BACKGROUND:
Fixation of unstable ankle fractures, including fixation of posterior malleolus fracture fragments with the attached, intact posteroinferior tibiofibular ligament (PITFL), reportedly provides more stable fixation than transsyndesmotic screws.

QUESTIONS/PURPOSES:
To confirm this observation we compared the Foot and Ankle Outcome Score (FAOS) and radiographic maintenance of fixation for fractures treated through direct posterior malleolar fixation versus syndesmotic screw fixation.

METHODS:
We prospectively followed 31 one patients with unstable ankle fractures treated with (1) open posterior malleolus fixation whenever the posterior malleolus was fractured, regardless of fragment size (PM group; n = 9); (2) locked syndesmotic screws in the absence of a posterior malleolar fracture (S group; n = 14); or (3) combined fixation in fracture-dislocations and more severe soft tissue injury (C group; n = 8). All patients had preoperative MRI confirming syndesmotic injury and an intact PITFL; postoperative and followup radiographs were evaluated for syndesmotic congruence. The minimum followup was 12 months (mean, 15 months; range, 12-31 months).

RESULTS:
Postoperative and followup FAOS scores were similar in the three groups. The tibiofibular clear space was greater in the S versus the PM group, but we found no other differences in the postoperative versus followup measurements between the PM, S, and C groups.

CONCLUSIONS:
Syndesmotic fixation through the posterior malleolus and PITFL is maintained at followup, and these patients have functional outcomes at least equivalent to outcomes for patients having syndesmotic screw fixation.

LEVEL OF EVIDENCE:
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.