Injuries to the tibiofibular syndesmosis are common, both as isolated injuries and as a component of rotational ankle fractures. Recent evidence suggests a high incidence of tibiofibular syndesmosis malreduction with poor clinical outcomes associated with syndesmotic malreduction. Despite the notable clinical consequences of malreduction and heightened awareness surrounding the issue of syndesmotic malreduction, intraoperative methods to assess the adequacy of syndesmotic reduction remain imperfect. Although postoperative axial computed tomographic (CT) scans are often used to assess the adequacy of syndesmotic reduction postoperatively, the routine use of intraoperative CT is limited by the availability of technology as well as the limited ability to perform side-by-side comparison with the uninjured ankle intraoperatively. Although more readily available for intraoperative assessment, fluoroscopy has consistently demonstrated shortcomings with respect to assessment of syndesmotic reduction. Although the literature clearly suggests that there is no perfect method to consistently obtain anatomic reduction of the syndesmosis, several intraoperative methods to optimize syndesmotic malreduction, including the importance of anatomic fracture fixation, open visualization of syndesmotic reduction, posterior inferior tibiofibular ligament repair or anatomic posterior malleolar fracture fixation, and deep deltoid ligament repair, have been suggested. The following will include a review of these concepts as well as relevant recent literature to provide a basis for improving methods to assess the adequacy of syndesmotic reduction intraoperatively.