International Journal of Research in Orthopaedics

Gangadhran N et al. Int J Res Orthop. 2021 May;7(3):518-525

http://www.ijoro.org

DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20211604
Original Research Article

Study on functional outcome of bimalleolar ankle fractures

treated by open reduction and internal fixation
Nithin Gangadhran1*, Manju G. Pillai2

1
Department Of Orthopaedics, KMCT Medical College, Calicut, Kerala, India
2
Department Of Orthopaedics , Pushpagiri Insititue of Medical Sciences, Thiruvalla, Kerala, India

Received: 30 December 2020

Revised: 01 April 2021
Accepted: 02 April 2021

*Correspondence:
Dr. Nithin Gangadhran,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Ankle injury is the most common weight bearing orthopaedic musculoskeletal trauma encountered in
emergency medicine and practice. Ankle joint is highly congruous and any disturbance of normal articular relationship
may result in some progressive arthrosis of biomechanical dysfunction. As with all intra-articular fractures it
necessitates accurate reduction and stable internal fixation. The objectives were to study the functional outcome of
surgical treatment of bimalleolar ankle fractures and to know the complications of open reduction internal fixation of
bimalleolar fractures.
Methods: 45 patients with malleolar fractures were included in this prospective longitudinal interventional study.
Patients who underwent operative treatment were followed up regularly for 6 months with OPD visits and X-ray
imaging at each stage. Patient parameters were recorded at immediate post op period, 6 weeks, 12 weeks and 24 weeks.
Baird and Jackson scoring system for ankle were used for the functional outcome measurement.
Results: Most common type of injury pattern was supination-external rotation with 21 cases (47% of cases). The results
are excellent to good in 65% of patients, 27% of patients had fair and 8% had poor result. Syndesmotic screw fixation
was done with 4.5 mm cortical screw in 7 cases. Most common complication was surgical site infection in 3 cases
(6.67%). 2 patients underwent implant removal due to unresolved infection at 3 months.
Conclusions: The results of operative fixation were satisfactory in 90% of patients. Most of the complications were
minor and resolved within three weeks.

Keywords: Bimalleolar fracture, Baird and Jackson scoring, Functional outcome of ankle fracture, Operative
management

INTRODUCTION Ankle joint is highly congruous and any disturbance of the

normal articular relationship may result in some
Ankle injury is the most common weight bearing progressive arthrosis in some biomechanical dysfunction.1
orthopaedic musculoskeletal trauma encountered in In the clinical setting determination of ankle stability is
emergency medicine and practice.1 There is an increase in critical when planning fracture management. Stable
incidence of ankle fractures in the older patients fracture can be treated conservatively with good results
population due to increased propensity to falls, increased although outcomes in the management of unstable ankle
weight and polypharmacy. fractures are often better with surgical treatment. The
superiority of open reduction internal fixation over closed

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treatment have been thoroughly demonstrated in the analyzed using SPSS software. Association between
literature.2 various factors were assessed using chi square test and p
value <0.05 was set as statistically significant.
Malleolar fractures are one of the most common fractures
in orthopaedic traumatology. As with all intra articular RESULTS
fractures, malleolar fractures necessitate accurate
reduction and stable internal fixation. Lateral malleolar Forty five cases of bimalleolar fractures managed
fractures in the setting of a competent deep deltoid surgically by various techniques are presented. The study
ligament can usually be treated non-operative with good comprises of 56% female patients and 44% male patients.
results. In contrast, a lateral malleolar fracture with an Most common age group affected is 61-70 years (32%, 14
incompetent deep deltoid ligament is clinically equivalent cases). Right side was involved in 26 cases (58%)
to a bimalleolar ankle fracture and may result in talar compared to left side (19 cases). Twisting injury following
subluxation and degenerative arthritis when treated non- domestic fall was major cause of injury constituting 71%
operative.3 The objective of this study was to study the of the patients. Supination-external rotation injury type
functional outcome of surgical treatment of bimalleolar was the most common fracture pattern constituting 47% of
ankle fractures and to know the complications of open the cases. Surgical techniques used were open reduction
reduction internal fixation of bimalleolar fractures. and internal fixation of lateral malleolus with 1/3rd tubular
plate/recon plate with or without syndesmotic screw
METHODS fixation and the medial malleolus with 4 mm cannulated
cancellous/malleolar screws or tension band wiring. Most
Prospective interventional study was done on patients with common complication faced was postoperative skin
bimalleolar fractures of ankle who attended Pushpagiri infection in 3 cases and 2 patients among them had to
institute of medical science and research centre, undergo implant removal at 3 months. Chances of non-
Thiruvalla, Kerala between December 2012 and union of medial malleolus due to periosteal interposition is
November 2014. Study was conducted after obtaining avoided by open reduction. Understanding the mechanism
prior approval from ethics committee of the institution. A of injury is essential for good reduction and internal
written informed consent was taken from all patients after fixation. The bend of lateral malleolar should be
explaining the detailed nature of the study. During the reproduced during lateral plating for fibula. Fibular length
study all consecutive subjects with bimalleolar fractures of should be maintained for good ankle stability. Good
ankle in age group of 20 to 70 years were selected and anatomical reduction is essential for good clinical outcome
operated upon by same team of orthopaedic surgeons and irrespective of the type of fracture. At the end of the study
followed up for a period of 6 months. excellent to good results were seen in 29 (65%) cases, 12
(27%) cases had fair results and 4 (8%) had poor result.
Exclusion criteria Statistical analysis was done and found that age of the
patient was a significant determinant of postoperative
Patients below 20 and above 70 years of age, with medical functional outcome and pain. (p value 0.002 and 0.011
contraindications to surgery, with paralytic limb, open respectively).There was no statistical significance of
fractures and other associated fractures in the same limb postoperative outcome with respect to sex of the patient,
were excluded from the study. mode of injury, type of injury, co-morbidities.

