Int J Clin Exp Med 2016;9(3):5517-5524
www.ijcem.com /ISSN:1940-5901/IJCEM0019979
Original Article
Clinical application of three-column theory to
tibiofibular syndesmosis injury after ankle fractures
Chaoliang Wang, Sufang Huang, Xuesheng Sun, Tao Zhu, Songke Kang, Xinxia Li, Lilin Shen, Chu Lin, Ning
Zhang, Qiang Li, Bo Gao
Department of Orthopedics, People’s Hospital of Laiwu City, Laiwu 271100, Shandong Province, China
Received November 18, 2015; Accepted January 25, 2016; Epub March 15, 2016; Published March 30, 2016
Abstract: To explore the clinical effects of internal fixation on ankle fractures combined with tibiofibular syndesmo-
sis injury under the guidance of three-column theory. Clinical data of 54 patients with ankle fractures combined
with tibiofibular syndesmosis injury, who were treated from June 2008 to May 2014, were retrospectively analyzed
in this study. According to the characteristics of pathological anatomy and mechanisms of injury, ankle joint was
divided into three columns. Above three columns were involved when ankle fractures combined with tibiofibular
syndesmosis separation appeared. There were lateral column fracture in 54 sites, ligament injury of middle col-
umn in 26 sites, avulsion fracture of the middle column in 28 sites, ligament injury of medial column in 31 sites,
and medial column fracture in 13 sites. At least two columns should be fixed after the three columns were injured.
Visual analogue scale pain scores were recorded at 6 months after surgery. Imaging results were evaluated using
modified Baird and Jackson evaluation criteria after fracture reduction and fixation. The function of ankle joint was
assessed utilizing American Orthopaedic Foot and Ankle Society ankle-hindfoot score system. A total of 54 patients
were followed up for 6-48 months (averagely 21 months). Healing time was 11-15 weeks (averagely 13.6 weeks).
Visual analogue scale pain scores were between 0 and 6 (averagely 1.4). American Orthopaedic Foot and Ankle
Society ankle-hindfoot score was 82-100, averagely 96. Radiological evaluation of therapeutic effects showed 52
excellent cases and 2 good cases with an excellent and good rate of 100%. Three-column classification for ankle
fractures is a simple and comprehensive theory. Fixation of two columns can stabilize the tibiofibular syndesmosis
after three columns were injured.
Keywords: Ankle fractures, tibiofibular syndesmosis injury, internal fixation, functional assessment
Introduction unstable tibiofibular syndesmosis after fixation
for ankle fractures [14]. However, there is no
Ankle can be easily injured during sports [3]. simple effective method to choose a surgical
Ankle fractures frequently combine with liga- approach or fixation method. Ankle fracture
ment injuries surrounding the ankle joint. types commonly used in clinic are AO-Danis-
Approximately 10% patients with ankle frac- weber classification and Langer-Hanse classifi-
tures combined with tibiofibular syndesmosis cation. Above types are too simple or too cum-
injury [17]. Complete tibiofibular syndesmosis bersome, difficult to remember, do not cover all
is important to maintain a stable structure of types of fractures, and provide limited assis-
the ankle joint. If talus moves 1 mm outward tance to the determination of the surgical pro-
and the contact surface of tibial astragaloid gram for ankle fractures combined with tibio-
joint reduces 42%, the probability of occur- fibular syndesmosis injury. Wang Manyi pro-
rence of traumatic arthritis will increase [15]. posed the three-column theory to guide ankle
Improper treatment for tibiofibular syndesmo- fractures combined with tibiofibular syndesmo-
sis injury will cause long-term ankle pain, even sis injury. Among the three columns, the stabili-
disability. Ankle fractures combined with tibio- zation of two columns can achieve the fixation
fibular syndesmosis separation is challenging of the tibiofibular syndesmosis. The present
in clinical treatment. A previous study con- study retrospectively analyzed complete infor-
firmed that fixation was still necessary during mation on 54 patients with ankle fractures,
Three-column classification for ankle fractures
injuries in 4 cases. These patients affected
closed fractures. According to Langer-Hanse
classification, there were supination-external
rotation in 20 cases, supination and adduction
in 14 cases, pronation and abduction in 8
cases, and pronation-external rotation in 4
cases. Patients with acute open injury were
subjected to debridement, reduction and fixa-
tion during emergency surgery. In this study,
tibiofibular syndesmosis separation is identi-
fied by following signs: obvious local pain, wid-
ened inferior tibiofibular gap at ankle points
shown by X-ray, which was 2 mm wider than
normal control. CT images in the axial plane
revealed that the difference of anterior and
posterior tibiofibular gaps was more than 2.0
mm [6]. During the surgery, patients were diag-
nosed as tibiofibular syndesmosis separation
by retractor test.
