Foot and Ankle Surgery 20 (2014) 48–51
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Impact of trimalleolar ankle fractures: How do patients fare post-operatively? Choon Chiet Hong MBBS (Sing), MRCS (Edin)a, Nazrul Nashi b, Shuvendu Prosad Roy M.S. Orthopedicsa, Ken Jin Tan MBBS (Sing), MRCS (Edin), Mmed (Ortho), FRCS (Edin)a,* a b
University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 February 2013 Received in revised form 18 July 2013 Accepted 10 October 2013
Background: We aim to evaluate the clinical and functional outcome of trimalleolar fractures and the ability of patients to return to sporting activities. Methods: A retrospective review of 31 patients with operatively managed trimalleolar fractures was conducted. Their Olerud and Molander scores and ability to return to sports was analyzed at 1 year postoperatively. Results: Dislocations were more likely to result from trimalleolar fractures (p < 0.001). 11 (52.4%) of our patients had residual pain at 1 year. 13 (61.9%) and 10 (47.6%) had persistent ankle stiffness and swelling. Out of 12 patients who were involved in sports pre-operatively, only 4 (33.3%) patients were able to return to sports. 3 (25%) patients were unable to do sports at all. Increasing posterior malleolar fragment size correlates with poorer functional outcome. Conclusions: Patients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures. Residual deficits affect the majority of our patients and a notable proportion was unable to return to sporting activities. ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Trimalleolar ankle fracture Trauma Return to sports Posterior malleolar fracture Functional outcome
1. Introduction Ankle fractures are common injuries seen in Orthopaedic practice. Ankle fractures can be classified based on the number of malleoli involved, namely unimalleolar, bimalleolar or trimalleolar fractures. Unstable ankle fractures usually involve fracturedislocations and displacement of the malleoli. Such unstable fractures require early reduction and surgical management to enable stabilization and early mobilization. This is because inadequate reduction often results in early osteoarthritis, pain and loss of ankle joint function [1–3]. Uni- and bimalleolar fractures account for the majority of ankle fractures while trimalleolar fractures are less common, occurring in 7% of all ankle fractures [4]. Trimalleolar ankle fractures have also been shown to result in poorer outcome depending on the size of the posterior malleolar fragment [5,6]. Most surgeons use the size of the posterior
* Corresponding author at: University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. Tel.: +65 6779 5555; fax: +65 6775 0913. E-mail address: [email protected] (K.J. Tan).
malleolar fragment as the single most important parameter to decide if the fragment should be fixed. Several studies have shown that fixation of posterior fragment is indicated if it involves more than 25% of the articular surface [5,7–9]. Despite this, there is a lack of studies reviewing the functional outcomes of trimalleolar ankle fractures. We aim to evaluate the incidence of trimalleolar ankle fractures in our institution, the clinical and functional outcome of operatively treated trimalleolar fractures and the ability to return to sporting activities. 2. Methods A retrospective review of all patients admitted to our institution for operative fixation of ankle fractures from January 2009 to December 2010 was performed. These patients were identified using the hospital’s diagnosis and operative code system. Their case notes, electronic records and X-rays were reviewed. This study was approved by the Institutional Review Board (IRB). We excluded patients with open fracture, poly-trauma, concomitant fractures in the ipsilateral lower limb, pathological fracture, concomitant neurovascular injury in the ipsilateral lower limb, pilon fracture, inability to provide consent and skeletally
1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.fas.2013.10.001
C.C. Hong et al. / Foot and Ankle Surgery 20 (2014) 48–51
