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C OPYRIGHT Ó 2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Effect of Posterior Malleolus Fracture on

Syndesmotic Reduction
A Cadaveric Study
Elizabeth Fitzpatrick, MD, Jessica E. Goetz, PhD, Tinnart Sittapairoj, MD, Vinay Hosuru Siddappa, MD,
John E. Femino, MD, and Phinit Phisitkul, MD
Downloaded from http://journals.lww.com/jbjsjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/14/2021

Investigation performed at the University of Iowa Hospitals and Clinics, Iowa City, Iowa

Background: Syndesmotic malreduction and fractures of the posterior malleolus negatively influence outcomes of
rotational ankle fractures. Recent data have shown that posterior malleolus fixation contributes to the stability of the
syndesmosis. The purpose of this study was to analyze syndesmotic reduction within the context of different sizes of
posterior malleolus fracture fragments and different qualities of reduction.
Methods: A model of stage-IV supination-external rotation injury was created in 9 through-the-knee cadaveric specimens.
The specimens were randomized to receive either a small (one-third of the incisura, n = 4) or a large (two-thirds of the
incisura, n = 5) posterior malleolus fracture. High-resolution computed tomography (CT) scans were obtained of each
intact specimen and then with clamp reduction of the syndesmosis along with a fracture fragment that was (1) unreduced,
(2) anatomically reduced, or (3) fixed with a 4.8-mm-gap malreduction. Syndesmotic reduction in both the anterior-
posterior and the medial-lateral direction was assessed relative to the intact specimen.
Results: Clamp reduction of the syndesmosis increased medial translation of the distal part of the fibula in the speci-
mens with an unfixed or an anatomically fixed posterior malleolus fracture fragment and caused lateral displacement of
the distal part of the fibula in the specimens with gap malreduction of the posterior malleolus fracture. Clamp reduction of
the syndesmosis caused a slight anterior shift of the fibula in the specimens with a small unfixed or anatomically fixed
posterior malleolus fracture fragment and caused a posterior shift of the fibula in the specimens with gap malreduction of
a large fragment.
Conclusions: The overall anterior-posterior reduction of the syndesmosis was generally unaffected by a posterior mal-
leolus fracture except when there was malreduction of a large fragment. Medial-lateral syndesmotic reduction was
affected by the conditions of the posterior malleolus fixation, with malreduction of the posterior malleolus leading to
syndesmotic malreduction.
Clinical Relevance: When posterior malleolus fractures occur with syndesmotic injury, anatomic fracture reduction and
fixation are paramount as they can affect syndesmotic reduction, especially with larger fragments.

I
njuries to the ankle, ranging from sprains to fractures re-
quiring operative treatment, are very common orthopaedic
injuries1. In the spectrum of rotational ankle fractures,
syndesmotic reduction has proven to be an important and
challenging problem. Up to 20% of operatively treated rota-
tional ankle fractures are associated with injuries to the
syndesmosis. Studies have shown that malreduction of the
syndesmosis negatively influences outcomes2-6. Conventional
syndesmotic fixation using tenaculum reduction and a syn-
desmotic screw has been associated with syndesmotic malre-
duction due to subtle changes in the clamping directions7,8.
Therefore, it is important to continue to keep a critical eye on
syndesmotic reduction and all components of the syndesmotic
injury.
Posterior malleolus fractures of the distal part of the tibia
are commonly associated with syndesmotic injury. An im-
portant component of the syndesmosis is the posterior-inferior
tibiofibular ligament (PITFL), which provides 42% of the
strength of the syndesmosis as demonstrated by Ogilvie-Harris
et al.9 and reliably remains intact with posterior malleolus

Disclosure: No external funding was provided for this investigation. The Disclosure of Potential Conflicts of Interest forms are provided with the online
version of the article (http://links.lww.com/JBJS/E593).

