Trimalleolar

Trimalleolar Fractures

Perspectives on Trimalleolar Fractures with Cristian Ortiz, MD Trailer

A trimalleolar injury is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the posterior malleolus. This complex injury can be difficult to treat appropriately. In this interview, Dr. Cristian Ortiz highlights the diagnosis, his treatment algorithm, and controversies of this indication.

Perspectives on Trimalleolar Injuries with James Sferra, MD

In this interview, Dr. James Sferra highlights the diagnosis, his treatment algorithm, and controversies of this indication.

Perspectives on Ankle and Syndesmotic Injury with Richard Marks, MD

In this video, Dr. Marks highlights considerations for fixation of the ankle and possible treatment options for injuries of the tibiofibular syndesmotic ligament.

Acumed Offers the Most Complete Selection of Trimalleolar Fracture Treatment Options on the Market*

Considered by many lower extremity surgeons to be among their most challenging cases, trimalleolar fractures involve the lateral malleolus, the medial malleolus, and the posterior malleolus. Acumed offers a range of options to treat these fracture types, whether simple or complex.

Ankle Plating System 3

Small Fragment Base Set

Fibula Rod System

4.0 mm Cannulated Screws

Acutrak 2 Headless Compression Screws

Product Comparison Charts

Click chart to enlarge

Click chart to enlarge

Clinical Studies

Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation

Publication Excerpt

“Our data demonstrates that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent
fractures when prone positioning and direct fixation of the posterior malleolus were first performed.”

Journal Abstract

Background
We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen.

Methods
The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture.

Results
In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001).

Conclusion
Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. Level of Evidence Level III, retrospective comparative series.

Reference

Miller MA, McDonald TC, Graves ML, et al. Stability of the syndesmosis after posterior malleolar fracture fixation. Foot Ankle Int. 2018; 39(1):99-104.

“A to P” Screw vs Posterolateral Plate for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures

Publication Excerpt

“Patients with trimalleolar ankle fractures in whom the posterior malleolus was treated with posterolateral buttress plating had superior clinical outcomes at follow-up compared with those treated with AP screws.”

Journal Abstract

Objective
To compare radiographic and clinical midterm outcomes of posterior malleolar fractures treated with posterior buttress plating
versus anterior to posterior lag screw fixation.

Methods
Design: Retrospective case series. Setting: Level I trauma center. Patients/Participants: Between January 2002 and December
2010, patients with posterior malleolar fractures were identified by Current Procedural Terminology code and their charts
reviewed for eligibility. Intervention: Posterior malleolar fixation using either anterior to posterior (AP) lag screws or posterior
buttress plating. Main Outcome Measurements: Demographic data, length of follow-up, range of motion, and postoperative
Short Musculoskeletal Function Assessment (SMFA) scores were the main outcome measurements. Immediate postoperative
radiographs for residual gap/step-off and final follow-up radiographs for the degree of arthritis that developed were evaluated.

Results
Thirty-seven patients were eligible for the study, and 27 chose to participate. Sixteen patients underwent posterior buttress
plating, and 11 underwent AP screw fixation with mean follow-up times of 54.9 and 32 months, respectively. Demographic data
were similar between groups. The posterolateral plating group demonstrated superior postoperative SMFA scores compared
with the AP screw group with statistically significant differences in the SMFA bother index (26.7 vs. 9.2, P = 0.03) and trends
toward improvement in the mobility (28.3 vs. 12.9, P = 0.08) and functional indices (20.2 vs. 9.4, P = 0.08). There were no
significant differences in the range of motion or the development of ankle arthritis over time.

Conclusions
Patients with trimalleolar ankle fractures in whom the posterior malleolus was treated with posterolateral buttress plating had
superior clinical outcomes at follow-up compared with those treated with AP screws.

Reference

O’Connor T, Mueller B, Ly TV, et al. "A to p" screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. J Orthop Trauma. 2015; 29(4):e151-6.

The Fibula Nail for Treatment of Ankle Fractures in Elderly and High Risk Patients

Publication Excerpt

“The fibula nail provides an alternative to standard plate fixation that uses a minimal approach and, therefore, decreases the incidence of wound infection and the need for further surgery to remove prominent metalwork while providing stable fixation.”

Journal Abstract

Ankle fractures in the elderly are increasing in incidence, and comorbidities, including diabetes, steroid use, and osteoporosis, can make these injuries difficult to treat in this population. Prominent metal work, infection, and wound problems are common complications. The fibula nail provides an alternative to standard plate fixation that uses a minimal approach and, therefore, decreases the incidence of wound infection and the need for further surgery to remove prominent metalwork while providing stable fixation.

Reference

Appleton P, McQueen M, Court-Brown C. The fibula nail for treatment of ankle fractures in elderly and high risk patients. Tech Foot Ankle Surg. 2006;5(3):204-208.

Case Studies

Trimalleolar Ankle Fracture Dislocation Treatment Using Plate and Screw Fixation

A 70-year-old female with a closed trimalleolar fracture dislocation was treated with the Acumed Ankle Plating System 3 and Small Fragment Base Set.

Trimalleolar Ankle Fracture Treatment Using Plate and Screw Fixation

A 57-year-old man sustained a trimalleolar ankle fracture-dislocation that was treated with the Acumed Ankle Plating System 3.

Providing Stability to the Syndesmosis by Plating the Posterior Malleolus

A 69-year-old female who sustained an ankle dislocation with associated distal fibula, posterior pilon, and deltoid avulsion fractures was treated successfully with the Acumed Ankle Plating System 3.

*Competitive data on file with Acumed. GEN00-30-C; 2021.