A population of 100 was taken and a confidence level of Age distribution

95% was set. Confidence interval of 15 was selected based
on worst case percentage as 50% and required sample size 14 patients (32%) were from 61-70 year age group
was calculated as 30. Several previous studies were based followed by 13 (29%) patients each in 51-60 and 41- 50
on similar sample size. A total of 63 patients had attended years age group (Figure 1). The youngest patient was 23
the casualty with bimalleolar fractures of ankle and out of year old and oldest was 70 year age. The mean age in this
these 8 patients had open fractures, 6 patients were above study is 53.5 years.
the age of 70 years and 4 had other fractures in same limb.
Hence 45 patients who satisfied the inclusion criteria were Statistical analysis of data was done for age and
selected for the study. Patients who underwent operative complications and chi-square value was found to be 8.753
treatment were followed up regularly for 6 months with and p value was calculated to be 0.460. There was no
OPD visits and X-ray imaging at each stage. Patient statistical significance noted in the study.
parameters were recorded at immediate post-op period, 6
weeks, 12 weeks and 24 weeks. Baird and Jackson scoring Statistical analysis of age and pain was done and chi-
system for ankle were used for the functional outcome square value was 9.033 and p value 0.011, which was
measurement. Ankle ranges of movements were measured found to be significant.
with goniometer. Baird and Jackson score for each patient
was critically analyzed and outcome of each patient Statistical analysis of age and result was done and chi-
categorised as excellent, good, fair and poor depending on square value was 14.562 and p value 0.002 which was
total scores. Data was entered into Microsoft excel and found to be significant.

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Younger patients had better tolerance level to pain and Analysis of mode of injury and complications was done
hence their functional outcome was better with respect to and chi-square value was 9.844 and p value 0.363 which
older patients in this study. was found to be statistically insignificant (Figure 3).

Analysis of mode of injury and pain was done and chi-

14 13 13 square value was 0.495 and p value 0.781 which was
12 11 statistically insignificant.
10 number
Statistical analysis of mode of injury and result was done
8 and chi-square was 0.184 and p value 0.980 which was
6 4 insignificant.
4
2 1
0
21-30 31-40 41-50 51-60 61-70 29%
fall
Figure 1: Age distribution.
road traffic
Sex distribution accident
71%
Majority of the patients were females 25 (56%) patients
and 20 (44%) patients were males (Figure 2).

Analysis of sex and result was done and chi-square value

Figure 3: Percentage of subjects in the study
was 1.286 and p value was 0.526 which was found to be
according to mode of injury.
statistically insignificant.
Side of injury
Analysis of sex and result was done and chi-square value
was 2.131 and p value was 0.546 which was found to be
Right ankle was involved in 26 (58%) patients and in 19
statistically insignificant.
(42%) patients left ankle was involved (Figure 4).