immature patients. All patients were 18 years old and above and completed at least 1 year of follow up. Pertinent data on patients’ demographics, clinical assessments, pre-operative X-ray findings, operative details, post-operative X-rays and complications were extracted and analyzed statistically. Fractures were classified radiographically into uni-, bi- and trimalleolar fractures as well as into group A, B, or C according to the Danis–Weber classification [10]. However, we excluded the uni- and bimalleolar ankle fractures from our study. Lateral view of the ankle radiographs were used to measure and calculate the posterior malleolar fragment size as a percentage of the articular surface. Measurements were made using our radiographic system (Centricity Enterprise Web, GE Healthcare). Post-operative radiographs were reviewed and union was defined as complete cortical bridging between proximal and distal fragments with no visible fracture line. The first author did all the measurements so as to minimize inter-observer differences and maintain consistency. Outcome measurements were that of union rates, Visual Analogue Scale (VAS), Olerud and Molander (O&M) score [11], ability to return to sporting activities, satisfaction with surgery and presence of surgical complications. The O&M score is a validated ankle specific functional scoring system. It is a patient self-reported questionnaire used to evaluate ankle specific functional outcome and impact of certain intervention over time. It covers 9 areas: (1) pain; (2) stiffness; (3) swelling; (4) stair-climbing; (5) running; (6) jumping; (7) squatting; (8) supports; and (9) work and activities of daily living. Scores range from a minimum (zero) to a maximum (100) points. In addition, satisfaction with surgery was based on self-report by the patients. All surgeries were performed by fellowship-trained Orthopaedic consultants and specialist registrars. Surgeries were performed under anaesthesia and fluoroscopy guidance. Plate and screw constructs were used in a standard manner. 25 (80.6%) of the medial malleolus fractures were fixed with two 3.5 mm partially threaded cancellous screws while 3 (9.7%) of them had tension band wiring using 2 Kirschner wires. Another 3 (9.7%) cases of medial malleolus fractures had a mixture of one 3.5 mm partially threaded screw with a single Kirschner wiring. On the other hand, 19 (61.3%) of the lateral malleolus fractures were fixed with a one third tubular plate while 12 (38.7%) cases were fixed with the 3.5 mm LC-DCP plate. Syndesmosis fixation was performed at the surgeons’ discretion intra-operatively after routine syndesmosis complex examination under fluoroscopy. It is indicated if the routine syndesmosis examination under fluoroscopy showed unstable syndesmosis. Cotton’s test is commonly employed in our institution to test the integrity of the syndesmosis. We routinely use syndesmotic screw fixation for ankle fractures with an unstable syndesmosis. A 3.5 cm cortical screw is placed at the apex of the syndesmosis 2 cm above the tibiotalar joint [12]. It is inserted obliquely from the fibula to the tibia starting posterolaterally aiming anteromedially with a tricortical purchase while the ankle is in neutral dorsiflexion. On top of that, fixation of the posterior malleolar fragment remains controversial. As a guide, posterior malleolar fragment size >25% are usually fixed as it was shown to produce better outcomes radiographically and clinically [5,7,14–16]. However, in this study, we analyze retrospectively all operatively treated trimalleolar ankle fractures and therefore the criteria for fixation then cannot be fully defined. We have checked with the majority of the surgeons who performed the surgeries then and the consensus was that majority agree with fixation of the posterior malleolar fragment if they are >25% but if the posterior fragment remained stable on ankle range of motion testing after reduction and fixation of both malleolus, some of the surgeons may not proceed with posterior malleolar fragment fixation. Post-operatively, a backslab was applied with the ankle in neutral position and the patient kept on non-weight bearing on the
49
affected limb for 6 weeks. All patients were reviewed 2 weeks postoperatively for wound inspection and suture removal if needed and then 6 weeks post-operatively for review and advancement of weight bearing status with assistance from the physiotherapists. At 2 weeks, they were reviewed by our physiotherapist and started on ankle range of motion and proprioceptive exercises if there were no wound complications. Weight bearing exercises were started after the initial 6 weeks of non-weight bearing. If the patient received a syndesmotic screw fixation, we routinely removed the screw under local anaesthesia at about 8–12 weeks post ankle fracture fixation. The patient is allowed to weight bear as tolerated after the initial 6 weeks of non-weight bearing and this will continue after the screw removal. Further rehabilitative sessions were conducted by the physiotherapist until the patients were able to return to their pre-injury levels of daily activities. Subsequent reviews were at 3, 6 and 12 months with radiographic monitoring, clinical assessment and functional outcome survey using the O&M score. Data entry was performed using a spreadsheet application (Excel 2003, Microsoft Corp., Redmond, WA). Frequency tables and descriptive statistics (mean, standard deviation or median where appropriate) were presented for all variables. Categorical variables were presented as proportions and continuous variables were presented as mean. Chi-square test was used for comparison between categorical variables. Spearman correlation test was used as well. Statistical significance was set at p 0.05 and data analysis was performed using SPSS (SPSS Inc., Chicago, IL, Version 16). 