AO type C ankle fractures with additional posterior malleolus fragment: radiological and functional results of osseous reconstruction of the tibiofibular syndesmosis
In brief
Fixing posterior ankle fragments achieved anatomic syndesmosis alignment in 85% vs 29%
In this 26-patient prospective cohort, fixing the posterior malleolus fragment was associated with anatomical syndesmosis alignment in 85% of patients, compared with 29% without fixation. The fixation group also had better reported function, fewer stabilization screws and no complications versus 55% in the group without fixation; the small, nonrandomized study needs confirmation before changing practice.
- Journal
- European journal of orthopaedic surgery & traumatology : orthopedie traumatologie (Q1)
- Published
- 9 October 2026
- Study design
- Prospective / inception cohort
- Evidence level
- Level 2, Moderate (CEBM 2b)
- Authors
- Adriaan Laurens Franx, Floortje Huizing, Samuel Marinus Verhage, Pieta Krijnen, Inger Birgitta Schipper, Jochem Maarten Hoogendoorn
- PMID
- 42853318
- DOI
- 10.1007/s00590-026-04975-9
Why clinicians should know about it
- Picked for Anatomy (paper of the day, 10 October 2026): Posterior malleolus fixation improves syndesmosis outcomes
Abstract
PURPOSE: This study compares the syndesmosis congruity and functional outcomes after syndesmotic reconstruction by open reduction and internal fixation (ORIF) of posterior malleolar fractures (PMFs) sized > 5% versus no fixation in type C ankle fractures. METHODS: This multicenter prospective cohort study compared ORIF of PMFs (FIX) with no fixation (NO-FIX). Both groups underwent fibular and medial malleolus fixation according to AO principles, with trans-syndesmotic stabilization screws in case of instability. The primary outcome was syndesmotic alignment assessed on post-operative bilateral CT scans. The main secondary outcome measures were patient-reported functional outcome up to 1 year assessed with AAOS and OMAS questionnaires, and complications. RESULTS: 26 patients (17 FIX, 9 NO-FIX) were included, with a median PMF size of 20%. Syndesmotic stabilization with fib-tib screws was used in 6% of FIX vs 44% of NO-FIX (p = 0.03). Anatomical reduction (primary outcome) was achieved in 85% (FIX) versus 29% (NO-FIX, p = 0.02). AAOS and OMAS scores during follow-up were superior in FIX (linear mixed models, p < 0.01). The complication rate was higher in NO-FIX (55% vs. 0%, p < 0.001). CONCLUSION: in this study, ORIF of the PMF resulted in a higher rate of anatomically reduced syndesmosis, lesser need for syndesmotic stabilization screws, better functional outcome and fewer complications compared to no fixation. Fixation of PMFs in suprasyndesmotic fibula fractures with PMFs > 5% may be valuable, but more studies are needed to confirm this hypothesis due to study limitations.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.