44% 19
right
male
left
female 26
56%

Figure 4: Percentage of subjects in the study

according to side of injury.
Figure 2: Percentage of subjects in the study
according to sex. Type of injury

Mode of injury In this study 21 (47%) patients had supination external

rotation injuries, which is the majority followed by 11
The major cause of fracture in present study was fall by (24%) patients having pronation abduction injury and 8
either twisting, slipping or stumbling in 32 cases (71%) (18%) patients pronation external rotation injury.
and in 13 cases (29%), fracture was due to road traffic Remaining 5 (11%) patients had pronation abduction
accident. injury (Figure 5).

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Analysis of type of injury and complications was done and Analysis of DM and complications was done and chi-
chi-square value was 23.444 and p value was 0.661 which square value was 8.068 and p value was 0.527 which was
was statistically insignificant. statistically insignificant.

Analysis of type of injury and pain was done and chi- Analysis of DM and pain was done and chi-square value
square value was 2.414 and p value was 0.878 which was was 4.675 and p value was 0.097 which was statistically
statistically insignificant. insignificant.

Analysis of type of injury and result was done and chi- Analysis of DM and result was done and chi-square value
square value was 5.187 and p value was 0.818 which was was 7.361 and p value was 0.061 which was statistically
found to be statistically insignificant. insignificant.

Implants used

11 Medial malleolus were used in 4 mm cannulated

SER cancellous screw 34 cases, malleolar screw 9 cases,
SADD tension band wiring 1 case, 1/3rdtubular plate 1 case.
21
PER Lateral malleolus were used in 1/3rd tubular plate 39
8 cases.
PABD

Recon plate was used in 6 cases.

5
Syndesmotic screw (3.5mm cortical screw) was used in 7
Figure 5: Percentage of subjects in the study cases (Figure 7).
according to type of injury.
45 39 Cannulated
Comorbidities 40 34 cancellous
35
30 screw
In this study 6 patients were having hypertension, 12 were 25 Malleolar
having type II diabetes mellitus, 1 each had bronchial 20 screw
15 9 7
asthma and coronary artery disease. During the course of 10 6
fracture treatment all the diabetic patients were brought 5 1100 000 0 00000 TBW
under strict diabetic control. 8 out of 20 males were 0
smokers and none of the females were having any
addictions (Figure 6). 1/3rd
tubular
plate
14 12 Recron
12 plate
10 8
8 6 Figure 7: Implants used in present study.
6
4 Complications
2 1 1
0 3 patients had superficial skin infection which healed by 3
HTN DM CAD BA SMOKER weeks. 2 patients had to undergo implant removal before 3
months due to unresolved infection at surgical site.
Figure 6: Percentage of co-morbidites.
Statistical analysis of complications was done and chi-
square value was 8.663 and p value was 0.469 which was
Analysis of co-morbidities and result was done and chi- insignificant. Statistical analysis of comorbidities and
square value was 29.789 and p value was 0.192 which was
complications was done and chi-square value was 35.596
statistically insignificant.
and p value was 1.000 which was insignificant.
Analysis of co-morbidities and pain was done and chi-
square value was 9.396 and p value 0.896 which was
statistically insignificant.

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Final outcome Ability to work

Ankle pain 29 (64%) patients were able to perform usual occupation

without restriction and the rest 16 (34%) patients were able
In this series 35 patients (78%) had mild to moderate pain to perform usual occupation with restriction in some
during strenuous activities and 10 patients (22%) had pain strenuous activities.
with activities of daily living.
Motion of ankle
Stability of ankle
40 (89%) patients had range of motion of the ankle within
None of the patients had instability of ankle. 10° of uninjured ankle and 4 (9%) patients were having
motion within 20° of uninjured ankle. The remaining 1
Ability to walk (2%) patient had dorsiflexion of ankle less than 50.

40 (89%) of patients could walk desired distances with or Radiological result

without limp or mild pain. 5 patients (11%) had moderate
restriction in ability to walk. 40 patients (89%) had intact ankle mortise with normal
clear space, normal superior joint space and no talar tilt. 4
Ability to run patients (9%) had mild reactive changes at joint margin
and remaining 1 patient (2%) had severe narrowing of joint
18 (40%) patients were able to run desired distances space (<1 mm), widening of medial clear space, sclerotic
without pain, 19 (42%) patients were able to run desired subchondral bone and osteophyte formation (Table 1).
distances with slight pain and 8 (18%) patients had
moderate restriction or ability to run short distance only. Composite score

Excellent results were achieved in 13 (29%), good in 16

(36%), fair in 12 (27%) and poor in 4 (8%) of patients
(Table 2).