3. Results There were 205 patients from our database. 31 patients met the inclusion criteria. The patients had a mean age of 46 (range 20–76) years old. The male to female ratio was 10 patients:21 patients. Using the Weber classification, 23 had Weber B and 8 suffered Weber C. There was notably more Weber B than C in our study sample. 15 patients suffered fracture dislocation. Fracture dislocations were more likely to result in trimalleolar fracture pattern (p = 0.001). Patient demographics and fracture classification are shown in Table 1. Of all the trimalleolar fractures, only 8 had the posterior fragment fixed. The posterior fragment size ranged from 6% to 46%, with a mean percentage of 22.3. The average size of fragment fixed was 33% (range 25–46%) while those fragments that were not fixed averaged at 18.6% (range 6–36%). In those patients who suffered fracture dislocation, it was found that the posterior fragment size was larger (25.9%) than those who did not dislocate their ankle
Table 1 Patient demographics. Demographics
N = 31
Mean age (range), years Male, n (%) Fracture dislocation, n (%) Posterior malleolus size, n (range), % Posterior malleolus fixed, n (%) Posterior malleolus size >25%, n (%)
46 (20–76) 10 (32.3) 15 (48.4) 22.7 (6–46) 8 (38.1) 10 (32.3)
Fracture classification (%) Weber B Weber C
23 (74.2) 8 (25.8)
Outcome variables
N = 21
Residual ankle pain, n (%) Residual ankle stiffness, n (%) Residual ankle swelling, n (%) VAS, mean (range) Olerud and Molander score, mean (range)
11 (52.4) 13 (61.9) 10 (47.6) 2.05 (0–9) 78.3 (30–100)
C.C. Hong et al. / Foot and Ankle Surgery 20 (2014) 48–51
50
Table 2 Comparison of posterior fragment size between trimalleolar ankle fracture with dislocation and those without dislocation. Trimalleolar ankle fractures
Fracture dislocation
No dislocation
p value
done under local anaesthesia. Removal of implants was performed in two patients with no complications. These implants were removed at least a year later from the date of surgery after clinical and radiographic evidence of union.
Mean posterior fragment size (%)
25.9
19.6
0.076
4. Discussion
(19.6%) although it was not statistically significant (p = 0.076) (Table 2). 21 patients completed the functional outcome survey. Outcome analysis showed 11 (52.4%) of our patients still complained of residual pain at 1 year while 13 (61.9%) and 10 (47.6%) still had persistent ankle stiffness and swelling. There were no significant difference between the group who had the posterior fragment fixed (O&M score 78.7) and those who did not (O&M score 77.3). Age, gender, fracture dislocation and size of posterior malleolar fragment were not predictors of residual symptoms. Patients who sustained a Weber C ankle fracture had poorer O&M score (67.1) compared to those with Weber B (83.9) injury (p = 0.039). Despite that, the majority of our patients still had good to excellent functional outcome scores according to the O&M score (mean score 78.3, range 30–100). The mean VAS was 2.05 (range 0–9) (Table 1). Using the Spearman correlation test, poorer O&M scores were seen with increasing posterior fragment size (r = 0.781, p = 0.039) (Fig. 1). More than half of our patients (12/21 patients) were involved in sports activities prior to their ankle injury. Only 4 patients are able to return to their pre-injury level of sports without any difficulty after fixation of trimalleolar ankle fracture. There were 3 patients who were unable to return to sports activities at all (Table 3). There was no significant difference in age and gender between those who could or could not return to pre-injury sporting activities. There was also no significant difference that could be seen between posterior fragment size and ability to return to sports. In general, 20 of our patients were satisfied with the ankle surgery postoperatively and all cases achieved union. There were no significant complications except for one case of trimalleolar ankle fracture with prominent screw requiring change of screw
Fig. 1. Correlation between posterior malleolar fragment size and the O&M score.
