Technical TrickSurgical Fixation of Quadrimalleolar Fractures of the AnkleRammelt, Stefan MD, PhDa; Bartoníček, Jan MD, PhDb; Kroker, Livia MDa; Neumann, Annika Pauline MDaAuthor Information aUniversity Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus at TU Dresden, Dresden, Germany; and bDepartment of Orthopaedics, First Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic. Reprints: Stefan Rammelt, MD, University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at TU Dresden, Fetscherstrasse 74, 01307 Dresden, Germany (e-mail: [email protected]). The authors report no conflict of interest. Journal of Orthopaedic Trauma: June 2021 - Volume 35 - Issue 6 - p e216-e222 doi: 10.1097/BOT.0000000000001915 Buy SDC Metrics Abstract Summary: We present a technique of fixation of trimalleolar fractures with additional fracture of the anterior tibial tubercle (“quadrimalleolar”) or anterior fibular rim (“quadrimalleolar equivalent”). Twenty-four patients with a mean age of 60 years were treated with open reduction and internal fixation of all 4 malleoli. There were 17 quadrimalleolar and 6 quadrimalleolar equivalent fractures. One patient had both anterior tibial and fibular avulsion fracture in addition to a trimalleolar ankle fracture. Surgical approaches and internal fixation were tailored individually. Twenty patients were operated in the prone position with direct fixation of the posterior malleolus and 4 patients in the supine position with anterior to posterior screw fixation of the posterior malleolus. After fixation of al 4 malleoli, only 1 patient (4%) required a syndesmotic screw for residual syndesmotic instability on intraoperative testing. There were no infections and no wound healing problems. All patients went on to solid union. Nineteen patients (79%) were followed for a mean of 77 months (range, 15–156 months). The Foot Function Index averaged 15 (range, 50 to 0), the Olerud and Molander Score averaged 79 (range, 45–100), and the American Orthopaedic Foot and Ankle Society Ankle and Hindfoot Scale averaged 87 (range, 39–100). Fixation of the anterior and posterior tibial fragments increases syndesmotic stability by providing a bone-to-bone fixation. Anatomic reduction of the anterior and posterior tibial rim restores the physiological shape of the tibial incisura and therefore facilitates fibular reduction. Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.