Ankle Fractures

The majority of ankle fractures can be diagnosed on plain radiographs using the AP, lateral, and mortise views. It is advisable,

however, in the setting of significant ankle injuries such as
fracture-dislocations or fractures sustained via a high-energy
mechanism to obtain films of the foot as well as the knee to rule out
associated injuries for which the ankle injury serves as a distraction
and may lead to a missed diagnosis. A tibial-fibular radiograph is
indicated if physical examination points to tenderness over the shaft
of the fibula as this may represent a Maisonneuve pattern injury.

Several important radiographic findings must be
identified in order to establish the integrity of the joint. An initial
evaluation of the radiographs should first focus on the tibiotalar
articulation and assess for fibular shortening, widening of the joint
space, malrotation of the fibula, and talar tilt. The specific anatomic
relationships that need to be established radiographically are listed
in Table 57-3.

An asymmetry of the articulation between the talus and
the tibia and fibula on the mortise film, represented by differences in
measurements of the medial, superior, and lateral clear spaces, may
indicate ankle instability and subluxation. The degree to which an
asymmetry at the mortise is tolerable is controversial, although 1 mm
of tibiotalar displacement has been shown in a static cadaveric ankle
model to decrease the contact area by 42%.¹⁸³
Dynamic cadaveric ankle models have disputed the existence of this
decrease in contact area; however, the current standard of care is to
achieve an anatomic reduction of the mortise on static
non-weight-bearing films.³⁹
Therefore, after an initial cursory evaluation of radiographs is
completed as a screen for an osseous ankle injury, a more detailed
evaluation of each view should then be undertaken with quantification
of specific radiographic relationships.

The accepted standard measurements to describe an
adequate reduction with the foot in neutral have been established and
validated.⁹⁵,¹⁷⁷
Parameters that suggest unstable fracture patterns include lateral
malleolar displacement greater than 2 mm with resultant talar shift on
the AP or lateral, significant medial malleolar displacement, deltoid
ligament disruption defined by greater than 5 mm medial clear space,
syndesmosis injury identified by tibial-fibular clear space greater
than 5 mm or tibial-fibular overlap of less than 10 mm (both on the
AP), or a tibial-fibular overlap of less than 1 mm on the mortise view (Fig. 57-3).

The most useful radiographic signs of fibular length are
the talocrural angle and the “ball sign.” The talocrural angle is
measured between a line perpendicular to the tibial plafond and a line
connecting the tips of the medial and lateral malleoli. Normal range is
83 ± 4 degrees or a deviation from the talocrural angle measurement on
the contralateral side¹⁹⁷ (see Fig. 57-3).
The “ball” or “dime sign” is described on the AP view as an unbroken
curve connecting the recess in the distal tip of the fibula and the
lateral process of the talus when the fibula is out to length (Fig. 57-4).²⁴⁰

The presence of instability is readily determined in
bimalleolar ankle fractures; however, this is not the case when a
fibula fracture occurs in association with a medial-sided ligamentous
injury. Traditional teaching has in the past mandated that where the
physical examination points toward a medial-sided injury, a manual
stress view of the ankle should be performed.¹⁶⁷,¹⁶⁹,¹⁷⁰,¹⁷¹
The purpose of the stress view is to identify deltoid ligament injury
by creating a widening of the medial clear space, which would be
indicative of potential instability. To obtain an accurate stress test,
the ankle must be stressed in dorsiflexion and external rotation.¹²⁰,¹⁷² Although the validity of the stress view has been recently called into question, when positive stress

examinations have been elicited in fractures where no medial sided
symptoms existed, a stress view is still advocated at most centers.⁵³,¹³⁰,¹⁷⁶
Another method for performing a stress test is the gravity stress view.
Advocated as a less painful stress view, it was originally described in
cadaveric specimens and later validated clinically.¹⁴¹,²⁰⁰
During the gravity stress view, the patient lies in the lateral
decubitus position on the side of the affected ankle with the distal
leg, ankle, and foot allowed to hang dependent off the end of the table
while a mortise view is obtained (Fig. 57-5).
This patient positioning, in effect, acts to impart an external
rotational force as in the manual stress view. Without
physician-assisted dorsiflexion of the ankle, however, a false widening
of the mortise may be seen as the talus is wider anteriorly than
posteriorly.

