The surgical repair of transmalleolar fractures commonly involves reduction and internal fixation of the boney injuries. In the absence of extreme syndesmotic disruptions, little attention has been given in the recent literature to the role of the syndesmosis in general or to the anterior inferior tibiofibular ligament (AITFL) in particular in preserving the stability of the ankle mortise. In this paper, the author describes a surgical approach to evaluate and repair AITFL ligament injuries in transmalleolar ankle fractures. A significant portion of these injuries are associated with an avulsion of the tibial or fibular insertion resulting in an intra-articular fracture in the distal tibiofibular joint which may not be apparent on plain x-rays. Direct visualization of the injury allows accurate assessment of the injury pattern and obviates the need for more costly imaging studies such as computed tomography and magnetic resonance imaging scans. Anatomic repair of the AITFL injury restores the stability of the ankle mortise and improves the stability of the bone repair, allowing for early return to functional exercises and activities. Syndesmotic screw fixation of transmalleolar ankle fractures was not necessary when the AITFL was repaired directly by the techniques described.

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