Clinical Orthopaedics and Related Research®

, Volume 468, Issue 4, pp 1129–1135 | Cite as

Posterior Malleolar Stabilization of Syndesmotic Injuries is Equivalent to Screw Fixation

  • Anna N. MillerEmail author
  • Eben A. Carroll
  • Robert J. Parker
  • David L. Helfet
  • Dean G. Lorich
Clinical Research



To confirm this observation we compared the Foot and Ankle Outcome Score (FAOS) and radiographic maintenance of fixation for fractures treated through direct posterior malleolar fixation versus syndesmotic screw fixation.


We prospectively followed 31 one patients with unstable ankle fractures treated with (1) open posterior malleolus fixation whenever the posterior malleolus was fractured, regardless of fragment size (PM group; n = 9); (2) locked syndesmotic screws in the absence of a posterior malleolar fracture (S group; n = 14); or (3) combined fixation in fracture-dislocations and more severe soft tissue injury (C group; n = 8). All patients had preoperative MRI confirming syndesmotic injury and an intact PITFL; postoperative and followup radiographs were evaluated for syndesmotic congruence. The minimum followup was 12 months (mean, 15 months; range, 12–31 months).


Postoperative and followup FAOS scores were similar in the three groups. The tibiofibular clear space was greater in the S versus the PM group, but we found no other differences in the postoperative versus followup measurements between the PM, S, and C groups.


Syndesmotic fixation through the posterior malleolus and PITFL is maintained at followup, and these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation.

Level of Evidence

Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


Ankle Fracture Clear Space Syndesmotic Injury Posterior Malleolus Syndesmotic Screw 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Dr. Stephen Lyman for work on the statistical portion of our study and Omesh Paul for assistance with data collection.