J Bone Joint Surg Am. 2018;100:243-8 d http://dx.doi.org/10.2106/JBJS.17.00217

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fractures as demonstrated by magnetic resonance imaging
(MRI) studies8,10. Fixation of the posterior malleolus is be-
coming more popular as data regarding clinical outcomes have
increased3,10-12. Fixation strategies range from percutaneous
anterior-to-posterior screw placement with indirect judgment
of reduction via fluoroscopy to open posterior approaches with
direct visualization of the fracture.
Since posterior malleolus fractures of the tibia have been
shown to be associated with an intact PITFL8,10, it is reasonable to
assume that this component of the syndesmosis could have an
effect on reduction. Studies have demonstrated that fixation of
the posterior malleolus provides stability to the syndesmosis that
is equal, if not superior, to that provided by traditional syndes-
motic screws alone10,13. Miller et al. demonstrated that the short-
term results of posterior malleolus fracture fixation to stabilize
the syndesmosis were equivalent to those of traditional stabili-
zation of the syndesmosis with syndesmotic screws7. Those au-
thors advocated fixation of all posterior malleolus fractures,
regardless of size, to allow superior stabilization of the syndes-
mosis and because of fewer surgical risks, such as the need for a
second surgical procedure to remove syndesmotic screws.
As is the case for the syndesmosis, anatomic fixation of
the posterior malleolus is of great importance, as >1 mm of
articular step-off can lead to radiographic evidence of osteo-
arthritis12. However, there are components of malreduction
other than articular step-off. For example, in an unpublished
clinical series at our institution, we found that many patients
presented with an interposed fragment at the level of the
posterior malleolus fracture (Fig. 1). A review of 6 of these cases
showed that the average size of the interposed fragment (and
standard deviation) was 5.12 ± 1.39 mm in the anterior-to-
posterior dimension. An interposed fragment of this size may
block reduction, specifically when reduction is assessed by in-
direct means such as fluoroscopy. There may also be other
fracture characteristics, such as a hinge of soft tissue, that can
lead to malreduction without articular step-off. Little is known
Fig. 1
Axial CT sections from patients with a posterior malleolus fracture. Interposed fragments are indicated with arrows.
E F F E C T O F P O S T E R I O R M A L L E O LU S F R A C T U R E ON SYNDESMOTIC
REDUCTION
about whether or how anatomic or nonanatomic fixation of the
posterior malleolus affects syndesmotic reduction. Thus, we
conducted a cadaveric study to analyze the effects of posterior
malleolus fracture size and reduction quality on the ability to
anatomically reduce the syndesmosis. We hypothesized that
malreduction of a posterior malleolus fracture would lead to
malreduction of the syndesmosis.
Materials and Methods
Specimen Preparation
N ine through-the-knee cadaveric specimens with an intact
proximal tibiofibular joint were obtained from the
Anatomy Gifts Registry (Hanover, Maryland). The average age
at death was 56.4 years (range, 18 to 70 years). Four cadavers
were male and 5 were female. Superficial soft tissues were
dissected to expose the joint and the periarticular ligaments.
The fibula was left intact to simulate the syndesmotic injury
after anatomic fixation of the fibula. Fiducial screws were
placed in the medial aspect of the tibia and the lateral aspect of
the fibula at a level 10 mm proximal to the tibiotalar joint line
in order to standardize the position and orientation of the
syndesmotic reduction clamping during subsequent posterior
malleolus fixation conditions. On the lateral side, the osseous
insertion of the peroneal retinaculum on the lateral malleolar
ridge was used as the anterior-posterior landmark. On the
medial side, the midpoint of the anterior-posterior diameter of
the distal part of the tibia was used as the anterior-posterior
landmark. Specimens were then evaluated using a high-
resolution (0.18-mm in-plane voxels; 0.75-mm slice spacing),
dual-energy computed tomography (CT) scan to generate a
baseline condition. The specimens were placed in a custom foot
frame when they were intact and for all subsequent CT scans to
ensure equivalent orientation of the specimen in the scanner;
the ankle joint was flexed 90°, the specimen was aligned with
the direction of the scanner bed, and the second ray was ori-
ented in the vertical plane.
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Posterior Malleolus Fracture and Fixation
A model of Lauge-Hansen stage-IV supination-external ro-
tation injury was then created by sharply releasing the
anterior-inferior tibiofibular ligament, superficial and deep
deltoid ligaments, and interosseous membrane to a level
10 mm above the joint line. A hole was predrilled in the
nonfractured specimen to ensure screw placement for an
anatomic reduction during fixation of the posterior malleo-
lus fracture. The specimens were then randomized into 2
