Background: Syndesmotic instability is a significant concern in the management of unstable ankle fractures, occurring
in approximately 10% to 13% of these cases. Early recognition and stabilization of syndesmotic injuries are essential to
ensure optimal long-term outcomes. Several techniques are currently in use, often involving complex procedure and/or
costly devices. Our study presents a syndesmosis fixation technique using K-wires that is both simple and cost-effective.

Methods: This is a retrospective single-center case series. Three hundred seventy-seven ankle fractures with intraoperative
syndesmosis instability and subsequent syndesmosis fixation with a K-wire were treated between 2002 and 2012. Of the
377 patients, 51 died and we were able to obtain long-term questionnaire completions from 94 patients (29% of presumed
living patients), with a mean follow-up of 10.6 ± 3.0 years.

Results: The mean age was 46.6 ± 18.5 years; 42% were Danis-Weber type B and 58% type C fractures. Syndesmosis
fixation failure was observed in 9 (2%) patients, and 5 (1%) patients had K-wire displacement without loss of syndesmosis
reduction. The Manchester-Oxford Foot Questionnaire (MOXFQ) was obtained 10±3 years after surgery. The mean
MOXFQ pain score was 25.9 ± 25.4, the mean functional score was 18 ± 24.8, and the mean social score was 13.7 ± 22.2.

Conclusion: We report long-term (10.6 ± 3 years) functional outcomes using a validated patient-reported questionnaire
in patients who underwent syndesmosis fixation with 2 K-wires for unstable ankle fractures. In the subset of patients we
were able to find in follow-up, we found low rates of syndesmosis fixation failure, low pain scores, and excellent functional
outcomes. The availability and low cost of these implants make this technique an accessible and cost-effective solution to
consider for syndesmosis fixation.

Level of Evidence: Level IV, retrospective case series.