The study protocol received approval from the
Ethics Committee of Laiwu City People’s
Figure 1. Definition of the three columns of ankle Hospital, China. Written informed consent was
fracture. The lateral column consists of lateral liga-
ment complex (lateral A), distal fibula (lateral B),
obtained from each subject prior to inclusion in
fibular tibiofibular syndesmosis level (lateral C) and the study.
proximal fibula (lateral D) from far to near. The me-
dial column consists of deltoid ligament (medial A) Principles of management
and medial malleolus (medial B) from far to near. The
middle column consists of tibiofibular syndesmosis After hospitalization, the patient should raise
ligament (anterior tibiofibular ligament, posterior tib- the affected limb and receive cold compress.
iofibular ligament, transverse tibiofibular ligament
and interosseous ligament) and interosseous mem-
Closed injury patients should make an opera-
brane (middle A) and anterior tibial or fibular attach- tion within 6-8 hours after injury. For local swell-
ment site of tibiofibular syndesmosis (middle B). ing patients, a brace should be used to fix the
affected limb until detumescence (7-14 days
after injury). Surgery could be conducted when
who were treated in our hospital from June soft tissue conditions were improved and skin
2010 to May 2014, and sought to observe wrinkles appeared. X-ray and CT three-dimen-
characteristics of ankle fractures combined sional reconstruction were performed.
with tibiofibular syndesmosis injury and mecha-
nisms of injury and to explore the clinical effects Definition of three columns of the ankle joint
of internal fixation on above injuries under the
guidance of three-column theory. The three columns are composed of lateral col-
umn, medial column and middle column, which
Materials and methods is classified according to the structure of ankle
joint. The lateral column consists of lateral liga-
General data ment complex (lateral A), distal fibula (lateral B),
fibular tibiofibular syndesmosis level (lateral C)
A total of 54 ankle fracture patients with com- and proximal fibula (lateral D) from far to near.
plete follow-up data, who were treated from The medial column consists of deltoid ligament
June 2008 to May 2014, were retrospectively (medial A) and medial malleolus (medial B) from
analyzed. There were 43 males and 11 females, far to near. The middle column consists of tibio-
at the age of 21-58 years old, averagely 36.7 fibular syndesmosis ligament (anterior tibiofibu-
years old. The causes of injuries contain high lar ligament, posterior tibiofibular ligament,
fall injuries in 23 cases, traffic injuries in 16 transverse tibiofibular ligament and interosse-
cases, sports injuries in 11 cases, and other ous ligament) and interosseous membrane
5518 Int J Clin Exp Med 2016;9(3):5517-5524
Three-column classification for ankle fractures
Figure 2. Fracture cases at lateral column C + middle column A + medial column B. Fracture diagram (A); using fixa-
tion through lateral ankle approach + medial approach, preoperative anteroposterior (B) and lateral (C) radiographs;
postoperative anteroposterior (D) and lateral (E) radiographs.
Figure 3. Fracture cases at lateral column C + middle column B + medial column B. Fracture diagram (A); using
fixation through posterolateral ankle approach + medial approach, preoperative anteroposterior (B) and lateral (C)
radiographs; postoperative anteroposterior (D) and lateral (E) radiographs.
Figure 4. Fracture cases at lateral column D + middle column A + medial column A. Fracture diagram (A); using fixa-
tion through posterolateral ankle approach, preoperative anteroposterior (B) and lateral (C) radiographs; postopera-
tive anteroposterior (D) and lateral (E) radiographs.
(middle A) and anterior tibial attachment site of contains outward shift and inward shift.
tibiofibular syndesmosis (middle B, anterior According to sites of fibula fracture, outward
tibia, Tillaux fracture) or posterior tibial attach- displacement is composed of lateral C + middle
ment site (middle B, posterior tibia), anterior A + medial B (Figure 2), lateral C + middle B +
fibular attachment site of tibiofibular syndes- medial B (Figure 3), lateral D + middle A + medi-
mosis (middle B, anterior fibula, Wagstaffe frac- al A (Figure 4), lateral D + middle A + medial B
ture) [18] or posterior fibular attachment site (Figure 5), lateral D + middle B + medial A
(middle B, posterior fibula) (Figure 1). Shift (Figure 6), and lateral D + middle B + medial B
direction of distal fracture after ankle fracture (Figure 7).