Table 1: Final score according to subjective, objective and radiological criteria.

Criteria Grade a Grade b Grade c Grade d Grade e Total

Pain 10 35 0 0 0 45
Stability of ankle 45 0 0 0 0 45
Ability to walk 25 15 5 0 0 45
Ability to run 18 19 5 3 0 45
Ability to work 29 16 0 0 0 45
Ankle movements 40 4 0 0 1 45
Radiography 40 4 0 0 1 45

Table 2: Composite score.

Composite scores Number of patients Percentage (%)

96-100 (excellent) 13 29
91-95 ( good) 16 36
81-90 (fair) 12 27
0-80 (poor) 4 8
Total 45 100

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a b c d

e f g

h i j k

l m n

Figure 8: Clinical and radiological pictures of cases supination external rotation injury; (a) pre-operative
X-ray, (b) post-operative X-ray (ORIF with 4 mm CCS and 1/3rd tubular plate); (c, d) follow up at 6 months
(dorsiflexion of ankle and plantar flexion of ankle), pronation external rotation injury; (e, f) pre-operative X-ray;
(g) post-operative X-ray (ORIF with 4 mm CCS and 1/3rd tubular plate); (h and i) follow up at 6 months
(dorsiflexion of ankle and plantar flexion of ankle), pronation abduction injury; (j, k) pre-operative X-ray; (l) post-
operative X-ray (ORIF with 4 mm CCS, 1/3rd tubular plate and syndesmotic screw); (m, n) follow up at 6 months
(dorsiflexion of ankle and plantar flexion of ankle).

DISCUSSION ankle joint may subluxate and may be associated with

fracture of both malleoli which would be either simple or
Evidence of healed ankle fractures has been described in compound. It was assumed that the compound fracture
the remains of mummies from ancient Egypt. A detailed dislocation of ankle does not need any treatment because
account of lesions around ankle joint was given by the patients probably die in 7 days. Sir Percival Pott (1714-
Hippocrates as early as 300 BC. He mentioned that the 1788) was a surgeon at St. Bartholomew’s hospital,

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London in the year 1756. He sustained compound fracture The first and perhaps the most important contribution to
of ankle due to fall while riding a horse. The treatment the understanding of ankle fractures is credited to Lauge-
during this period was amputation for compound fracture Hansen in 1942. His doctoral thesis was not widely read or
having suffered he made a detailed description and studied appreciated until his first english publication in 1948. This
the pathological anatomy of ankle fractures. He introduced was followed by other important articles further defining
the reposition in semi flexion to reduce the fracture.4 and explaining the basis of sequential ankle fracture injury
based on experimental and radiographic studies. Two
In 1771, Jean Pierre David was the first to try to explain additional periods developed since Lauge-Hansen
the mechanism of injury in fractures of ankle and wrote classification. The AO-ASIF period (1957) of ankle
that ligaments that held the fibula in combination with fracture case was pioneered by Willenegger Allgrower,
outward movement of the foot (external rotation) resulted Muller and Schneider. Collectively this group pursued on
in a fracture of the distal fibula. During the next 150 years, bold new course of operative treatment based on unique
most experimental studies on the production of ankle metallic implants and bio-mechanical principles. Weber
injuries were done by French. In 1816, Dupuytren used a devised a classification scheme based on the original
cadaver experiments to produce ankle fractures by principles of Danis (1947-1949) which became known as
abduction or outward movement of foot.5 In 1822, Sir the Danis-Weber classification of AO (1972-1975).
Astley Cooper of London, described a wide range of ankle
fractures including the anterior and posterior margins of In 1994, Wilson et al described the malleolar fractures
lower end of tibia. resulting from isolated plantar flexion injuries both
malleoli are fractured obliquely in the sagittal plank,
In 1828, Earl was the first to describe the posterior lip though the lateral malleolar fracture runs posteriorly and
fracture of tibia.6 upwards, whereas medial malleolar fracture courses
posteriorly and downward. The results of 144 malleolar
In 1840, Maisonneuve, a pupil of Dupuytren was the first fractures during a 10 year period that were classified and
and almost only surgeon before 20th century to emphasize treated according to the AO system. Assessment of
the role of external rotation in the production of ankle outcome was done using the scoring system of Baird and
fractures showing how the external rotation of the talus in Jackson. Excellent and good results were achieved in 107
the ankle mortise could produce the high fracture of fibula of the 144 patients surgically treated.17
that bears his name.7 In 1848, Tillaux described an external
rotation fracture in which the anterolateral corner of the Majority of bimalleolar fractures that we studied were
lower tibia was avulsed by the tibio-fibular ligament.8 In supination external rotation injuries. The most common
1875, Wagstaffe described a fibular counterpart of the aetiology being road traffic accident. Females are more
tillaux fracture. In 1894, Lane was the first to recommend prone with age incidence of 61-70 years. Understanding
operative treatment in order to achieve an anatomic the mechanism of injury is essential for good reduction and
reduction of ankle. internal fixation. The bend of lateral malleolus should be
reproduced during lateral plating for fibula. Fibular length
In 1911, Destot described the comminuted fracture of the should be maintained for good ankle stability. Good
tibial plafond that has since been referred to as pilon or anatomical reduction is essential for good clinical outcome
pestle fracture.9 Destot used roentgenographic imagines to irrespective of the type of fracture. The results of operative
enhance his observations of ankle fractures. In 1922, fixation are satisfactory in 90% of patients. Chances of
Ashurst and Bromer, published a classic study on non-union of medial malleolus due to periosteal
classification and mechanism of fractures of leg bones interposition is avoided. Most of the complications were
involving ankles.10 They divided the fractures into minor and resolved within three weeks. Tension band
categories of adduction, abduction, external rotation and wiring is the method preferred for small fragments and
compression. Ashurst and Bromer were the first USG osteoporotic bone. Cast immobilization for four weeks did
anatomic, surgical and radiographic studies to postulate not affect movements at ankle because the duration was
their classification scheme, but they emphasized the bony very short.
components while ignoring the concomitant ligamentous
injuries. CONCLUSION