The role of computed tomography (CT) in the evaluation
of ankle fractures is limited. The CT scan provides cross sectional
information, which clarifies the relationship of the tibia and fibula
at the mortise, the fit of the talus within the mortise, as well as
information regarding possible associated injuries to the peroneal or
posterior tibial tendons.¹⁹¹,¹⁹²,¹⁹³,²¹⁷
The greatest asset of CT scans in the setting of ankle fractures is to
diagnose tibial plafond impaction injuries, posterior malleolar
fractures, and

associated injuries of the talus.¹²³,¹⁴⁷,¹⁴⁸
The size of the posterior malleolar fragment, which determines
operative treatment, is notoriously poorly quantified on plain films
with low interobserver and intraobserver reliability. The CT scan is
clearly useful in cases where the size of the posterior malleolus is
questionable.⁶⁰ Other uses for CT scans of the ankle are evaluation of chronic ankle sprains and subtalar injuries.¹³⁶,¹³⁷

A mobile C-arm with the capability to provide
three-dimensional intraoperative imaging has become available and has
been found useful in ankle fracture surgery. Use of this machine allows
for images comparable to those obtained via a CT scanner to be obtained
intraoperatively and can help guide reductions, especially of
articulations that are difficult to assess with plain films such as the
syndesmosis.⁹,¹⁸⁸ The major drawback of using this technology is its current high costs.

Magnetic resonance imaging (MRI) of the ankle in the
acute evaluation of ankle injuries is mainly used to evaluate the
tendinous structures. In patients presenting with chronic or
unresolving pain, MRI is useful in evaluation of chronic ligament
ruptures as well as evaluation of the articular cartilage and possible
osteochondral injuries impeding the recovery of the patient.³⁵,¹²⁰

The Lauge-Hansen classification system is based on a rotational mechanism of injury (Fig. 57-6).
It is perhaps the recognition that the fracture pattern is associated
with a rotational injury, as opposed to an axial load type of injury,
which must be ascertained before assigning the injury a classification
system. The Lauge-Hansen classification system was developed from a
cadaveric experiment where the tibia was fixed and a rotational
deforming force was applied to the ankle in one of three different
directions. For a given foot position and deforming force at the ankle,
a consistently reproducible pattern of osseous and ligamentous injury
was described. The first part of the name in the classification system
describes the position of the foot at the time of injury, while the
second part of the name describes the direction of force applied to the
foot. Four injury patterns are described: supination-adduction (SA),
supination-external rotation (SER), pronation-adduction (PA), and
pronation-external rotation (PER).

Supination-Adduction. This injury pattern occurs when a
supinated foot experiences a forceful adduction force without a
rotational moment (see Fig. 57-6). Here, the
first structure injured is either the lateral collateral ligament or
the fibula. A fibula fracture created by this mechanism appears as a
low transverse fracture line at a level below the syndesmosis. As the
severity of the adduction moment increases, the talus gets displaced
toward the medial malleolus and a vertical fracture line is created
extending from the medial axilla of the joint and proximally into the
metaphyseal cortex of the tibia. This tends to be a large shear
fragment and is rarely associated with comminution at the medial
malleolus. Frequently, the medial tibial plafond will present an
impaction injury, which is not always easily recognized on plain films
although CT scan will demonstrate this injury clearly.