  1. 1.
    Ali MS, McLaren CA, Rouholamin E, O’Connor BT. Ankle fractures in the elderly: nonoperative or operative treatment. J Orthop Trauma. 1987;1:275–280.CrossRefPubMedGoogle Scholar
  2. 2.
    Bauer M, Jonsson K, Nilsson B. Thirty-year follow-up of ankle fractures. Acta Orthop Scand. 1985;56:103–106.PubMedCrossRefGoogle Scholar
  3. 3.
    Beumer A, van Hemert WL, Niesing R, Entius CA, Ginai AZ, Mulder PG, Swierstra BA. Radiographic measurement of the distal tibiofibular syndesmosis has limited use. Clin Orthop Relat Res. 2004;423:227–234.CrossRefPubMedGoogle Scholar
  4. 4.
    Brage ME, Bennett CR, Whitehurst JB, Getty PJ, Toledano A. Observer reliability in ankle radiographic measurements. Foot Ankle Int. 1997;18:324–329.PubMedGoogle Scholar
  5. 5.
    Burns WC 2nd, Prakash K, Adelaar R, Beaudoin A, Krause W. Tibiotalar joint dynamics: indications for the syndesmotic screw—a cadaver study. Foot Ankle. 1993;14:153–158.PubMedGoogle Scholar
  6. 6.
    Dattani R, Patnaik S, Kantak A, Srikanth B, Selvan TP. Injuries to the tibiofibular syndesmosis. J Bone Joint Surg Br. 2008;90:405–410.CrossRefPubMedGoogle Scholar
  7. 7.
    Ebraheim NA, Lu J, Yang H, Mekhail AO, Yeasting RA. Radiographic and CT evaluation of tibiofibular syndesmotic diastasis: a cadaver study. Foot Ankle Int. 1997;18:693–698.PubMedGoogle Scholar
  8. 8.
    Ebraheim NA, Mekhail AO, Gargasz SS. Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. Foot Ankle Int. 1997;18:513–521.PubMedGoogle Scholar
  9. 9.
    Forberger J, Sabandal PV, Dietrich M, Gralla J, Lattmann T, Platz A. Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity. Foot Ankle Int. 2009;30:309–314.CrossRefPubMedGoogle Scholar
  10. 10.
    Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165–171.CrossRefPubMedGoogle Scholar
  11. 11.
    Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006;27:788–792.PubMedGoogle Scholar
  12. 12.
    Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. The ability of the Lauge-Hansen classification to predict ligament injury and mechanism in ankle fractures: an MRI study. J Orthop Trauma. 2006;20:267–272.CrossRefPubMedGoogle Scholar
  13. 13.
    Harper MC. An anatomic and radiographic investigation of the tibiofibular clear space. Foot Ankle. 1993;14:455–458.PubMedGoogle Scholar
  14. 14.
    Hughes JL, Weber H, Willenegger H, Kuner EH. Evaluation of ankle fractures: non-operative and operative treatment. Clin Orthop Relat Res. 1979;138:111–119.PubMedGoogle Scholar
  15. 15.
    Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29:1565–1570.CrossRefPubMedGoogle Scholar
  16. 16.
    Kennedy JG, Soffe KE, Dalla Vedova P, Stephens MM, O’Brien T, Walsh MG, McManus F. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma. 2000;14:359–366.CrossRefPubMedGoogle Scholar
  17. 17.
    Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 1950;60:957–985.PubMedGoogle Scholar
  18. 18.
    Mast JW, Teipner WA. A reproducible approach to the internal fixation of adult ankle fractures: rationale, technique, and early results. Orthop Clin North Am. 1980;11:661–679.PubMedGoogle Scholar
  19. 19.
    Miller AN, Carroll EA, Parker RJ, Boraiah S, Helfet DL, Lorich DG. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int. 2009;30:419–426.CrossRefPubMedGoogle Scholar
  20. 20.
    Mont MA, Sedlin ED, Weiner LS, Miller AR. Postoperative radiographs as predictors of clinical outcome in unstable ankle fractures. J Orthop Trauma. 1992;6:352–357.CrossRefPubMedGoogle Scholar
  21. 21.
    Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, Lorich DG. Radiographic measurements do not predict syndesmotic injury in ankle fractures: an MRI study. Clin Orthop Relat Res. 2005;436:216–221.CrossRefPubMedGoogle Scholar
  22. 22.
    Ogilvie-Harris DJ, Reed SC, Hedman TP. Disruption of the ankle syndesmosis: biomechanical study of the ligamentous restraints. Arthroscopy. 1994;10:558–560.PubMedGoogle Scholar
  23. 23.
    Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am. 1983;65:667–677.PubMedGoogle Scholar
  24. 24.
    Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, Laros GS. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am. 1985;67:67–78.PubMedGoogle Scholar
  25. 25.
    Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am. 1976;58:356–357.PubMedGoogle Scholar
  26. 26.
    Roos EM, Brandsson S, Karlsson J. Validation of the foot and ankle outcome score for ankle ligament reconstruction. Foot Ankle Int. 2001;22:788–794.PubMedGoogle Scholar
  27. 27.
    Takao M, Uchio Y, Naito K, Fukazawa I, Kakimaru T, Ochi M. Diagnosis and treatment of combined intra-articular disorders in acute distal fibular fractures. J Trauma. 2004;57:1303–1307.CrossRefPubMedGoogle Scholar
  28. 28.
    Tornetta P III, Spoo JE, Reynolds FA, Lee C. Overtightening of the ankle syndesmosis: is it really possible? J Bone Joint Surg Am. 2001;83:489–492.PubMedGoogle Scholar
  29. 29.
    Tunturi T, Kemppainen K, Patiala H, Suokas M, Tamminen O, Rokkanen P. Importance of anatomical reduction for subjective recovery after ankle fracture. Acta Orthop Scand. 1983;54:641–647.PubMedCrossRefGoogle Scholar
  30. 30.
    van den Bekerom MP, Haverkamp D, Kloen P. Biomechanical and clinical evaluation of posterior malleolar fractures: a systematic review of the literature. J Trauma. 2009;66:279–284.CrossRefPubMedGoogle Scholar
  31. 31.
    Weening B, Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005;19:102–108.CrossRefPubMedGoogle Scholar
  32. 32.
    Yde J, Kristensen KD. Ankle fractures: supination-eversion fractures of stage IV: primary and late results of operative and non-operative treatment. Acta Orthop Scand. 1980;51:981–990.PubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2009

Authors and Affiliations

  • Anna N. Miller
    • 1
    Email author
  • Eben A. Carroll
    • 2
  • Robert J. Parker
    • 1
  • David L. Helfet
    • 1
  • Dean G. Lorich
    • 1
  1. 1.Hospital for Special SurgeryNew YorkUSA
  2. 2.Wake Forest University School of MedicineWinston-SalemUSA

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