{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,9]],"date-time":"2026-08-09T18:41:14Z","timestamp":1786300874812,"version":"build-2736575974"},"reference-count":32,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"8","content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVES:<\/jats:title>\n                    <jats:p>To evaluate treatment trends for trimalleolar fractures, specifically assessing whether increased posterior malleolus fixation was associated with reduced syndesmotic repair.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS:<\/jats:title>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design:<\/jats:title>\n                    <jats:p>Retrospective cohort analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting:<\/jats:title>\n                    <jats:p>PearlDiver (Mariner data set) database (2010\u20132021).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient Selection Criteria:<\/jats:title>\n                    <jats:p>\n                      Patients were stratified according to ICD-9\/10 and\n                      <jats:italic toggle=\"yes\">Current Procedural Technology<\/jats:italic>\n                      codes into 4 cohorts based on index procedure: trimalleolar open reduction and internal fixation (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: younger than18 years, pregnancy, prior ankle osteoarthritis, connective tissue disease, or syndesmotic repair unrelated to trimalleolar ankle fractures.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcome Measures and Comparisons:<\/jats:title>\n                    <jats:p>Annual percentage incidence of syndesmotic repair within these cohorts was tabulated and compound annual growth rate (CAGR) and Mann\u2013Kendall analysis was performed to assess trends. \u03c72 analysis evaluated characteristics associated with posterior fixation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS:<\/jats:title>\n                    <jats:p>\n                      From 2010 to 2021, the incidence of concomitant posterior malleolus fixation in trimalleolar ORIF increased from 17.6% to 21.4% (CAGR: +6.2%, Mann\u2013Kendall\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      -value: 0.011). The incidence of trimalleolar ORIF without posterior fixation decreased from 82.4% to 78.6% (CAGR: \u22123.0%, Mann\u2013Kendall\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      -value: 0.04). The incidence of syndesmotic repair after trimalleolar fixation increased from 10.1% to 29.3% (CAGR for posterior fixation: +17.0%, Mann\u2013Kendall\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      -value: &lt;0.001; CAGR for no posterior fixation: +13.1%, Mann\u2013Kendall\n                      <jats:italic toggle=\"yes\">P<\/jats:italic>\n                      -value: &lt;0.001). Trimalleolar ORIF with posterior fixation demonstrated similar rates of malunion, nonunion, and reoperation at 2 years postoperative, with no significant differences on \u03c72 analysis, compared with those without posterior malleolus fixation.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS:<\/jats:title>\n                    <jats:p>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 after trimalleolar ORIF also increased.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LEVEL OF EVIDENCE:<\/jats:title>\n                    <jats:p>Therapeutic, Level IV. See Instructions for Authors for a complete description of levels of evidence.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/bot.0000000000003181","type":"journal-article","created":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T13:02:09Z","timestamp":1775826129000},"page":"416-423","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Trends in Posterior Malleolus Fixation and Subsequent Syndesmotic Repair in Trimalleolar Ankle Fractures"],"prefix":"10.1097","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3707-4022","authenticated-orcid":false,"given":"Aditya","family":"Joshi","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Bethesda, MD;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-8416-2289","authenticated-orcid":false,"given":"Jordan","family":"Helbing","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Bethesda, MD;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-0975-5083","authenticated-orcid":false,"given":"Mark","family":"Haft","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Howard County, MD; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4858-3756","authenticated-orcid":false,"given":"Ethan","family":"Harris","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Howard County, MD; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3592-7004","authenticated-orcid":false,"given":"Nigel","family":"Hsu","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Howard County, MD; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5070-2770","authenticated-orcid":false,"given":"Amiethab","family":"Aiyer","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Baltimore, MD."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7981-2882","authenticated-orcid":false,"given":"John M.","family":"Thompson","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, Johns Hopkins University Schools of Medicine, National Capital Region, Bethesda, MD;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"276","reference":[{"key":"R1-20260809","doi-asserted-by":"crossref","first-page":"24730114231154217","DOI":"10.1177\/24730114231154217","article-title":"Risk factors associated with worse clinical outcomes of ankle fractures involving the posterior malleolus","volume":"8","author":"Rajan","year":"2023","journal-title":"Foot Ankle Orthop"},{"key":"R2-20260809","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1053\/j.jfas.2015.04.001","article-title":"Management of posterior malleolar fractures: a systematic review","volume":"55","author":"Odak","year":"2016","journal-title":"J Foot Ankle Surg"},{"key":"R3-20260809","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1177\/1071100720969431","article-title":"Traditional approach vs posterior approach for ankle fractures involving the posterior malleolus","volume":"42","author":"Pilskog","year":"2021","journal-title":"Foot Ankle Int"},{"key":"R4-20260809","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1177\/1071100717735839","article-title":"Stability of the syndesmosis after posterior malleolar fracture fixation","volume":"39","author":"Miller","year":"2018","journal-title":"Foot Ankle Int"},{"key":"R5-20260809","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1097\/01.blo.0000203489.21206.a9","article-title":"Fixation of posterior malleolar fractures provides greater syndesmotic stability","volume":"447","author":"Gardner","year":"2006","journal-title":"Clin Orthop Relat Res"},{"key":"R6-20260809","doi-asserted-by":"crossref","first-page":"24730114231200485","DOI":"10.1177\/24730114231200485","article-title":"Reduction of posterior malleolus fractures with open fixation compared to percutaneous treatment","volume":"8","author":"Haws","year":"2023","journal-title":"Foot Ankle Orthop"},{"key":"R7-20260809","doi-asserted-by":"crossref","first-page":"e19.00207","DOI":"10.2106\/JBJS.RVW.19.00207","article-title":"Posterior malleolar fractures: a critical analysis review","volume":"8","author":"Rammelt","year":"2020","journal-title":"JBJS Rev"},{"key":"R8-20260809","first-page":"e32191","article-title":"The management of posterior malleolus fractures in unstable ankle injuries: where do we stand now?","volume":"14","author":"Serlis","year":"2022","journal-title":"Cureus"},{"key":"R9-20260809","doi-asserted-by":"crossref","first-page":"385","DOI":"10.3113\/FAI.2011.0385","article-title":"Surgeon practices regarding operative treatment of posterior malleolus fractures","volume":"32","author":"Gardner","year":"2011","journal-title":"Foot Ankle Int"},{"key":"R10-20260809","doi-asserted-by":"crossref","first-page":"e0058","DOI":"10.2106\/JBJS.OA.18.00058","article-title":"Posterior malleolar ankle fractures: an effort at improving outcomes","volume":"4","author":"Mason","year":"2019","journal-title":"JB JS Open Access"},{"key":"R11-20260809","first-page":"265","article-title":"Revision open reduction and internal fixation of ankle and syndesmosis malunions","volume":"68","author":"Clare","year":"2019","journal-title":"Instr Course Lect"},{"key":"R12-20260809","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1097\/BOT.0b013e31822a526a","article-title":"The functional consequence of syndesmotic joint malreduction at a minimum 2-year follow-up","volume":"26","author":"Sagi","year":"2012","journal-title":"J Orthop Trauma"},{"key":"R13-20260809","doi-asserted-by":"crossref","first-page":"1031","DOI":"10.1007\/s00402-021-03772-9","article-title":"Leave it or fix it? 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