It is important to take note that the presence of a
vertical shear pattern of the medial malleolus fracture is the sine que
non of this injury pattern and may be the only osseous injury with the
lateral-sided injury being purely ligamentous. The SA pattern
represents up to 20% of ankle fractures.⁷⁶

Supination-External Rotation. The SER pattern (see Fig. 57-6) is the most prevalent ankle fracture pattern, with a prevalence of 40% to 75%.⁷⁶
Here, the foot is in a supinated position while an external rotation
force is imparted to the ankle relative to a fixed tibia. A shearing
force is therefore imparted to the fibula and the medial
osteoligamentous complex experiences an avulsion-type force.¹²⁶

The injury begins laterally at the anterior
tibial-fibular ligament (ATFL) and, when present as an isolated injury,
represents an SER1 pattern. An SER2 injury is an oblique fracture line
of the fibula associated with either a midsubstance rupture of the ATFL
or an avulsion fracture of the ATFL insertion into the tibia (Chaput
tubercle) or its origin on the fibula (Wagstaffe tubercle). SER2 fibula
fractures share three common characteristics: minimal displacement,
fracture at the level of the syndesmosis but not affecting the
syndesmosis, and fracture line proceeding from distal anterior to
proximal posterior. SER3 injuries share all the characteristics of the
SER2 injuries with the addition of either a posterior tibial-fibular
ligament rupture or fracture of the posterior malleolus. In the SER4
pattern, the injury progresses to the medial-sided structures where the
medial malleolus osteoligamentous complex (MMOLC) is injured. The
injury may be an isolated medial malleolus fracture (an oblique
fracture line at the level of the axilla in the majority of cases), or
an isolated deltoid ligament injury (the deep and superficial portions
of the deltoid are ruptured) representing an SER4 “equivalent” lesion.
More recently, a combination of both a medial malleolus and deltoid
injury has been characterized (Fig. 57-7). In
this fracture pattern, the anterior colliculus of the medial malleolus
is fractured; while the posterior colliculus remains intact, the injury
passes through the deep fibers of the deltoid ligament that are
attached to the posterior colliculus of the medial malleolus.¹⁷¹,²⁰³,²²⁶
It has therefore been suggested that the size of the medial malleolar
fragment was the most important variable in predicting deltoid
competence. When the medial malleolus fragment is greater than 2.8 cm
wide (supracollicular fracture), the deltoid ligament is likely intact
and stress view is negative. When the fragment is less than 1.7 cm wide
(anterior collicular or intercollicular fracture), the deltoid may be
incompetent and the stress view should be performed. It is in the
situation where an SER4 equivalent lesion is suspected that a stress
view is advocated by some authors.¹⁶⁷,¹⁶⁹,¹⁷⁰,¹⁷¹
As mentioned previously, the utility of the stress view has been called
into question by several authors who doubt its usefulness in
distinguishing ankle instability as widening has been found in ankles
without any medial symptoms and widening also was found in ankles with
negative MRIs of deltoid ligaments.¹⁰³

Other indicators that should be used to differentiate an
SER2 injury from an SER4 equivalent injury is evidence of anterior or
posterior subluxation of the talus, significant shortening (greater
than 2 mm) of the fibula, and mild lateral subluxation without any
stress. It is important to make the distinction between SER2 and SER4
injuries as the former have been shown to have a good outcome with
nonoperative treatment despite mild talar subluxation on stress views.¹⁵,³⁷,¹⁰⁶,²³²

Pronation-Abduction. PA injuries (Fig. 57-8) occur via an abduction force while the ankle is in a relatively pronated position and make up 5% to 21% of ankle fractures.⁷⁷
The typical appearance is an avulsion-type medial malleolus fracture
while bending forces at the fibula create a relatively transverse
fracture or commonly have either lateral butterfly or comminution
related to the bending failure. The fibula usually fractures 5 to 7 cm
above the joint.¹¹⁷ As in most cases
of comminuted fractures, judging length and rotation is challenging,
making the operative fixation more difficult than the supination injury
patterns. As this injury represents the direct counterpart to the SA
injury that may present with a medial plafond impaction, an
anterolateral tibial plafond fracture may be present and may contribute
to residual talar tilt or subluxation.¹¹⁷,²²⁴
Stress radiographs are important to assess the integrity of the
syndesmosis and help differentiate direct blow injuries (stable) from
indirect injuries (unstable). Isolated medial malleolar fractures are
differentiated from higher-grade PA of PER injuries with the stress
radiograph as well. Intraoperatively, manual stress examination should
be performed following fibular fixation to assess integrity of the
syndesmosis.

