Bimall vs.

Trimall Ankle fractures:

Outcome Study
• Orthopeadic Chief Resident at Thomas
Jefferson University Hospital and the
Rothman Institute
• Administrative and Academic Chief
Resident 2010-2011
• Interest:
• Spine Surgery
• Medical Illustrations
• Medical education
• Medical Leadership – Emergent Leader Physician
Chadi Tannoury, MD • Enjoys Arts, Music, Martial Arts, Travel,
Social Networking
• Contact: chadi.tannoury@gmail.com
 A Comparison of Outcomes of
Bimalleolar and Trimalleolar Ankle
Fractures
Chadi Tannoury, M.D.
Thomas Jefferson University Hospital
& The Rothman Institute
S.P.I.N.E. Meeting – Lebanon June 2010
 Disclosure

*Disclosure of Financial Interest

The author have not received nothing of value from or does not own stock (or stock
options) in a commercial company or institution related directly or indirectly to the subject
of this topic.
 Bimalleolar and Trimalleolar Ankle
Fractures
 Higher energy injuries among
rotational ankle fractures
 Compared to unimalleolar
ankle fractures
 Greater residual pain

 Longer lasting
dysfunction
 Higher risk of
posttraumatic arthritis
 Literature Review
 Tri vs. Bimall Outcomes:
 More pain & dysfunction - Higher risk of arthritis
McDaniel et al CORR 1977
 Similar pain & dysfunction - Higher risk of arthritis
Beris et al CORR 1997

 Bony vs. Lig Bimall:

 Worse functional scores - Similar pain scores
Tejwani et al JBJS 2007
 Literature - Shortcomings
 Inconsistent results (pain – dysfunction)
 Limited comparisons regarding long-term
outcomes of bimalleolar to trimalleolar ankle
fractures
 Limited comparisons regarding
 Bony vs. ligamentous Bimall
 Trimall w or w/o post large fragment
Purpose
 To retrospectively
evaluate and compare
outcomes and
complications of
medium-term results of
surgical treatment of
bimalleolar and
trimalleolar ankle
fractures
 Treatment Period
 February 2001 through January 2007
 117 patients with closed ankle fractures & syndesmotic instability
 74 patients with bimalleolar fractures

 43 patients with trimalleolar fractures

 All procedures performed by One surgeon

 Clinical Assessment
 American
Orthopaedic Foot
and Ankle Society
(AOFAS) Ankle-
Hindfoot system
 Visual analog scale
(VAS) for pain
 Results Assessment
 Satisfaction
 Excellent

 Good

 Fair

 Poor

 Failure
 Revision

 Nonunion
 Radiographic Assessment

 Fracture union

 Mortise congruency

 Arthrosis
 Statistical analysis
 Fisher exact test

 Pearson Chi-Square test

 P<0.05 is statistically significant

 Preoperative Data
Bimalleolar Trimalleolar
Male: Female 38:36 19:24

Mean age 37.2 47.3

Age range 15 – 73 17 - 71

Right: Left 40:34 19:24

No statistical difference between groups
 Follow-up
Mean follow-up in months
 Bimalleolar 48.0 [22-87]

 Trimalleolar 53.9 [21-92]

Revision surgery
 Bimalleolar – 0 of 74
 Trimalleolar – 0 of 43

No statistical difference between groups

 Results
BI-Malleolar Frx TRI-Malleolar Frx
 70 of 74 (94.6%) patients  42 of 43 (97.7%) patients
presented for final follow-up presented for final follow-up
 Union rate:  Union rate
 100% by 12 weeks after surgery  100% by 12 weeks after surgery

 Alignment:  Alignment
 All acceptable  All acceptable
 Post-Op Results
Scores/Overall ***Bimall Trimall P value Significant diff
Mean AOFAS 88.9 82.1 P=0.085 NO
Mean VAS 1.9 3.1 P=0.046 YES
P-T-Arthritis 1.4% (1/70) 4.8% (2/42) P=0.278 3.5 Fold inc

Bimall Frx Bony ***Lig P value Significant diff

Mean AOFAS 82.6 90.5 P=0.129 No
Mean VAS 2.9 1.7 P=0.131 No

Trimall Frx w ORIF - PM Small PM P value Significant diff

Mean AOFAS 77.7 83.5 P=0.50 No
Mean VAS 2.5 3.3 P=0.51 No
Scores/Overall ***Bimall Trimall P value Significant diff
Mean AOFAS 88.9 82.1 P=0.085 NO
Mean VAS 1.9 3.1 P=0.046 YES
P-T-Arthritis 1.4% (1/70) 4.8% (2/42) P=0.278 3.5 Fold inc

Bimall Frx Bony ***Lig P value Significant diff

Mean AOFAS 82.6 90.5 P=0.129 No

Mean VAS 2.9 1.7 P=0.131 No
Trimall Frx w ORIF - PM Small PM P value Significant diff
Mean AOFAS 77.7 83.5 P=0.50 No
Mean VAS 2.5 3.3 P=0.51 No
Scores/Overall ***Bimall Trimall P value Significant diff
Mean AOFAS 88.9 82.1 P=0.085 NO
Mean VAS 1.9 3.1 P=0.046 YES
P-T-Arthritis 1.4% (1/70) 4.8% (2/42) P=0.278 3.5 Fold inc

Bimall Frx Bony ***Lig P value Significant diff

Mean AOFAS 82.6 90.5 P=0.129 No
Mean VAS 2.9 1.7 P=0.131 No

Trimall Frx w ORIF - PM Small PM P value Significant diff

Mean AOFAS 77.7 83.5 P=0.50 No
Mean VAS 2.5 3.3 P=0.51 No
 Satisfaction
Bimalleolar Trimalleolar

Excellent 40 (56.6%) 13 (30%)

Good 14 (20.8%) 11 (26.7%)

Fair 8 (11.3%) 11 (26.7%)

Poor 8 (11.3%) 7 (16.6%)

P=0.044
 Discussion
 Patients with bimalleolar ankle fractures
had:
 Higher functional scores (P=0.085)

 Lower incidence of post-traumatic

arthritis (P=0.278)
 Higher rates of satisfaction
(P=0.044)
 Lower pain scores (P=0.046)
 Conclusion
Surgical treatment of Bimalleolar
ankle fractures is more predictable
in alleviating symptoms and
restoring function than trimalleolar
ankle fractures.
The End
Thank you.