The posterior inferior tibiofibular ligament is the strongest syndesmotic ligament, connecting the posterior tibial malleolus to the posterior fibula. Its deep portion forms the transverse ligament — the posterior ankle labrum.
Primary posterior syndesmotic stabiliser resisting posterior fibular displacement and talar external rotation. Its deep transverse portion deepens the tibiotalar joint posteriorly.
The last syndesmotic structure to fail — its disruption indicates complete instability requiring surgical fixation. Avulsion from the posterior tibial malleolus produces the posterior malleolar fracture.
PITFL tibial attachment avulsion producing the posterior malleolus, requiring fixation when displaced beyond 25% of the articular surface.
All three syndesmotic ligaments ruptured producing fibular diastasis, requiring screw or TightRope fixation.
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