Table 3 Ability to return to pre-injury sports activities base on self report survey. Ankle fracture
Trimalleolar ankle fracture
Ability to return to pre-injury sports activities No difficulty
Minimal difficulty
Moderate difficulty
Unable to do so
4 (33.3%)
2 (16.7%)
3 (25%)
3 (25%)
Ankle fractures are extremely common with incidences reported to be around 107–184/100,000/year [13]. A concomitant posterior malleolus fracture occurs in 7–44% of all ankle fractures [4,7]. Presence of the posterior malleolar fragment is associated with poorer outcomes and predisposition to development of osteoarthritis especially if the fragment is larger than 25% of the articular surface [9,13]. Tejwani et al. reported that presence of a posterior malleolar fragment in unstable ankle fractures results in worse outcomes at 1 year but this seems to even out over time at 2 years [13]. Juan et al. reported that functional outcomes in terms of AOFAS scores are better in those with posterior malleolar fragment
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Impact of trimalleolar ankle fractures: How do patients fare post-operatively? Choon Chiet Hong MBBS (Sing), MRCS (Edin)a, Nazrul Nashi b, Shuvendu Prosad Roy M.S. Orthopedicsa, Ken Jin Tan MBBS (Sing), MRCS (Edin), Mmed (Ortho), FRCS (Edin)a,* a b
University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore
A R T I C L E I N F O
A B S T R A C T
Article history: Received 7 February 2013 Received in revised form 18 July 2013 Accepted 10 October 2013
Background: We aim to evaluate the clinical and functional outcome of trimalleolar fractures and the ability of patients to return to sporting activities. Methods: A retrospective review of 31 patients with operatively managed trimalleolar fractures was conducted. Their Olerud and Molander scores and ability to return to sports was analyzed at 1 year postoperatively. Results: Dislocations were more likely to result from trimalleolar fractures (p < 0.001). 11 (52.4%) of our patients had residual pain at 1 year. 13 (61.9%) and 10 (47.6%) had persistent ankle stiffness and swelling. Out of 12 patients who were involved in sports pre-operatively, only 4 (33.3%) patients were able to return to sports. 3 (25%) patients were unable to do sports at all. Increasing posterior malleolar fragment size correlates with poorer functional outcome. Conclusions: Patients have poorer functional outcome with increasing posterior malleolar fragment size in trimalleolar fractures. Residual deficits affect the majority of our patients and a notable proportion was unable to return to sporting activities. ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Trimalleolar ankle fracture Trauma Return to sports Posterior malleolar fracture Functional outcome
1. Introduction Ankle fractures are common injuries seen in Orthopaedic practice. Ankle fractures can be classified based on the number of malleoli involved, namely unimalleolar, bimalleolar or trimalleolar fractures. Unstable ankle fractures usually involve fracturedislocations and displacement of the malleoli. Such unstable fractures require early reduction and surgical management to enable stabilization and early mobilization. This is because inadequate reduction often results in early osteoarthritis, pain and loss of ankle joint function [1–3]. Uni- and bimalleolar fractures account for the majority of ankle fractures while trimalleolar fractures are less common, occurring in 7% of all ankle fractures [4]. Trimalleolar ankle fractures have also been shown to result in poorer outcome depending on the size of the posterior malleolar fragment [5,6]. Most surgeons use the size of the posterior
* Corresponding author at: University Orthopaedic, Hand and Reconstructive Microsurgery Cluster, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. Tel.: +65 6779 5555; fax: +65 6775 0913. E-mail address: [email protected] (K.J. Tan).
malleolar fragment as the single most important parameter to decide if the fragment should be fixed. Several studies have shown that fixation of posterior fragment is indicated if it involves more than 25% of the articular surface [5,7–9]. Despite this, there is a lack of studies reviewing the functional outcomes of trimalleolar ankle fractures. We aim to evaluate the incidence of trimalleolar ankle fractures in our institution, the clinical and functional outcome of operatively treated trimalleolar fractures and the ability to return to sporting activities. 2. Methods A retrospective review of all patients admitted to our institution for operative fixation of ankle fractures from January 2009 to December 2010 was performed. These patients were identified using the hospital’s diagnosis and operative code system. Their case notes, electronic records and X-rays were reviewed. This study was approved by the Institutional Review Board (IRB). We excluded patients with open fracture, poly-trauma, concomitant fractures in the ipsilateral lower limb, pathological fracture, concomitant neurovascular injury in the ipsilateral lower limb, pilon fracture, inability to provide consent and skeletally
1268-7731/$ – see front matter ß 2013 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.fas.2013.10.001
C.C. Hong et al. / Foot and Ankle Surgery 20 (2014) 48–51
