analyses, from a comparative study published in Foot & Ankle International in 1997, suggest that screw fixation at 2 centimetres proximal to the tibiotalar joint line is also adequate. Biodegradable implants such as bioabsorbable screws, which do not require postoperative removal, may be used as an alternative to metallic hardware. However, biodegradable implants still limit rotation of the ankle and dorsiflexion of the foot. Non-operative treatment In cases where only the posterior ligaments of the tibiofibular syndesmosis are partially damaged, non-operative treatment such as long-leg casting for at least 6 weeks is recommended. Immobilisation techniques such as casting are often paired with non-weight bearing precautions. Gradually, physiotherapy rehabilitation programs allow patients to weight-bear after at least 8 weeks of postoperative casting. Orthopaedic surgeons also administer these non-operative treatments for cases where the medial malleolus remains intact. Operative treatment Open Reduction Internal Fixation (ORIF) Open-reduction surgery is typically not performed at the level of the proximal fibula, as dissection near the proximal end may risk severing the common peroneal nerve. Instead, reducing the proximal fibula at the level of the distal tibiofibular syndesmosis is recommended. A hook test is performed, using a curved hook, to assess the stability of the fibula. If instability is detected, further distraction of the fibula can be done to repair the full bone. The fibula can then be guided into the fibular notch located on the tibia, effectively restoring its length. Internal rotation of the foot may then be used to correct anatomical alignment. Following open-reduction, internal fixation is usually performed to stabilise the ankle mortise. To account for the distal fibula being slightly posterior to the distal tibia, drill holes are angled at 30° from the anteromedial aspect of the tibia to the posterolateral aspect of the fibula. Trans-syndesmotic screws can be inserted in this way to ensure tibia fixation. Additional supra-syndesmotic screws may be temporarily inserted, for approximately 3 to 6 months, if instability is still present after fibular reduction. To reduce the fibula and restore the ankle mortise to its proper anatomical configuration, partial dorsiflexion of the foot is maintained prior to intraoperative screw fixation. This is because, in a neutral or maximally dorsiflexed position of the foot, the trochlear surface of the talus may reduce maximal postoperative dorsiflexion due to rigidity after screw fixation. Assessing the severity of syndesmotic lesions can be performed with fluoroscopic screening. Guidance under fluoroscopy can also assist