groups using a random-number generator. In 1 group, a
small posterior malleolus fracture fragment consisting of
one-third of the incisura was created (n = 4), whereas, in the
other group, a large fragment consisting of two-thirds of the
incisura was created (n = 5). Each fracture was created from
anterolateral to posteromedial, beginning from within the
incisura. First, the anterior-to-posterior distance of the in-
cisura of the tibial plafond was measured with digital calipers
at the level of the joint, and the desired fracture-fragment
size—one-third or two-thirds of this distance—was calcu-
lated. The fibula was then distracted from the tibia with a
retractor while preserving the PITFL. Fractures were initiated
using a 0.5-mm-thick saw blade and completed using an
osteotome. We aimed the orientation of the osteotomy to be
in 21° of external rotation in relation to the bimalleolar angle,
in keeping with previously described morphologies of pos-
terior malleolus fractures14. All cuts were made by a single
investigator (P.P.).
Each fractured specimen was evaluated using CT scans
acquired under 3 different conditions: with an unreduced
(nondisplaced) fracture, with the fracture fixed in an ana-
tomic position, and with the fracture fixed in a malreduced
position with a gap. For the unreduced fracture condition, the
syndesmosis was clamped using the previously placed fiducial
screws to define the clamp axis. The level of clamp com-
pression was determined by adding 1 “click” in the ratcheting
system after the 2 prongs of the clamp started to engage into
the screw head. We marked this level of compression on the
clamp so that it was consistent for all posterior malleolus
fixation conditions. A CT scan of this unreduced fracture state
was acquired. The syndesmotic reduction clamp was then
removed, and anatomic fixation of the posterior malleolus
fracture was performed by directing a single 3.5-mm-diam-
eter cortical screw from anterior to posterior through the
predrilled hole. After fixation, the syndesmosis was once again
clamped along the axis defined by the fiducial screws, and a
CT scan of this anatomically reduced fracture state was ob-
tained. Then, to evaluate the effects of malreduction of the
fracture fragment, the syndesmotic clamp and the 3.5-mm
fixation screw were removed to permit placement of a 4.8-mm
wooden shim between the tibia and the posterior malleolus
fracture fragment. This simulated a gap at the fracture site due
to an interposed articular fragment. The fixation was then
replaced through the previously drilled hole, syndesmotic
reduction was performed along the marked axis, and the final
CT scan was obtained. Four CT scans were obtained of each
cadaveric specimen, for a total of 36 CT scans.
E F F E C T O F P O S T E R I O R M A L L E O LU S F R A C T U R E ON SYNDESMOTIC
REDUCTION
Measurement of the Syndesmosis
Syndesmotic reduction was measured in both anterior-
posterior and medial-lateral directions using a validated
landmark-based technique8,13. First, the tibia, fibula, and pos-
terior malleolus fragment (if present) were manually seg-
mented from an axial CT slice 10 mm above the joint using
OsiriX software (Pixmeo). Segmentation was the only manual
step and was performed by a single investigator (J.E.G.). Seg-
mentations were imported into an objective, custom, auto-
matic analysis routine developed in MATLAB (MathWorks).
Syndesmotic reduction measurements relative to osseous
landmarks were then performed as previously described13.
Briefly, the algorithm automatically defined a reference line
tangential to the most lateral aspects of the anterior and pos-
terior tubercles of the incisura. A perpendicular to this line was
then drawn at the anterior tubercle. Medial-lateral translation
was measured as the distance from the medial-most location of
the fibula relative to the incisura line, with positive measure-
ments being lateral to the line and negative measurements
being medial to it. The anterior-posterior position was the
distance between the anterior-most location on the fibula rel-
ative to the perpendicular reference line (Fig. 2). All reference
lines and selections of surface geometry to define the mea-
surements of the syndesmosis were made objectively by the
algorithm on the basis of osseous curvature and were per-
formed fully automatically.
As a result of the different fixation conditions of the
posterior malleolus fracture fragment, the posterior osseous
landmark required for this analysis moved. To account for this,
Fig. 2
Representative schematic of the reference points used for measurements
with a reference line tangential to the most lateral aspects of the anterior
and posterior tubercles of the incisura. The anterior-posterior (AP) distance
was the minimum perpendicular distance from the reference line to the
anterior-most location of the fibula (shown in blue). The medial-lateral (ML)
distance was the maximum perpendicular distance from the incisura ref-
erence line to the medial-most location of the fibula (shown in pink).
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REDUCTION