immature patients. All patients were 18 years old and above and completed at least 1 year of follow up. Pertinent data on patients’ demographics, clinical assessments, pre-operative X-ray findings, operative details, post-operative X-rays and complications were extracted and analyzed statistically. Fractures were classified radiographically into uni-, bi- and trimalleolar fractures as well as into group A, B, or C according to the Danis–Weber classification [10]. However, we excluded the uni- and bimalleolar ankle fractures from our study. Lateral view of the ankle radiographs were used to measure and calculate the posterior malleolar fragment size as a percentage of the articular surface. Measurements were made using our radiographic system (Centricity Enterprise Web, GE Healthcare). Post-operative radiographs were reviewed and union was defined as complete cortical bridging between proximal and distal fragments with no visible fracture line. The first author did all the measurements so as to minimize inter-observer differences and maintain consistency. Outcome measurements were that of union rates, Visual Analogue Scale (VAS), Olerud and Molander (O&M) score [11], ability to return to sporting activities, satisfaction with surgery and presence of surgical complications. The O&M score is a validated ankle specific functional scoring system. It is a patient self-reported questionnaire used to evaluate ankle specific functional outcome and impact of certain intervention over time. It covers 9 areas: (1) pain; (2) stiffness; (3) swelling; (4) stair-climbing; (5) running; (6) jumping; (7) squatting; (8) supports; and (9) work and activities of daily living. Scores range from a minimum (zero) to a maximum (100) points. In addition, satisfaction with surgery was based on self-report by the patients. All surgeries were performed by fellowship-trained Orthopaedic consultants and specialist registrars. Surgeries were performed under anaesthesia and fluoroscopy guidance. Plate and screw constructs were used in a standard manner. 25 (80.6%) of the medial malleolus fractures were fixed with two 3.5 mm partially threaded cancellous screws while 3 (9.7%) of them had tension band wiring using 2 Kirschner wires. Another 3 (9.7%) cases of medial malleolus fractures had a mixture of one 3.5 mm partially threaded screw with a single Kirschner wiring. On the other hand, 19 (61.3%) of the lateral malleolus fractures were fixed with a one third tubular plate while 12 (38.7%) cases were fixed with the 3.5 mm LC-DCP plate. Syndesmosis fixation was performed at the surgeons’ discretion intra-operatively after routine syndesmosis complex examination under fluoroscopy. It is indicated if the routine syndesmosis examination under fluoroscopy showed unstable syndesmosis. Cotton’s test is commonly employed in our institution to test the integrity of the syndesmosis. We routinely use syndesmotic screw fixation for ankle fractures with an unstable syndesmosis. A 3.5 cm cortical screw is placed at the apex of the syndesmosis 2 cm above the tibiotalar joint [12]. It is inserted obliquely from the fibula to the tibia starting posterolaterally aiming anteromedially with a tricortical purchase while the ankle is in neutral dorsiflexion. On top of that, fixation of the posterior malleolar fragment remains controversial. As a guide, posterior malleolar fragment size >25% are usually fixed as it was shown to produce better outcomes radiographically and clinically [5,7,14–16]. However, in this study, we analyze retrospectively all operatively treated trimalleolar ankle fractures and therefore the criteria for fixation then cannot be fully defined. We have checked with the majority of the surgeons who performed the surgeries then and the consensus was that majority agree with fixation of the posterior malleolar fragment if they are >25% but if the posterior fragment remained stable on ankle range of motion testing after reduction and fixation of both malleolus, some of the surgeons may not proceed with posterior malleolar fragment fixation. Post-operatively, a backslab was applied with the ankle in neutral position and the patient kept on non-weight bearing on the
49
affected limb for 6 weeks. All patients were reviewed 2 weeks postoperatively for wound inspection and suture removal if needed and then 6 weeks post-operatively for review and advancement of weight bearing status with assistance from the physiotherapists. At 2 weeks, they were reviewed by our physiotherapist and started on ankle range of motion and proprioceptive exercises if there were no wound complications. Weight bearing exercises were started after the initial 6 weeks of non-weight bearing. If the patient received a syndesmotic screw fixation, we routinely removed the screw under local anaesthesia at about 8–12 weeks post ankle fracture fixation. The patient is allowed to weight bear as tolerated after the initial 6 weeks of non-weight bearing and this will continue after the screw removal. Further rehabilitative sessions were conducted by the physiotherapist until the patients were able to return to their pre-injury levels of daily activities. Subsequent reviews were at 3, 6 and 12 months with radiographic monitoring, clinical assessment and functional outcome survey using the O&M score. Data entry was performed using a spreadsheet application (Excel 2003, Microsoft Corp., Redmond, WA). Frequency tables and descriptive statistics (mean, standard deviation or median where appropriate) were presented for all variables. Categorical variables were presented as proportions and continuous variables were presented as mean. Chi-square test was used for comparison between categorical variables. Spearman correlation test was used as well. Statistical significance was set at p 0.05 and data analysis was performed using SPSS (SPSS Inc., Chicago, IL, Version 16). 