Introduction: Trimalleolar ankle fractures have a worse prognosis than other ankle fractures and are in most cases associated with other injuries. Adequate reduction is the key to restoring ankle function. Four percent of the syndesmosis may remain unstable due to poor reduction or interposed structures. The objective of this paper is to study the incidence and epidemiology of syndesmotic loose bodies in trimalleolar ankle fractures.
Materials and methods: Thirty-nine trimalleolar ankle fractures were retrospectively studied. Radiographs and computed tomography (CT) were performed. Fractures were classified according to Weber/Arbeitsgemeinschaft für Osteosynthesefragen (AO), and posterior malleolar fractures were classified according to Haraguchi and Bartoníček/Rammelt.
Inclusion criteria: Adult patients with acute trimalleolar ankle fractures treated by the same surgical team were included. Pathological fractures and patients treated by another team were excluded. Age, sex, laterality, and the presence of loose syndesmotic bodies were documented. Student's t-test and Chi-squared tests were performed to analyze the statistical relationship between the studied variables.
Results: Seven patients were men and 32 were women, with a mean age of 60 years (range 25–98 years). We found 33 B3 fractures (45%) of which were associated with loose bodies. There were only six C2 fractures, and two of them were associated with loose bodies (33%) (p = 0.0004). There were significant differences in the distribution by sex for the presence of syndesmotic loose bodies. The incidence is 57% for males and 41% for females. No association between loose bodies and Haraguchi or Bartoníček/Rammelt types was found. All loose bodies were visible on CT, and only two cases on X-ray.
Conclusion: The incidence of loose bodies in the series studied is 43.5%. Syndesmotic loose bodies are statistically associated with B3 fractures. The statistical incidence is higher in men. Performing CT scans on all trimalleolar fractures is mandatory. Level of evidence—IV.
Rammelt S, German J, Guillermo A, et al. Quadrimalleolar fractures of the ankle: think 360°—a step-by-step guide on evaluation and fixation. J Foot Ankle Surg (Asia Pac) 2021;8(4):193–200. DOI: 10.5005/jp-journals-10040-1199
Rammelt S, Kroker L, Neumann AP. Quadrimalleolar fractures of the ankle: principles and medium-term results of surgical fixation. Foot Ankle Orthop 2022;7(1):2473011421S0041. DOI: 10.1177/2473011421S00410
Rammelt S, Obruba P. An update on the evaluation and treatment of syndesmotic injuries. Eur J Trauma Emerg Surg 2015;41(6):601–614. DOI: 10.1007/s00068-014-0466-8
Rammelt S, Bartoníček J, Kroker L, et al. Surgical fixation of quadrimalleolar fractures of the ankle. J Orthop Trauma 2021;35(6):e216–e222. DOI: 10.1097/BOT.0000000000001915
Martin KD, Tripp CT, Huh J. Outcomes of posterior arthroscopic reduction and internal fixation (PARIF) for the posterior malleolar fragment in trimalleolar ankle fractures. Foot Ankle Int 2021;42(2):157–165. DOI: 10.1177/1071100720955149
Mueller E, Kleinertz H, Tessarzyk M, et al. Intercalary fragments in posterior malleolar fractures: incidence, treatment implications, and distribution within CT-based classification systems. Eur J Trauma Emerg Surg 2023;49(2):851–858. DOI: 10.1007/s00068-022-02119-2
Xie W, Lu H, Xu H, et al. Morphological analysis of posterior malleolar fractures with intra-articular impacted fragment in computed tomography scans. J Orthop Traumatol 2021;22(1):52. DOI: 10.1186/s10195-021-00615-6
Bartoníček J, Rammelt S, Tuček M, et al. Posterior malleolar fractures of the ankle. Eur J Trauma Emerg Surg 2015;41(6):587–600. DOI: 10.1007/s00068-015-0560-6
Haraguchi N, Haruyama H, Toga H, et al. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg 2006;88(5):1085–1092. DOI: 10.2106/JBJS.E.00856
Sultan F, Zheng X, Pan Z, et al. Characteristics of intercalary fragment in posterior malleolus fractures. Foot Ankle Surg 2020;26(3):289–294. DOI: 10.1016/j.fas.2019.03.011
Thordarson DB, Bains R, Shepherd LE. The role of ankle arthroscopy on the surgical management of ankle fractures. Foot Ankle Int 2001;22(2):123–125. DOI: 10.1177/107110070102200207
Howard S, Hoang V, Sagers K, et al. Identifying intra-articular pathology with arthroscopy prior to open ankle fracture fixation. Arthrosc Sports Med Rehabil 2021;3(1):e177–e181. DOI: 10.1016/j.asmr.2020.08.020
Chen XZ, Chen Y, Liu CG, et al. Arthroscopy-assisted surgery for acute ankle fractures: a systematic review. Arthroscopy 2015;31(11):2224–2231. DOI: 10.1016/j.arthro.2015.03.043
Takao M, Ochi M, Naito K, et al. Arthroscopic diagnosis of tibiofibular syndesmosis disruption. Arthroscopy 2001;17(8):836–843. DOI: 10.1016/s0749-8063(01)90007-6
Braunstein M, Baumbach SF, Urresti-Gundlach M, et al. Arthroscopically assisted treatment of complex ankle fractures: intra-articular findings and 1-year follow-up. J Foot Ankle Surg 2020;59(1):9–15. DOI: 10.1053/j.jfas.2019.05.003
Palmanovich E, Brin YS, Laver L, et al. The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures. Int Orthop 2014;38(5):1051–1056. DOI: 10.1007/s00264-013-2224-7
Kumar A, Mishra P, Tandon A, et al. Effect of CT on management plan in malleolar ankle fractures. Foot Ankle Int 2018;39(1):59–66. DOI: 10.1177/1071100717732746
