https://doi.org/10.1177/1071100717716487 Foot & Ankle International® 1–6 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1071100717716487 journals.sagepub.com/home/fai Technique Tip Introduction Surgeons are increasingly using alternatives to traditional screws for syndesmostic stabilization such as suture-button devices. The clinical effectiveness of suture-button devices to stabilize the distal tibia-fibula articulation with a decreased incidence of iatrogenic syndesmotic malreduc- tion has already been demonstrated. 17 Additionally, biome- chanical cadaveric studies have compared such devices to metal screws and have generally shown clinically equiva- lent results when placed in an anatomic plane. 3,5,6,10,13 Despite this, the suture-button device may not be appropri- ate for all injuries to the syndesmosis. A fundamental principle in the operative management of ankle fractures with associated syndesmotic injury is to first restore fibular length/rotation and then correct syndesmotic alignment. Several studies have demonstrated altered joint contact pressures and kinematics when fibular length was not restored. 2,8,9,14-16 This correction is most commonly achieved by direct reduction and internal fixation at the fracture site. 1 However, for many higher fibula fractures, plate fixation at the fracture site is usually not performed and length/rotation can be restored indirectly by syndes- motic fixation alone. 7,11 Although a metal screw is rigid and resists bending and torsional forces in a multidirectional manner, a suture-button acts by resisting tension forces between the 2 buttons with dramatically less inherent mate- rial rigidity. Furthermore, although the inner diameter of a metal screw is typically equal to or greater than the drill tunnel used, suture-buttons do not fill the drill tunnel used to pass the device. Therefore, unlike a metal screw, a suture- button device is subject to translation within the drill tunnel. Although multiple biomechanical cadaveric studies have been performed, to our knowledge all relied on syndesmotic disruption in the setting of a length-stable fibular model and did not evaluate the implant’s ability to resist fibular shortening. 3,5,6,10,13,17 As such, for potentially axially unstable fibula fractures (ie, Weber C, Maisonneuve-type injuries with shortening) the suture-button device may be suboptimal if used alone. 1 The purpose of this article is to highlight this potential tech- nical limitation of suture-button devices and demonstrate a novel, minimally invasive solution when encountered. Case Description Case 1 A 27-year-old male semiprofessional football player pre- sented for evaluation of a left ankle fracture-dislocation after suffering a twisting injury. He had presented to an outside institution where closed reduction and casting of the injury had been performed. Postreduction imaging obtained at our center demonstrated a Weber C fibular fracture consistent with an axially unstable Maisonneuve injury (Figure 1). Case 2 A 20-year-old woman presented for evaluation of her left ankle injury 2 days after suffering a twisting injury while roller skating. Imaging demonstrated a Weber C fibula frac- ture with medial clear space widening on stress view radio- graph consistent with an unstable Maisonneuve injury (Figure 2). 716487FAI XX X 10.1177/1071100717716487Foot & Ankle InternationalRiedel et al research-article 2017 1 Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA, USA 2 Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA Corresponding Author: Matthew D. Riedel, MD, Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit Street, St. 535, Boston, MA 02114, USA. Email: mdriedel@partners.org Augmenting Suture-Button Fixation for Maisonneuve Injuries with Fibular Shortening: Technique Tip Matthew D. Riedel, MD 1 , Christopher P. Miller, MD 2 , and John Y. Kwon, MD 2 Level of Evidence: Level V, case report and clinical tip. Keywords: trauma, maisonneuve injury, ankle fracture, malreduction, fixation options