Journal List > J Korean Foot Ankle Soc > v.20(2) > 1043414

J Korean Foot Ankle Soc. 2016 Jun;20(2):67-72. Korean.
Published online June 09, 2016.
Copyright © 2016 The Korean Foot and Ankle Society. All rights reserved.
Two-Year Follow-up Results of Anteroposterior Cannulated Screw Fixation of Posterior Malleolar Fragment in the Trimalleolar Fracture
Sung Yoon Jung, Myoung Jin Lee, and Young Hun Jung
Department of Orthopedic Surgery, College of Medicine, Dong-A University, Busan, Korea.

Corresponding Author: Myoung Jin Lee. Department of Orthopedic Surgery, College of Medicine, Dong-A University, 32 Daesingongwon-ro, Seo-gu, Busan 49201, Korea. Tel: 82-51-240-5166, Fax: 82-51-254-6757, Email:
Received March 24, 2016; Revised April 26, 2016; Accepted April 27, 2016.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use.



The purpose of this study was to assess the 2-year follow-up results of patients with a trimalleolar fracture, who had undergone an anterior incision cannulated screw fixation of the posterior malleolar fragment, which had more than 25% of articular involvement or had no cortical continuity with the distal tibia.

Materials and Methods

Among 28 patients with a trimalleolar fracture who had undergone fixation of the posterior malleolar fragment between February 2005 and February 2010, 14 patients, who underwent an anterior incision cannulated screw fixation of posterior malleolar fragment and were followed-up for more than 2 years, were selected. The postoperative clinical and radiological findings immediately and at the 1- and 2-year follow-up were compared. The clinical findings were evaluated as American Orthopaedic Foot and Ankle Society (AOFAS) score. The radiological assessment was evaluated as the maintenance of reduction, period to bone union, and the presence of nonunion, malunion, and complications.


The clinical outcome by mean AOFAS score revealed 83.0 points in the group with preoperative displacement below 2 mm and 80.7 points in the group with preoperative displacement above 2 mm postoperatively. The mean AOFAS score was 91.7 and 93.1 points in the group with preoperative displacement below 2 mm on 1- and 2-year follow-up, respectively, and 89.8 and 91.7 points in group with the preoperative displacement above 2 mm on 1- and 2-year follow-up, respectively. After a 2-year follow-up among 14 cases selected for this study, 13 cases showed an excellent reduction state and only 1 case (7.1%) showed a displacement of more than 2 mm. No complication were encountered in the group with preoperative displacement below 2 mm. On the other hand, among 8 patients in the group with preoperative displacement above 2 mm, there were 3 with limitations of the range of motion of the ankle joint (37.5%) and 1 post-traumatic arthritis (12.5%) at the 2-year follow-up.


Anterior incision cannulated screw fixation of the posterior malleolar fragment could be a valuable method for the treatment of trimalleolar fractures that provides satisfactory results.

Keywords: Ankle joint; Trimalleolar fracture; Posterior malleolar fragment; Anterior incision cannulated screw fixation


Figure 1
(A, B) Preoperative anteroposterior and lateral radiographs show trimalleolar fracture. (C, D) Computed tomography scan images show size of posterior fragment. (E, F) Postoperative anteroposterior and lateral radiographs show adequate reduction and fixation.
Click for larger imageDownload as PowerPoint slide


Table 1
Injury Mechanism, Types of Posterior Malleolar Fracture, Lauge-Hansen Classification and Dennis-Weber Classification (n=14)
Click for larger imageClick for full tableDownload as Excel file


Financial support:None.

Conflict of interest:None.

1. Nugent JF, Gale BD. Isolated posterior malleolar ankle fractures. J Foot Surg 1990;29:80–83.
2. Malka JS, Taillard W. Results of nonoperative and operative treatment of fractures of the ankle. Clin Orthop Relat Res 1969;67:159–168.
3. Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, et al. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am 1985;67:67–78.
4. Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 1989;29:1565–1570.
5. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle: an end result study. Clin Orthop Relat Res 1977;(122):37–45.
6. Forberger J, Sabandal PV, Dietrich M, Gralla J, Lattmann T, Platz A. Posterolateral approach to the displaced posterior malleolus: functional outcome and local morbidity. Foot Ankle Int 2009;30:309–314.
7. Amorosa LF, Brown GD, Greisberg J. A surgical approach to posterior pilon fractures. J Orthop Trauma 2010;24:188–193.
8. Huber M, Stutz PM, Gerber C. Open reduction and internal fixation of the posterior malleolus with a posterior antiglide plate using a postero-lateral approach: a preliminary report. J Foot Ankle Surg 1996;2:95–103.
9. Talbot M, Steenblock TR, Cole PA. Posterolateral approach for open reduction and internal fixation of trimalleolar ankle fractures. Can J Surg 2005;48:487–490.
10. Macrum E, Bell DR, Boling M, Lewek M, Padua D. Effect of limiting ankle-dorsiflexion range of motion on lower extremity kinematics and muscle-activation patterns during a squat. J Sport Rehabil 2012;21:144–150.
11. Holzer N, Salvo D, Marijnissen AC, Vincken KL, Ahmad AC, Serra E, et al. Radiographic evaluation of posttraumatic osteoarthritis of the ankle: the Kellgren-Lawrence scale is reliable and correlates with clinical symptoms. Osteoarthr Cartil 2015;23:363–369.
12. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem? Acta Orthop Scand 1998;69:43–47.
13. Neumaier Probst E, Maas R, Meenen NM. Isolated fracture of the posterolateral tibial lip (Volkmann' s triangle). Acta Radiol 1997;38:359–362.
14. Burwell HN, Charnley AD. The treatment of displaced fractures at the ankle by rigid internal fixation and early joint movement. J Bone Joint Surg Br 1965;47:634–660.
15. Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The jointcontact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am 1991;73:347–351.
16. Hartford JM, Gorczyca JT, McNamara JL, Mayor MB. Tibiotalar contact area. Contribution of posterior malleolus and deltoid ligament. Clin Orthop Relat Res 1995;(320):182–187.
17. Sachs W, Kanat IO, McLaughlin E, Burns DE. A surgical approach to a displaced ankle fracture. J Foot Surg 1984;3:302–307.
18. Lindsjö U. Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res 1985;(199):28–38.
19. Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg Am 1988;70:1348–1356.
20. Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165–171.
21. Heim UF. Trimalleolar fractures: late results after fixation of the posterior fragment. Orthopedics 1989;12:1053–1059.
22. Marsh JL, Saltzman C. Ankle fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green's fractures in adults. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. pp. 2147-2249.
23. Holt ES. Arthroscopic visualization of the tibial plafond during posterior malleolar fracture fixation. Foot Ankle Int 1994;15:206–208.