Trends in Posterior Malleolus Fixation and Subsequent Syndesmotic Repair in Trimalleolar Ankle Fractures

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Abstract

OBJECTIVES: To evaluate treatment trends for trimalleolar fractures, specifically assessing whether increased posterior malleolus fixation was associated with reduced syndesmotic repair. METHODS: Design: Retrospective cohort analysis Setting: PearlDiver (Mariner dataset) database (2010-2021) Patient Selection Criteria: Patients were stratified according to ICD-9/10 and CPT codes into four cohorts based on index procedure: trimalleolar ORIF with posterior lip fixation and syndesmotic repair, trimalleolar ORIF with posterior lip fixation and without syndesmotic repair, trimalleolar ORIF without posterior lip fixation and with syndesmotic repair, and trimalleolar ORIF without posterior lip fixation and without syndesmotic repair. Exclusion criteria included: less than 18 years old, pregnancy, prior ankle osteoarthritis, connective tissue disease, or syndesmotic repair unrelated to trimalleolar ankle fractures. Outcome Measures and Comparisons: Annual percentage incidence of syndesmotic repair within these cohorts was tabulated and compound annual growth rate (CAGR) and Mann Kendall analysis was performed to assess trends. χ2 analysis evaluated characteristics associated with posterior fixation. RESULTS: From 2010-2021, the incidence of concomitant posterior malleolus fixation in trimalleolar ORIF increased from 17.6% to 21.4% (CAGR: +6.2%, Mann Kendall p-value: 0.011). The incidence of trimalleolar ORIF without posterior fixation decreased from 82.4% to 78.6% (CAGR: -3.0%, Mann Kendall p-value: 0.04). The incidence of syndesmotic repair following trimalleolar fixation increased from 10.1% to 29.3% (CAGR for posterior fixation: +17.0%, Mann Kendall p-value: < 0.001; CAGR for no posterior fixation: +13.1%, Mann Kendall p-value: < 0.001). Trimalleolar ORIF with posterior fixation demonstrated similar rates of malunion, nonunion, and reoperation at two-years postoperative, with no significant differences on χ2 analysis, compared to those without posterior malleolus fixation. CONCLUSIONS: The incidence of trimalleolar ORIF with posterior lip fixation increased over the past decade, and contrary to the hypothesis, the rate of subsequent syndesmotic repair following trimalleolar ORIF also increased. LEVEL OF EVIDENCE: III