5519 Int J Clin Exp Med 2016;9(3):5517-5524
Three-column classification for ankle fractures
Figure 5. Fracture cases at lateral column D + middle column A + medial column B. Fracture diagram (A); using fixa-
tion through lateral ankle approach + medial approach, preoperative anteroposterior (B) and lateral (C) radiographs;
postoperative anteroposterior (D) and lateral (E) radiographs.
Figure 6. Fracture cases at lateral column D + middle column B + medial column A. Fracture diagram (A); using fixa-
tion through posterolateral ankle approach + anterolateral auxiliary incision, preoperative anteroposterior (B) and
lateral (C) radiographs; postoperative anteroposterior (D) and lateral (E) radiographs.
Figure 7. Fracture cases at lateral column D + middle column B + medial column B. Fracture diagram (A); using
fixation through posterolateral ankle approach + medial approach, preoperative anteroposterior (B) and lateral (C)
radiographs; postoperative anteroposterior (D) and lateral (E) radiographs.
Surgical approaches and steps sion. Anterolateral approach was selected for
fractures of lateral column combined with ante-
A surgical approach was selected according to rior inferior tibiofibular ligament tibial avulsion.
different injured columns. Lateral approach to An incision was used as possible to solve the
the fibula was selected for lateral column frac- problem. Procedures are as follows: (1) frac-
ture alone. Standard approach to the medial tures of medial malleolus were fixed using dou-
malleolus was selected for medial column frac- ble lag screws or wire tension band. Fractures
ture. Posterolateral approach was selected for of posterior or anterior ankle were fixed using
fractures of lateral column combined with pos- lag screw or hollow screw. Three layers of cor-
terior inferior tibiofibular ligament tibial avul- tex were fixed with one or two cortical bone
5520 Int J Clin Exp Med 2016;9(3):5517-5524
Three-column classification for ankle fractures
screws in the form of a lag screw from the top AO-Danis-weber classification [13]. In accor-
of the tibiofibular syndesmosis and paralleled dance with mechanisms of ankle injuries, the
with the ankle mortise in patients with tibiofibu- position of the foot when damage occurs, and
lar syndesmosis separation. (2) At least two the direction of rotation in the ankle mortise,
columns were fixed in patients with ankle frac- Langer-Hanse classification includes five types:
tures combined with tibiofibular syndesmosis supination-external rotation, supination-adduc-
separation. Fractures should be fixed first. The tion, pronation-abduction, rotation-external ro-
tibiofibular syndesmosis could be fixed with a tation and vertical compression. Langer-Hanse
screw for ligament rupture-induced tibiofibular classification only describes ankle injury mech-
syndesmosis separation. anism, but the mechanisms of ankle fractures
are diverse. Langer-Hanse classification sys-
Postoperative treatment and efficacy evalua- tem is better, but still cannot contain all kinds
tion of ankle injuries [1]. The types 1 and 2 of prona-
tion-external rotation and pronation-abduction
After surgery, short leg plaster was applied cannot be distinguished in Langer-Hanse clas-
for fixation for 4 weeks. Ankle joint moved sification [11]. In this study, 12.9% (8/54) ankle
positively or passively to restore the range injuries could not be classified according to
of motion of the ankle joint. At 6 weeks after Langer-Hanse classification. We could not tell
surgery, patients could bear weight partially.
the type 1 of pronation-external rotation from
Radiographs revealed that patients could ac-
type 1 of pronation-abduction in four patients,
cept full weight bearing after fracture healing.
and could not distinguish type 2 of pronation-
During follow-up, visual analogue scale was
external rotation from type 2 of pronation-
employed to assess patient’s pain. American
abduction in two patients with medial malleo-
Orthopaedic Foot and Ankle Society, ankle-
lus fractures combined with anterior tibiofibular
hindfoot score system, was utilized to evaluate
ligament injury. Lauge-Hansen classification
the function of ankle joint [10, 12]. Curative
appears early based on the mechanism of vio-
effects were evaluated: excellent 91-100
lence injury, and its core is to identify ankle
points, good 81-90 points, average 60-80
fracture mechanism in order to establish closed
points, and poor < 60 points. Score was mea-
reduction program. The effects of internal fixa-
sured in all patients at 6 months after surgery
tion that was widely used in recent years are
according to modified Baird and Jackson sub-
limited in guiding surgery program. Internal fixa-
jectivity and objectivity and X-ray [2].
tion does not have clear guidance in the choice
Results of incision and implants.
