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April 18, 2026Open Access

Three-Cortex Syndesmotic Fixation for Weber Type B/C Lateral Malleolus Fractures with Syndesmotic Disruption: Clinical and Radiologic Results

Key Points

The aim is to evaluate clinical and radiological outcomes of three-cortex syndesmotic fixation for Weber type B/C lateral malleolus fractures with syndesmotic disruption.
Analyzed 36 patients with Weber type B/C lateral malleolus fractures treated from 2011 to 2022.
Patients underwent open reduction and fixation with plates and screws, and 3.5 mm cortical syndesmosis fixation.
Preoperative and postoperative radiological assessments were reviewed, using ICC for agreement on several measurements.
Mean AOFAS postoperative score was 91.08 ± 9.90, indicating excellent functional outcomes.
Inter-observer agreement for preoperative parameters was excellent (ICC > 0.9), but poor for postoperative ATFR measurement (ICC < 0.5).
Significant differences in four radiological parameters after an average follow-up of 20 months, indicating improved stability.

Abstract

Background: Despite the frequent occurrence of ankle injuries, there is no consensus among orthopedic surgeons regarding the diagnosis and treatment of syndesmotic injuries. This study evaluates the clinical and radiological outcomes of three-cortex syndesmotic fixation in Weber type B/C lateral malleolus fractures (with or without medial malleolus involvement) associated with syndesmotic injury. Material and Method: This study analyzed thirty-six (36) patients with Weber type B/C lateral malleolus fractures treated between 2011 and 2022. All underwent open reduction and fixation with plates and screws for malleolar fractures, along with a 3.5 mm cortical syndesmosis fixation using three cortical engagements. Preoperative and postoperative radiological findings and final functional ankle assessments were reviewed. Intraclass correlation coefficients (ICC) were used to assess inter- and intra-observer agreement for tibiofibular clear space (TFCS), tibiofibular overlap (TFO), medial clear space (MCS), and anterior tibiofibular ratio (ATFR) measurements. The functional status of the ankle has been assessed using the American Orthopedic Foot and Ankle Society (AOFAS) scale. Results: The mean age of the patients was 50.56 ± 16.23 years, and the mean follow-up duration was 20.89 ± 24.93 months. Postoperative AOFAS scores averaged 91.08 ± 9.90. The inter-observer agreement for preoperative assessments was excellent across all parameters (ICC > 0.9). However, in the postoperative period, inter-observer agreement for ATFR measurement was poor (ICC 0.9). Intra-observer comparisons of preoperative (pre-op) and postoperative (post-op) measurements were poor across all parameters (ICC < 0.5); this can be attributed to the success of reduction, reflecting the positive directional change on all parameters. After an average follow-up of 20 months, four radiological parameters showed significant differences, indicating enhanced stability and reduced diastasis. Conclusions: Three-cortex syndesmotic screw fixation in Weber type B/C lateral malleolus fractures with syndesmotic injuries yielded excellent mid-term radiological and functional outcomes.

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