Unilateral CT systematically overestimates syndesmotic malreduction: clinical implications of bilateral CT assessment after ankle fracture fixation

Background Bilateral computed tomography (CT) accounts for patient-specific anatomical variation in postoperative syndesmotic assessment, but unilateral CT remains common. Methods This retrospective single-center cohort study included 144 patients who underwent ankle fracture fixation with syndesmotic stabilization and postoperative bilateral low-dose CT. Paired unilateral and bilateral classifications based on validated CT criteria were compared using McNemar’s test. Results Classification differed in 21 of 144 cases (14.6%). Relative to bilateral assessment, unilateral CT overestimated malreduction in 17 cases (11.8%) and missed malreduction in 4 cases (2.8%). Interobserver agreement was substantial ( κ = 0.795). Conclusions Unilateral CT more often classified syndesmotic reduction as malreduced than bilateral CT. Bilateral low-dose CT may improve interpretation when revision surgery is being considered.