A total of 54 cases were followed up for 6-48 Ankle AO classification is mainly based on the
months (averagely 21 months). The wound positional relationship between fibula fracture
healed well, no infection or local adverse reac- level and tibiofibular syndesmosis ligament,
tion was visible. Healing time was 11-15 weeks and carefully describes ankle injury [5]. Ankle
(averagely 13.6 weeks). Visual analogue scale fractures are classified into three types and
pain scores were between 0 and 6 (averagely corresponding subtypes: type A: fibula fracture
1.4). American Orthopaedic Foot and Ankle below tibiofibular syndesmosis plane; A1: fibula
Society ankle-hindfoot score was 82-100, aver- fracture alone, A2: combined with medial mal-
agely 96. Radiological evaluation of therapeu- leolus injury, A3: combined with posterior medi-
tic effects showed 52 excellent cases and 2 al fracture. Type B: fibula fracture on tibiofibular
good cases with an excellent and good rate of syndesmosis plane; B1: fibula fracture alone,
100%. In accordance with the three-column B2: combined with medial injury, B3: combined
theory, ankle injury combined with tibiofibular with medial injury and posterolateral tibia frac-
syndesmosis separation belonged to three- ture. Type C: fibula fracture above tibiofibular
column injuries, and the fixation of two columns syndesmosis plane; C1: fibular shaft fractures
could stabilize the tibiofibular syndesmosis. alone, C2: compound fracture of the fibular
shaft, C3: proximal fibula fracture. The type A of
Discussion AO classification refers to supination adductor
Ankle fracture types injury. The type B of AO classification refers to
supination-external rotation injury. The type C
Ankle fracture types commonly used in clinic of AO classification refers to pronation-abduc-
are Langer-Hanse classification [8, 9] and tion and pronation-eversion injury [4]. AO clas-
5521 Int J Clin Exp Med 2016;9(3):5517-5524
Three-column classification for ankle fractures
sification based primarily on the fracture site is brevis muscles. Compression screw or hollow
a detailed and comprehensive classification, screw is applied for middle-column avulsion
and facilitates the acquisition and manage- fractures. Using anterolateral approach, a
ment of cases, but ignores the ligament sur- curved incision is made along anterolateral fib-
rounding the ankle and the structure of tibio- ula. Extensor retinaculum is cut open. The
fibular syndesmosis. AO classification is not extensor digitorum longus tendon, deep pero-
associated with anatomical characteristics and neal nerve and anterior tibial artery are retract-
mechanisms of fractures, and cannot guide to ed medially so as to expose fractures of the
choose treatment programs. lateral column. Fibula is fixed with reconstruc-
tion plate or 1/3 tubular plate. For the middle-
Ankle injuries are mostly caused by low-energy column fracture, lag screw or bone plate is uti-
rotation injury, and different from Pilon fracture lized according to the size of fracture blocks. (3)
induced by the axial load of distal tibial articular Fractures of medial column: using anteromedi-
surface [16]. In the present study, low-energy al or medial tibial approach, a curved incision
injury induced by falls and sprains accounted is made in the medial malleolus. Fractures
for 77.8% (42/54). Coronal, sagittal and hori- were fixed with two malleolus screws or wire
zontal CT scan revealed fracture line mainly dis- tension band. It is easy to expose fractures
tributed along front and rear direction of the through medial approach, but it is important to
fibula, medial malleolus and lateral malleolus, protect saphenous nerve and saphenous vein.