Fig. 3
Representative overlay of the fibular translation that occurred with each posterior malleolus intervention in a single specimen from the large and small-
fragment groups. The red dashed line indicates the fracture line in the given specimen plotted over the intact tibia cross section. Fx = fracture.

the analysis routine aligned fracture-data sets for each speci-
men with the associated baseline data using an iterative closest-
point algorithm to match the nonfractured distal part of the
tibia to the intact distal part of the tibia. With the data sets
aligned, all fibular movements were then calculated relative to
the single set of reference lines created from the baseline,
intact-bone conditions. Syndesmotic reduction was expressed
as a shift in fibular position relative to the intact case by sub-
tracting the intact-specimen anterior-posterior and medial-
lateral fibular position measurements from those made after
intervention (Fig. 3). Repeated-measures 2-way analysis of
variance (ANOVA) with Tukey multiple comparisons tests
(GraphPad Prism 6; GraphPad Software) was used to investi-
gate differences due to fixation quality and fragment size.
those with an anatomically reduced fracture fragment in-
creased medial translation of the distal part of the fibula by an
average of 0.85 ± 0.56 mm and 0.38 ± 0.48 mm, respectively,
when the fracture fragment was small and by 1.14 ± 0.41 mm
and 0.85 ± 0.32 mm, respectively, when it was large. Con-
versely, the gap malreduction induced a lateral displacement of
the distal part of the fibula, with an average translation of 0.54 ±
0.84 mm in the specimens with a small fracture fragment and
of 0.90 ± 0.57 mm in those with a large fragment (Fig. 5).
Pairwise statistical comparisons showed significant differences
between the gap-malreduction group and both the unreduced
and the anatomically reduced groups (p values ranging from
<0.001 to 0.05).

