The Journal of Bone and Joint Surgery, Vol 66, Issue 4 490-503, Copyright © 1984 by Journal of Bone and Joint Surgery, Inc
Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures
HC Leeds and MG Ehrlich
We studied the late results after bimalleolar and trimalleolar ankle
fractures in thirty-four patients after an average follow-up of four years.
Twenty-one patients had had open reduction and internal fixation of the
medial malleolus only and thirteen, internal fixation of both the medial
malleolus and the lateral malleolus. Twenty-four lesions were
supination-external rotation fractures; six, pronation-external rotation;
and four, supination-adduction fractures. All initial and post-reduction
roentgenograms were evaluated, and the patients were re-evaluated two to
seven years after fracture. Re-evaluation included physical examination as
well as standardized and stress roentgenograms of both ankles. Criteria
were developed for measuring the width of the syndesmosis and assessing the
late roentgenographic, subjective, and objective results, as well as any
late instability of the syndesmosis and osteoarthritis. Significant
correlations were found between: (1) the adequacy of the reduction of the
syndesmosis and late arthritis, (2) the adequacy of the initial reduction
of the syndesmosis and the late stability of the syndesmosis, (3) the late
stability of the syndesmosis and the final outcome, and (4) the adequacy of
the reduction of the lateral malleolus and that of the syndesmosis. Based
on the findings in this small series and on the evidence published in the
literature, we concluded that adequate reduction of the syndesmosis is
necessary to achieve a stable ankle following supination-external rotation
and pronation-external rotation fractures of the ankle, and that the
reduction of the syndesmosis will be unsatisfactory if the lateral
malleolus is not well reduced.
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