AOFAS functional outcome score stratified by fracture patterns (Weber Type B vs. C). Observer-specific changes are analyzed independently. Statistical significance was assessed using the Mann–Whitney U test or an independent T-test where appropriate (α = 0.05).

4. Discussion

This study assessed the mid-term radiological and clinical outcomes of surgical treatment for Weber type B/C lateral malleolar fractures (with or without medial malleolar involvement) with syndesmotic disruption. Diagnosing syndesmotic injuries, evaluating reduction and mal-reduction, and radiologically assessing adequate reduction remain significant challenges for orthopedic surgeons, due to the lack of a gold standard and inconsistent results across radiologic measurements [4,9,10,11].

The effectiveness of weight-bearing X-rays compared to non-weight-bearing X-rays in accurately detecting syndesmotic injuries has been highlighted in the literature [12]. Weight bearing transmits up to 17% of stress on the distal fibula [13,14], which subsequently transfers strain to the syndesmosis. This suggests that weight-bearing radiographs may offer more physiologically accurate assessments of syndesmotic ligament integrity by better demonstrating tibiofibular widening than a non-weight-bearing position [12,15,16].

However, in the case of a fractured ankle, obtaining weight-bearing radiographs appears impractical due to intolerable pain throughout the preoperative and early postoperative phases.

However, some studies present conflicting findings, asserting that weight bearing has a minimal effect on the distal tibiofibular syndesmosis. Experimental studies have suggested that weight bearing has little effect on the three-dimensional(3D) properties of the distal tibiofibular joint (DTFJ) when syndesmotic ligaments are intact [17]. In another investigation, the anatomy and rotational dynamics of the DTFJ were analyzed under physiological weight-bearing conditions, using weight-bearing cone beam computed tomography (WBCT) in 32 healthy subjects. The results showed that, in the neutral loaded ankle, the fibula was anteriorly positioned in the tibial incisura in 88% of cases. The mean antero-posterior motion was 1.5 mm, with a mean fibular rotation of 3 degrees during ankle rotation. No significant changes in tibiofibular clear space were observed between internal and external rotation [18].

Other research supporting non-weight-bearing radiographs has shown that the TFCS is a reliable indicator, as it remains consistent regardless of rotational changes [19,20,21,22,23]. Classical parameters such as TFCS, TFO, and MCS, as described by Harper and Keller, were employed in this study [6].

Proportional measurements obtained from lateral radiographs have also been proposed as being more informative for identifying syndesmotic separation than traditional AP/mortise radiographs [8,23,24,25,26,27]. Consequently, the ATFR was incorporated into this study to provide additional diagnostic precision. This study examined classical parameters (TFCS, TFO, MCS) and the sagittal plane parameter (ATFR) to evaluate three cortical syndesmotic screw fixation methods for syndesmotic injuries involving the lateral malleolus (with or without medial malleolar involvement) during midterm follow-up, which yielded successful clinical and radiologic outcomes.

A contentious issue in syndesmotic fixation is whether involving three or four cortices yields superior outcomes. No statistically significant clinical or radiological differences between the two methods are reported in the majority of cadaverbiomechanical and clinical studies [28,29,30,31,32,33]. However, three studies favored three cortices [34,35,36], while two favored four cortices [37,38]. Based on these findings, the three-cortex fixation method was considered effective and feasible for this study.

Karapınar et al. [35] demonstrated that four-cortex syndesmotic screw fixation is significantly associated with a higher incidence of tibiofibular syndesmosis obliteration, a finding that may adversely affect physiological joint mobility. In contrast, three-cortex fixation was shown to better preserve the syndesmotic space, thereby permitting natural micromotion of the distal tibiofibular joint. This approach is considered more anatomical and biomechanically favorable. These results support the selective use of three-cortex fixation as a means to prevent long-term syndesmotic fusion and to maintain the functional kinematics of the ankle joint.

The literature presents a nuanced perspective regarding the use of syndesmotic screw (SS) fixation compared to suture endo-button (SB) systems [39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58]. Several randomized controlled trials and meta-analyses suggest that SB fixation may offer certain clinical advantages, including earlier return to weight bearing, reduced reoperation rates, and improved functional scores in some cohorts [39,40,44,45,55]. For example, Xie et al. and Laflamme et al. reported significantly higher AOFAS scores and reduced complication rates with SB fixation [40,43], while Gan et al. and Migliorini et al. demonstrated better functional outcomes and fewer postoperative complications in favor of dynamic fixation methods [53,55].

Despite these findings, multiple studies have reported no significant differences in functional or radiological outcomes between SB and SS fixation methods [41,42,44,46,48,51]. Ræder et al. and Lehtola et al., in randomized trials with two-year and six-year follow-ups, respectively, concluded that both methods were comparable in maintaining syndesmotic reduction and achieving satisfactory long-term function [41,46].