Results
Anterior-Posterior Displacement

W hen the syndesmotic clamping was done in the setting of

the small unreduced posterior malleolus fracture there
was a slight anterior shift of the fibula (0.73 mm). Similar shifts
(0.94 and 0.78 mm) occurred under both the anatomically
reduced and the gap-malreduced small-fragment conditions,
but this anterior fibular movement was not seen in the speci-
mens with a large posterior malleolus fragment (Fig. 4). Two-
way ANOVA indicated no significant effects of fragment size
(p = 0.73) or fracture reduction (p = 0.09) on the anterior-
posterior fibular position within the incisura. However, gap
malreduction of the large posterior fracture fragment caused
the fibula to shift 1.12 ± 0.96 mm posteriorly. Fibular position
resulting from syndesmotic clamping with a large fracture
fragment was significantly different between the intact and the Fig. 4
Average anterior-posterior displacement of the fibula in the incisura during
gap-malreduction conditions (multiplicity adjusted p = 0.03)
syndesmotic clamping with each posterior malleolus intervention. The data
and between an anatomically reduced and a gap-malreduced
fracture (multiplicity adjusted p = 0.01). are the mean differences (and standard deviation) relative to the intact
baseline case. Syndesmotic clamping in the presence of a small posterior
Medial-Lateral Displacement malleolus fracture generally caused a slight anterior fibular translation;
Two-way ANOVA indicated that the quality of fracture re- however, there was no significant difference between reduction groups. A
duction had a significant effect on the medial-lateral fibular large fracture fragment with a gap in the reduction led to a substantial
position with syndesmotic clamping (p < 0.001) but fragment posterior shift of the fibula with syndesmotic clamping, which was signif-
size did not (p = 0.54). Syndesmotic clamping in both the icantly different from the fibular translation in the large specimens with an
specimens with an unreduced posterior malleolus fracture and anatomically reduced fracture. *Indicates p = 0.012.
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Fig. 5
Average medial-lateral displacement of the fibula in the incisura during
syndesmotic clamping with each posterior malleolus intervention. The data
are the mean differences (and standard deviation) relative to the intact
baseline case. There were no differences in the medial-lateral fibular po-
sition with syndesmotic clamping between the specimens with an un-
reduced and those with an anatomically reduced posterior malleolus
fracture, regardless of fragment size. Syndesmotic clamping in the gap-
malreduction group led to significant lateral displacement of the fibula
compared with the unreduced fracture and anatomically reduced fracture
groups for both fragment sizes. *Indicates p < 0.05.
Discussion
T he importance of anatomic reduction of the syndesmosis is
well supported6,8. There has been a large effort to evaluate
reductions with CT scans and to find alternative fixation
methods to help overcome syndesmotic malreduction15-17.
Furthermore, the importance of malreduction in the devel-
opment of posttraumatic osteoarthritis and poor clinical
outcomes has been established11,13. However, the effect of
malreduction of a posterior malleolus fracture on the accur-
acy of syndesmotic reduction has not been studied, to our
knowledge. The aim of this study was to assess the effect of the
reduction of a posterior malleolus fracture on the alignment of
the syndesmosis.
The overall anterior-posterior reduction of the syndes-
mosis via neutral-axis clamping was generally not affected by
the presence of a posterior malleolus fracture when the frag-
ment was left unfixed (nondisplaced) or was fixed anatomi-
cally. However, large fracture fragments fixed in a malreduced
position did demonstrate an effect on the syndesmotic reduc-
tion. While there is evidence supporting fixation of large pos-
terior malleolus fractures because of the potential effects on
subluxation of the tibiotalar joint, the size of a posterior mal-
leolus fracture fragment may also influence the reduction of the
syndesmosis. Larger fragments are particularly important as
they constitute a large portion of the incisura. Without fixation
of those fragments, the tibiofibular joint will not be restored to
its anatomic position as a result of potential gapping or step-
offs in the incisura. This may reinforce the importance of
E F F E C T O F P O S T E R I O R M A L L E O LU S F R A C T U R E ON SYNDESMOTIC
REDUCTION
anatomic fixation, particularly in the setting of these larger
fragments.
Medial-lateral syndesmotic reduction was particularly
affected by the conditions of posterior malleolus fixation. The
best syndesmotic reduction results were achieved with ana-
tomic fixation of the fracture; however, the prefracture state
was not exactly replicated. This finding is not completely un-
expected as previous work has demonstrated slight over-
compression when the syndesmosis was clamped in a neutral
axis18. Gap malreduction of the posterior malleolus led to worse
syndesmotic malreduction despite anatomic clamping across
the syndesmosis, particularly with large fragments.