Almost 50 years after Earl’s report on posterior lip Majority of bimalleolar fractures that we studied were
fractures, Nelaton described fracture of the anterior lip of supination external rotation injuries. The most common
tibia.11 Muller (1945) recommended open reduction and aetiology being road traffic accident. Females are more
internal fixation of the ankle fractures and allowed prone with age incidence of 61-70 years. Understanding
immediate movement of the involved joint and the the mechanism of injury is essential for good reduction and
adjacent muscles. Bosworth in 1947, provided the first internal fixation. The bend of lateral malleolus should be
description of a low, external rotation fracture of the fibula reproduced during lateral plating for fibula. Fibular length
in which the displace proximal fragment became locked should be maintained for good ankle stability. Good
behind the posterior tibia, where it was held by an intact anatomical reduction is essential for good clinical outcome
interosseous membrane.12 irrespective of the type of fracture. The results of operative

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 Gangadhran N et al. Int J Res Orthop. 2021 May;7(3):518-525

fixation are satisfactory in 90% of patients. Chances of 8. Tillaux D. Recherches clinique setexperimentalessur
non-union of medial malleolus due to periosteal les fractures malleolaires. Bull Acad Med.
interposition is avoided. Most of the complications were 1872;1:817.
minor and resolved within three weeks. Tension band 9. Michelson J, Moskovitz P, Labropoulos P. The
wiring is the method preferred for small fragments and nomenclature for intra-articular vertical impact
osteoporotic bone. Cast immobilization for four weeks did fractures of the tibial plafond: pilon versus pylon.
not affect movements at ankle because the duration was Foot Ankle Int. 2004;25(3):149-50.
very short. 10. Ashurst APC, Bromer RS. Classification and
mechanism of fractures of the legbones involving the
ACKNOWLEDGEMENTS ankle: based on a study of three hundred cases from
the episcopal hospital. Arch Surg. 1922;4:51-129.
We would like to thank all our patients who sincerely 11. Nelaton A. Elements of pathologic chirorgicale. 2nd
formed very important part of this study. ed. Paris: Germer-Baillaine; 1874: 296.
12. Bosworth DM. Fracture-dislocation of the ankle with
Funding: No funding sources fixed displacement of the fibula behind the tibia. J
Conflict of interest: None declared Bone Joint Surg Am. 1947;29:130-5.
Ethical approval: The study was approved by the 13. Lauge-Hansen N. Fractures of the ankle. III: genetic
institutional ethics committee roentgenologic diagnosis of fractures of the ankle.
Am J Roentgenol Radium Ther Nucl Med.
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