Posterior Malleolus Fractures in Trimalleolar Ankle Fractures: Malleolus versus Transyndesmal Fixation

Bilgehan Tosun, Ozgur Selek, Umit Gok, Halil Ceylan, Bilgehan Tosun, Ozgur Selek, Umit Gok, Halil Ceylan

Abstract

Background: In ankle fractures involving the posterior malleolus, the issue of which types of fractures require posterior malleolus fixation is still controversial. Recent studies have demonstrated that trimalleolar fractures adversely affect the functional outcomes in comparison to bimalleolar fractures of the lateral and medial malleolus. The purpose of this study was to assess the effects of posterior malleolus fixation on the functional and radiological outcomes.

Materials and methods: Reduction quality, development of posttraumatic ankle osteoarthritis, and functional outcomes in 49 consecutive trimalleolar ankle fractures were evaluated retrospectively in patients with and without posterior malleolus fixation. Group I consisted of 29 patients, in which posterior malleolar fracture was left untreated. Twenty patients in Group II, posterior malleolar fragment was fixed directly by screws alone or plate screw. Twenty-one of these 49 patients were male (43%). The mean age was 47 years (range 20-82 years).

Results: The mean followup was 12 to 51 months with a mean of 15 months (range 12-51 months). Statistically significant differences were found between Group I and Group II in terms of ankle arthrosis. American Orthopaedic Foot and Ankle Society score was significantly lower in Group I compared to Groups II.

Conclusions: These results demonstrate that posterior malleolar fracture fixation is closely related to successful radiological and functional outcomes after trimalleolar fractures. Transyndesmal screw fixation may not be needed in the cases where the posterior malleolar fracture fixated. For these reasons, we recommend that all posterior malleolar fractures have to be fixed regardless of size.

Keywords: Ankle fracture; Ankle joint; ankle injuries; fracture fixation; malleolar fracture; posterior malleolus; posterolateral approach.

Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
(a) Preoperative sagittal computed tomography scan showing posterior malleolar fracture with displacement. (b) Early postoperative anteroposterior and lateral radiographs of ankle joint showing that medial malleolus fixed with tensions band wiring lateral malleolus with plate. One syndesmotic screw is also seen. But the posterior fragment is left alone (Group 1). (c) Anteroposterior and lateral radiographs of ankle joint showing degenerative arthritis at 3 years followup
Figure 2
Figure 2
Group II - (a) Sagittal computed tomography scan showing a posterior malleolar fragment >25% of the articular surface with displacement. (b) Transverse view of computed tomograph scan showing a large posterolateral fragment of the tibial plafond. (c) Anteroposterior and lateral radiographs of ankle joint, 1 year after surgery showing anatomically reduced posterior fragment. Lag screws were used to fix the posterior malleolus

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