These results reinforce the importance of achieving an-
atomic reduction with posterior malleolus fracture fixation,
which may influence operative strategies for these fractures.
Some techniques of percutaneous fixation of posterior malle-
olus fractures rely on indirect assessment of reduction via
fluoroscopy, in contrast to an open approach with direct vi-
sualization. Indirect reduction via fluoroscopy may limit de-
tection of subtle findings, such as a gap due to interposition of
osseous or soft-tissue fragments. This can lead to malreduction
without an articular step-off (which would likely be well-
visualized on fluoroscopy). With either approach, careful at-
tention should be paid to the reduction of the fracture. One
should evaluate the syndesmosis carefully after any manipu-
lation or fixation of a posterior malleolus fracture to ensure
that no malalignment or displacement occurred in this step of
fracture management.
The strength of this study lies in the evaluation of con-
comitant syndesmotic injury and posterior malleolus fracture.
To our knowledge, no other study has assessed the effect of
malreduction of a posterior malleolus fracture on the syndes-
mosis. We also evaluated posterior malleolus fragment size as a
factor in syndesmotic reduction. The syndesmotic clamping
method used in this model reliably reduces the fibula into the
center of the incisura, which subsequently allowed the poste-
rior malleolus interventions to be the sole cause of additional
changes in the syndesmotic reduction.
Our study has some weaknesses. First, it is a small, ca-
daveric study. A larger number of specimens might have allowed
stronger statistical analysis, but we were limited by specimen
availability. Also, we evaluated only 2-dimensional images and
displacement in the anterior-posterior and medial-lateral direc-
tions. This does not account for rotational malalignment of the
fibula in the incisura. Our posterior malleolus fixation comprised
a single screw, which may have allowed some rotation of the
fracture fragment with screw tightening and thus some rotational
malreduction of the fragment itself. While the cuts to create the
fracture fragments were all performed by a single investigator,
they were subject to measurement error. We also did not account
for bone loss due to the cut made by the saw blade. While this
may prevent a perfectly anatomic reduction, it may be within the
limits of bone loss that occurs with debridement of a normal
fracture line, comminution, and compression with fixation.
Another potential weakness is our simulation of fracture
malreduction. We placed a 4.8-mm wooden shim in the
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fracture site in an attempt to simulate a gap that may result
from an interposed osseous comminution fragment or a piece
of soft tissue such as a hinge of periosteum. This led to a
uniform gap and prevented anatomic reduction of the fracture.
This subtle malreduction can be difficult to assess via fluo-
roscopy in the operating room as it does not necessarily alter
the congruity of the joint surface. While the gap simulated in
this study may seem large, after a review of CT scans from
actual clinical cases at our institution it appears that these types
of fracture fragments do occur in this injury pattern (Fig. 1).
However, malreduction can be due to many reasons, including
translation in the medial-lateral direction or rotational mala-
lignment, which are not represented in this study.
We assessed the effect of posterior malleolus fractures on
the reduction of the syndesmosis in the setting of a rotational
ankle injury. We found that the overall anterior-posterior re-
duction of the syndesmosis using anatomic syndesmotic clamp-
ing was generally unaffected by the posterior malleolus fracture
except in the specimens with an extremely nonanatomic gap
malreduction of a large fracture fragment. Medial-lateral syn-
desmotic reduction was affected by the conditions of posterior
malleolus fixation. Malreduction of the posterior malleolus led
to corresponding syndesmotic malreduction. When posterior
malleolus fixation is indicated in patients with a syndesmotic
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E F F E C T O F P O S T E R I O R M A L L E O LU S F R A C T U R E ON SYNDESMOTIC
REDUCTION
injury, anatomic fracture fixation is paramount as it can affect
syndesmotic reduction, especially with larger fragments. Thought
should be given to fixation of all posterior malleolus fractures and
the technique used to ensure anatomic reduction. n
Elizabeth Fitzpatrick, MD1
Jessica E. Goetz, PhD1
Tinnart Sittapairoj, MD1
Vinay Hosuru Siddappa, MD2
John E. Femino, MD1
Phinit Phisitkul, MD1
1University of Iowa Hospitals and Clinics, Iowa City, Iowa
2Bengaluru, Karnataka, India
E-mail address for E. Fitzpatrick: Elizabeth-fitzpatrick-1@uiowa.edu
E-mail address for J.E. Goetz: jessica-goetz@uiowa.edu
E-mail address for T. Sittapairoj: tinnartsitta@yahoo.com
E-mail address for V. Hosuru Siddappa: sidorthonex@gmail.com
E-mail address for J.E. Femino: john-femino@uiowa.edu
E-mail address for P. Phisitkul: pphisitkul@gmail.com
ORCID iD for E. Fitzpatrick: 0000-0002-5185-6875
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