as well as tibial attachment point of inferior tib-
iofibular ligament ending point. To further Guidance of the three-column theory for ankle
understand the mechanisms of ankle fractures fractures combined with tibiofibular syndesmo-
and to guide clinical surgery, the three-column sis injury
theory of ankle joint proposed by Wang Manyi
was used to guide the surgery in 54 patients Tibiofibular syndesmosis injury is commonly
with ankle fractures. We found that nearly all associated with ankle fractures. Violent ab-
cases can be distinguished by this three-col- duction and external rotation are main reasons
umn theory, which consists of all types of ankle for tibiofibular syndesmosis injury. Tibiofibular
injuries, such as unusual Maisonneuve frac- syndesmosis separation will increase the width
ture, Tillaux fractures, and Wagstaffe fracture. of ankle mortise, and increase the range of
Thus, missed diagnosis can be avoided. The motion of talus in the ankle mortise, result-
core of the three-column theory is to consider ing in unstable ankle joint. Early correct diagno-
the distal bone and ligament structure of ankle sis and treatment of tibiofibular syndesmosis
fractures as a complex. According to the direc- injury are the key for the recovery of ankle func-
tion of complex shift inward or outward, the tion. Presently, the diagnosis and treatment of
type of fractures is analyzed and surgery pro- tibiofibular syndesmosis injury are controver-
gram is determined. The effects of ligament sial. More and more basic and clinical studies
and tibiofibular syndesmosis structure in ankle suggested that not all separated tibiofibular
injuries should be paid attention. Follow-up syndesmosis should be fixed [7]. Unstable
results showed that clinical effects were good ankle mortise after tibiofibular syndesmosis
in 54 patients with ankle injuries. separation and subsequent traumatic arthritis
are worrisome. At present, screws are common-
Surgical approaches and fixation ly used to fix tibiofibular syndesmosis separa-
tion. Following tibiofibular syndesmosis separa-
One advantage of the three-column theory is to tion, the function of fibula to restrict talus relo-
directly select the corresponding surgical cation weakens. Talus relocation during weight-
approach according to fractures of different bearing walking will reduce the contact area of ti-
columns. (1) Lateral column fractures: fibula biotalar joint and increase local stress of
anatomical plate, reconstruction plate or 1/3 the joint. Nevertheless, the stability of ankle
tubular plate is used through fibula lateral mortise is maintained by various factors, involv-
approach. (2) Fibula anterolateral or posterolat- ing lateral malleolus, lateral ligament com-
eral approach for fractures involving the col- plex, medial malleolus, medial deltoid ligament,
umn: anatomical distal fibula plate is utilized tibiofibular syndesmosis, interosseous mem-
through posterolateral approach by entering brane, even calf muscles. Tibiofibular syndes-
the posterior gap of peroneus longus and mosis separation is just the manifestations of
5522 Int J Clin Exp Med 2016;9(3):5517-5524
Three-column classification for ankle fractures
inferior tibiofibular ligament tear or ligament tures, we can simply find the fracture site. To
avulsion fractures. Structural integrity of the pay close attention to the effects of ankle liga-
medial ankle talus can ensure that talus does ment and tibiofibular syndesmosis on fractures
not shift in the ankle mortise. Therefore, as can effectively guide the surgery of ankle frac-
long as anatomical reduction and stable fixa- tures. In fact, fractures will not follow a subjec-
tion of the medial malleolus and lateral malleo- tive mode. Any theory needs to be improved
lus are conducted, the tibiofibular syndesmosis continuously in order to facilitate clinical treat-
can reset itself. Even if there is a potential sep- ment. The number of cases in this study is lim-
aration, the fixation is not needed if tibiofibular ited. Although encouraging results are obtained
gap is less than 4 mm. In this study, ankle inju- in initial stage, it still lacks large long-term fol-
ries combined with tibiofibular syndesmosis low-up data. The three-column theory of ankle
separation belongs to three-column injuries. fractures still needs further investigations and
Moreover, the fixation of two columns can stabi- improvement.
lize the tibiofibular syndesmosis. The fixation is
required for the following situations: (1) inferior Disclosure of conflict of interest
tibiofibular ligament injury does not need to be
None.
repaired, but open reduction and screw fixation
are needed for posterior inferior tibiofibular lig- Authors’ contribution
ament avulsion fractures at the tibial attach-
ment site or anterior inferior tibiofibular liga- Chaoliang Wang and Xuesheng Sun conceived
ment avulsion fractures at the tibial attachment and designed the experiments; Sufang Huang
site (Tillanx fracture), as well as rare anterior and Tao Zhu performed the experiments;
inferior tibiofibular ligament avulsion fractures Songke Kang and Xinxia Li analyzed the data;
at the fibular attachment site (Wagstaffe frac- Lilin Shen, Chu Lin, Ning Zhang and Bo Gao
ture). (2) Fractures of anterior tubercle of medi- contributed reagents/materials/analysis tools;
al malleolus, simultaneously deep deltoid liga- Chaoliang Wang wrote the paper. Xuesheng
ment rupture (from intertubercular sulcus and Sun was responsible for this article. All authors
posterior tubercle, mainly posterior tibiotalar read and approved the final manuscript.
ligament and middle tibiotalar ligament) exist
with triangular ligament rupture. (3) In three- Address correspondence to: Xuesheng Sun, Depart-
column classification, lateral column D + mid- ment of Orthopedics, People’s Hospital of Laiwu
dle column A + medial column A, i.e., Maison- City, Laiwu 271100, Shandong Province, China. Tel:
neuve fracture. Fixation with a screw in the tib- +866346278397; E-mail: lwwcl200368@163.com
iofibular syndesmosis can achieve excellent
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