3. Results There were 205 patients from our database. 31 patients met the inclusion criteria. The patients had a mean age of 46 (range 20–76) years old. The male to female ratio was 10 patients:21 patients. Using the Weber classification, 23 had Weber B and 8 suffered Weber C. There was notably more Weber B than C in our study sample. 15 patients suffered fracture dislocation. Fracture dislocations were more likely to result in trimalleolar fracture pattern (p = 0.001). Patient demographics and fracture classification are shown in Table 1. Of all the trimalleolar fractures, only 8 had the posterior fragment fixed. The posterior fragment size ranged from 6% to 46%, with a mean percentage of 22.3. The average size of fragment fixed was 33% (range 25–46%) while those fragments that were not fixed averaged at 18.6% (range 6–36%). In those patients who suffered fracture dislocation, it was found that the posterior fragment size was larger (25.9%) than those who did not dislocate their ankle
Table 1 Patient demographics. Demographics
N = 31
Mean age (range), years Male, n (%) Fracture dislocation, n (%) Posterior malleolus size, n (range), % Posterior malleolus fixed, n (%) Posterior malleolus size >25%, n (%)
46 (20–76) 10 (32.3) 15 (48.4) 22.7 (6–46) 8 (38.1) 10 (32.3)
Fracture classification (%) Weber B Weber C
23 (74.2) 8 (25.8)
Outcome variables
N = 21
Residual ankle pain, n (%) Residual ankle stiffness, n (%) Residual ankle swelling, n (%) VAS, mean (range) Olerud and Molander score, mean (range)
11 (52.4) 13 (61.9) 10 (47.6) 2.05 (0–9) 78.3 (30–100)
C.C. Hong et al. / Foot and Ankle Surgery 20 (2014) 48–51
50
Table 2 Comparison of posterior fragment size between trimalleolar ankle fracture with dislocation and those without dislocation. Trimalleolar ankle fractures
Fracture dislocation
No dislocation
p value
done under local anaesthesia. Removal of implants was performed in two patients with no complications. These implants were removed at least a year later from the date of surgery after clinical and radiographic evidence of union.
Mean posterior fragment size (%)
25.9
19.6
0.076
4. Discussion
(19.6%) although it was not statistically significant (p = 0.076) (Table 2). 21 patients completed the functional outcome survey. Outcome analysis showed 11 (52.4%) of our patients still complained of residual pain at 1 year while 13 (61.9%) and 10 (47.6%) still had persistent ankle stiffness and swelling. There were no significant difference between the group who had the posterior fragment fixed (O&M score 78.7) and those who did not (O&M score 77.3). Age, gender, fracture dislocation and size of posterior malleolar fragment were not predictors of residual symptoms. Patients who sustained a Weber C ankle fracture had poorer O&M score (67.1) compared to those with Weber B (83.9) injury (p = 0.039). Despite that, the majority of our patients still had good to excellent functional outcome scores according to the O&M score (mean score 78.3, range 30–100). The mean VAS was 2.05 (range 0–9) (Table 1). Using the Spearman correlation test, poorer O&M scores were seen with increasing posterior fragment size (r = 0.781, p = 0.039) (Fig. 1). More than half of our patients (12/21 patients) were involved in sports activities prior to their ankle injury. Only 4 patients are able to return to their pre-injury level of sports without any difficulty after fixation of trimalleolar ankle fracture. There were 3 patients who were unable to return to sports activities at all (Table 3). There was no significant difference in age and gender between those who could or could not return to pre-injury sporting activities. There was also no significant difference that could be seen between posterior fragment size and ability to return to sports. In general, 20 of our patients were satisfied with the ankle surgery postoperatively and all cases achieved union. There were no significant complications except for one case of trimalleolar ankle fracture with prominent screw requiring change of screw
Fig. 1. Correlation between posterior malleolar fragment size and the O&M score.
Table 3 Ability to return to pre-injury sports activities base on self report survey. Ankle fracture
Trimalleolar ankle fracture
Ability to return to pre-injury sports activities No difficulty
Minimal difficulty
Moderate difficulty
Unable to do so
4 (33.3%)
2 (16.7%)
3 (25%)
3 (25%)
Ankle fractures are extremely common with incidences reported to be around 107–184/100,000/year [13]. A concomitant posterior malleolus fracture occurs in 7–44% of all ankle fractures [4,7]. Presence of the posterior malleolar fragment is associated with poorer outcomes and predisposition to development of osteoarthritis especially if the fragment is larger than 25% of the articular surface [9,13]. Tejwani et al. reported that presence of a posterior malleolar fragment in unstable ankle fractures results in worse outcomes at 1 year but this seems to even out over time at 2 years [13]. Juan et al. reported that functional outcomes in terms of AOFAS scores are better in those with posterior malleolar fragment
