Relevance of posterior malleolar fracture fixation to ankle syndesmotic reduction, a comparative study


  • Amr Elshahhat Department of Orthopedic Surgery, Mansoura University, Mansoura, Egypt
  • Khaled Youssef Department of Orthopedic Surgery, Mansoura University, Mansoura, Egypt
  • Mohammed Elkasaby Department of Orthopedic Surgery, Mansoura University, Mansoura, Egypt
  • Osama Samir Gaarour Department of Orthopedic Surgery, Mansoura University, Mansoura, Egypt



Syndesmosis, Radiological, Computed tomography, Posterior malleolus


Background: Appropriate distal tibiofibular syndesmotic reduction is crucial to restore ankle stability, guard against future arthrosis with worse functional outcome. Optimal technique for syndesmotic reduction has been a matter of debate. This study aimed at radiological evaluation of syndesmotic integrity following two methods of reduction (posterior malleolar fixation and trans-syndesmotic screw fixation), additionally, correlating the posterior malleolus size to the radiological results of both techniques.

Methods: Syndesmotic integrity was compared after each technique as per translational and rotational fibular positions. Utilizing, preoperative and postoperative computed tomography scans of injured ankle, the fibular antero-posterior and Medio-lateral translation distances were measured. Additionally, the fibular rotation angle was calibrated. Incidence of inadequate reduction in each group was reported. Preoperative and postoperative radiological findings were compared and correlated to posterior malleolus size in relation to tibial articular distance.

Results: A significant difference between both techniques was noted in term of fibular rotation. In patients with PM ˂ 10% of tibial articular surface, a significant difference was obvious in postoperative AP-translational and rotational findings between both techniques. Overall malreduction incidence rate of 68.9% was reported in this study, with 84.7% rate in patients managed with SS-fixation, whilst 51.2% rate in those managed via PM-fixation.

Conclusions: Posterior malleolar fixation could limit syndesmotic malreduction risk whatsoever it’s size. Approaching CT reference values for syndesmotic reduction might benefit preoperative planning and detect intraoperative malreduction. Further future clinical studies correlating these findings to clinical outcome would be more helpful.


Solan MC, Sakellariou A. Posterior malleolus fractures: worth fixing. Bone Joint J. 2017;99(11): 1413-9.

Wang X, Yin J, Zhang C, Wang C, Geng X, Ma X, et al. Biomechanical study of screw fixation and plate fixation of a posterior malleolar fracture in a simulation of the normal gait cycle. Foot Ankle Int. 2017;38(10):1132-8.

Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res. 2006;447:165-71.

Sagi HC, Shah AR, Sanders RW. The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up. J Orthopaed Trauma. 2012;26(7):439-43.

Cherney SM, Cosgrove CT, Spraggs-Hughes AG, McAndrew CM, Ricci WM, Gardner MJ. Functional outcomes of syndesmotic injuries based on objective reduction accuracy at a minimum 1-year follow-up. J Orthopaed Trauma. 2018;32(1):43-51.

Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006; 27(10):788-92.

Harper MC, Keller TS. A radiographic evaluation of the tibiofibular syndesmosis. Foot Ankle Int. 1989;10(3):156-60.

Weber BG, Simpson LA. Corrective lengthening osteotomy of the fibula. Clin Orthop Relat Res. 1985;199:61-7.

Shah AS, Kadakia AR, Tan GJ, Karadsheh MS, Wolter TD, Sabb B. Radiographic evaluation of the normal distal tibiofibular syndesmosis. Foot Ankle Int. 2012;33(10):870-6.

Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am. 2006;88(5):1085-92.

Sora MC, Strobl B, Staykov D, Förster-Streffleur S. Evaluation of the ankle syndesmosis: a plastination slices study. Clin Anat. 2004;17(6):513-7.

Nault ML, Hébert-Davies J, Laflamme GY, Leduc S. CT scan assessment of the syndesmosis: a new reproducible method. J Orthopaed Trauma. 2013; 27(11):638-41.

Baca E, Ziroğlu NJEAoMR. Fixation of Posterior Malleolus is Enough for Syndesmotic Stability: Fact or Fiction?. 2020;36(4):239-45.

Mukhopadhyay S, Metcalfe A, Guha AR, Mohanty K, Hemmadi S, Lyons K, et al. Malreduction of syndesmosis--are we considering the anatomical variation? Injury. 2011;42(10):1073-6.

Schon JM, Brady AW, Krob JJ, Lockard CA, Marchetti DC, Dornan GJ, et al. Defining the three most responsive and specific CT measurements of ankle syndesmotic malreduction. Knee Surg Sports Traumatol Arthroscop. 2019;27(9):2863-76.

Kalem M, Şahin E, Songür M, Keser S, Kinik H. Comparison of three posterior malleolar fixation methods in trimalleolar ankle fractures. Acta Orthopaed Belgica. 2018;84(2):203-12.

Elgafy H, Semaan HB, Blessinger B, Wassef A, Ebraheim NA. Computed tomography of normal distal tibiofibular syndesmosis. Skeletal Radiol. 2010;39(6):559-64.

Lepojärvi S, Pakarinen H, Savola O, Haapea M, Sequeiros RB, Niinimäki J. Posterior translation of the fibula may indicate malreduction: CT study of normal variation in uninjured ankles. J Orthopaed Trauma. 2014;28(4):205-9.

Anand PA. Syndesmotic stability: Is there a radiological normal?-A systematic review. Foot a Ankle Surg. 2018;24(3):174-84.

Abdelaziz ME, Hagemeijer N, Guss D, El-Hawary A, El-Mowafi H, DiGiovanni CW. Evaluation of Syndesmosis Reduction on CT Scan. Foot Ankle Int. 2019;40(9):1087-93.

Veltman ES, Halma JJ, de Gast A. Longterm outcome of 886 posterior malleolar fractures: A systematic review of the literature. Foot Ankle Surg. 2016;22(2):73-7.

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(1):279-84.

Bartoníček J, Rammelt S, Tuček M. Posterior Malleolar Fractures: Changing Concepts and Recent Developments. Foot Ankle Clinics. 2017;22(1):125-45.

Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma. 1989;29(11):1565-70.






Original Research Articles