Syndesmotic screw fixation remains a widely utilized and cost-effective technique, particularly in settings where implant removal is not considered burdensome. When anatomical reduction is properly achieved, SS fixation has been shown to provide radiographically stable and functionally effective outcomes across mid- to long-term follow-up periods [41,46]. Furthermore, biomechanical studies such as that by Gräff et al. highlighted the superior joint surface contact area and mechanical strength of screw fixation constructs compared to suture-button systems [54].

However, growing clinical experience underscores certain limitations of syndesmotic screw fixation, including risks of mal-reduction, hardware breakage, and the requirement for secondary surgery. These limitations have contributed to the rising popularity of flexible fixation methods, particularly for athletic or high-demand patients [44,51,52].

Therefore, while suture endo-button systems are increasingly favored for their capacity to allow physiological micromotion and avoid hardware removal, syndesmotic screw fixation remains a valid and effective option. The optimal choice between dynamic and static fixation should be individualized based on patient characteristics, fracture complexity, functional expectations, economic considerations, and surgeon expertise.

Although extensive research has been conducted on Weber type B/C lateral malleolus fractures with or without medial malleolar involvement (associated with syndesmosis rupture), relatively few studies have specifically addressed the clinical and radiographic outcomes of three-cortex syndesmotic screw fixation for these injuries. Moreover, many existing studies lack rigorous radiological assessment criteria, particularly sagittal plane parameters, and fail to account for inter- and intra-observer reliability [59,60].

This study addressed these gaps by incorporating sagittal plane parameters and assessing inter-and intra-observer reliability. Postoperative evaluations revealed low inter-observer agreement for ATFR, which was likely due to variations in measuring the plate’s shadow on lateral radiographs. In contrast, preoperative inter-observer agreement for TFCS, TFO, MCS, and ATFR was strong, indicating exceptional consistency across the observers for all parameters.

Intra-observer comparisons of preoperative and postoperative measurements across all parameters yielded low or negative ICC values. This finding should not be interpreted as an indication of measurement inconsistency or error. Rather, it reflects the expected and intended directional shift in radiological parameters following successful surgical reduction in the syndesmosis. The marked postoperative changes in TFCS, TFO, MCS, and ATFR are indicative of restored alignment and ligamentous stability, which inherently limits the intra-subject reproducibility of measurements taken across distinct pre- and postoperative conditions.

Statistical analysis identified significant differences in TFCS, TFO, MCS, and ATFR between preoperative and postoperative measurements, suggesting the effective reduction and stabilization of the distal fibula in the fibular incisura, as well as ligamentous healing at final follow-up.

Gardner et al. conducted a study to assess the accuracy of standard postoperative radiographic assessments in detecting syndesmotic mal-reduction in ankle fractures, using computed tomography (CT) as the reference standard. In a cohort of 25 operatively treated patients, CT imaging identified syndesmotic mal-reduction in 52% of cases, whereas plain radiographs detected abnormalities in only 24%, corresponding to a sensitivity of just 31%. Notably, the majority of mal-reductions involved posterior translation of the fibula, which was not reliably visualized on standard radiographs. These findings underscore the limitations of conventional imaging in accurately evaluating syndesmotic reduction and highlight the value of intraoperative precision and, when appropriate, advanced imaging modalities. While we concur with the authors regarding the diagnostic superiority of CT, routine use is not adopted in our practice due to the considerations of cost, radiation exposure, and resource availability. Instead, postoperative CT is reserved for cases with clinical concern or questionable reduction on follow-up radiographs [5].

Despite the advantages of advanced imaging modalities like computed tomography (CT) and magnetic resonance imaging (MRI) [61,62,63,64], their clinical application during the postoperative routine follow-up is limited by implant artifacts, radiation exposure, and high costs, making standard AP/lateral radiographs a practical alternative.

5. Conclusions

This study demonstrates that standard AP/lateral radiographs, which are widely used in clinical practice, provide reliable and reproducible parameters for evaluating syndesmotic reduction, stabilization, and healing. Three-cortex fixation for syndesmotic separation in Weber type B/C lateral malleolus fractures (with or without medial malleolar involvement) yielded excellent mid-term radiological and functional results.

6. Limitations

This study has several limitations that should be acknowledged. First, the absence of postoperative comparative measurements with the contralateral (uninjured) ankle may slightly limit the precision of side-to-side radiographic evaluation. Second, the lack of a comparative surgical treatment group prevents a more comprehensive analysis of the relative efficacy of different fixation techniques. Third, the retrospective and observational nature of the study may introduce inherent selection and measurement biases; however, efforts were made to standardize radiographic assessment protocols and minimize variability.