SLR - August 2019 - Kyle A. Bray

Anterior Inferior Tibiofibular Ligament Avulsion Fractures in Operatively Treated Ankle Fractures: A Retrospective Analysis

Reference: Birnie, M. F., Schilt, K. L., Sanders, F. R., Kloen, P., & Schepers, T. (2019). Anterior Inferior Tibiofibular Ligament Avulsion Fractures in Operatively Treated Ankle Fractures: A Retrospective Analysis. Archives of Orthopaedic and Trauma Surgery, 139(6), 787-793.

Scientific Literature Review

Reviewed By: Kyle A. Bray, DPM
Residency Program: St. Vincent Charity Medical Center – Cleveland, OH

Podiatric Relevance: Ankle fractures are a common fracture treated by foot and ankle surgeons. Proper alignment and maintenance of stability allows for appropriate weightbearing mechanics following fracture fixation. Tilleaux-Chaput and Wagstaffe fractures are uncommon fractures that occur during rotational injuries. These unique fracture patterns are often acutely missed and may lead to permanent instability. The purpose of this retrospective analysis is to review the literature and determine the optimal treatment for anterior inferior tibiofibular ligament (AITFL) avulsion fractures.

Methods: This was a retrospective study conducted at a level 1 trauma center January 2009 through January 2017. Ankle fractures were classified using Lauge-Hansen, Weber, and Pott’s classifications based on CT and radiographic images. An AITFL avulsion fracture was then identified for each fracture if present using a modified Wagstaffe classification. Fragments were measured at their widest point and divided into two groups: 1) greater than or equal to 5mm and 2) less than 5mm. Fragments less than 5mm were not fixated. Fragments greater than or equal to 5mm were recorded with type of fixation performed and additional surgical procedures.

Results: 252 patients were included. 65 patients sustained an avulsion fracture. No patients in this group had a Wagstaffe type 1 fracture, 43.1 percent had a Wagstaffe type 2 fracture, 49.2 percent had Wagstaffe type 3 fracture, and 7.7 percent had Wagstaffe type 4 fracture. 53.8 percent were smaller than 5 mm and 46.2 percent were larger than 5mm. AITFL fractures were statistically significantly associated with trimalleolar fractures (p-value = 0.003). There was a statistically significant association between Wagstaffe type 2 and Weber B fractures (p-value < 0.0001). Wagstaffe Type 3 fractures were statistically significantly associated with Weber C fractures (p-value < 0.0001). 42 of 65 patients received fixation for an AITFL fracture. Direct fixation was performed in 13 patients. Indirect, or syndesmotic fixation, was performed in 17 patients and a combination repair consisting of direct avulsion fracture fixation with syndesmotic open reduction and fixation was performed in 12 patients. 37 patients required additional surgery secondary to complications or continued pain.

Conclusions:
Avulsion fractures of the AITFL were more common in this current study (25.8 percent) than previously identified in the literature. Avulsion fractures greater than or equal to 5 mm should be considered for fixation using a screw or plate technique. All 4 revisions occurred in the indirect or non-fixated group and trauma foot and ankle surgeons should be aware of the consequences of leaving these fractures unaffixed. 

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