Pronation External-Rotation. PER injuries (see Fig. 57-8)
occur when the pronated foot experiences an external rotator force and
account for up to 19% of all rotational ankle fractures.⁷⁶
Here again, the medial osteoligamentous complex is the first injured
via either a direct deltoid ligament rupture or a transverse medial
malleolar fracture. The next structure injured is the anterior inferior
tibial-fibular ligament (AITFL), followed by a fibular fracture. The
characteristic fibular lesion is a fracture at a level above the
syndesmosis that is typically spiral in nature. The fibula fracture
progresses in a direction opposite from its SER4 counterpart as the
fracture line progresses from distal posterior to proximal and anterior.¹⁶⁸
The last structure injured in this rotational mechanism is the
posterior tibial-fibular ligament or the posterior tubercle of the
distal tibia.¹¹¹ Since the fibula
fracture is typically in the area proximal to the syndesmosis,
evaluation of the syndesmosis intraoperatively is critical since it may
be ruptured. The clinician should be aware that although the PER injury
is the most commonly seen injury that is associated with a syndesmosis
injury, SER and PA mechanisms can also be associated with a syndesmosis
disruption and should be evaluated accordingly.¹⁶⁸

A PER variant known as the Maisonneuve fracture is
characterized by a proximal fibula shaft fracture. A Maisonneuve
fracture should always be suspected when an isolated medial malleolus
fracture is seen and is best screened for by palpation of the proximal
fibula and assessing for tenderness followed by a tibial-fibular
radiograph.

The AO-OTA classification (Fig. 57-9)
is based on the location of fracture lines and degree of comminution
and serves to describe the severity and degree of instability
associated with a particular fracture pattern.¹,¹⁵³
The AO-OTA classification expands on the Danis-Weber classification
scheme, which is still in use, is perhaps the most rudimentary of the
classification systems, and is based simply on the level of the fibula
fracture.⁴⁷,²³⁹
A Weber type A has a fibula fracture below the level of the
syndesmosis. A Weber type B occurs at the level of the syndesmosis,
while a type C is above the level of the syndesmosis.

Multiple studies have shown the Weber classification
system to be inadequate as the level of the fibula fracture does not
consistently predict the degree of syndesmosis injury since both B and
C fractures may be stable after isolated fibular fixation. The Weber
classification also ignores the status of the medial-sided structures
and does not base treatment on the status of this vital
osteoligamentous structure.¹⁴,³⁰,¹⁵⁷
The AO-OTA classification uses the Weber classification as its basis
but has been expanded to include medial-sided injuries and ligamentous
avulsions from the distal tibia. Although more comprehensive, the
AO-OTA classification has also been found to have a limited
interobserver and intraobserver reliability.⁴⁵,²²¹ Details of the classification system are described in Figure 57-9.

Ankle fractures are varied and complex and the current
existing classification schemes are limited in their ability to fully
categorize many injuries. Two recent studies serve to underscore the
limitations of the current classification systems. A recent study that
attempted to correlate MRI findings with positive stress views has
found that there were no statistically significant correlations between
the medial clear space measurements and MRI documentation of complete
deltoid ligament rupture.¹⁰³ Another
study comparing MRI findings to the Lauge-Hansen classification of a
particular fracture has found less than 50% correlation between the MRI
findings and the ligamentous injury predicted by the Lauge-Hansen
classification.⁶⁸ As our
understanding of ankle fractures evolves, it is becoming clear that
treatment decisions should be based less rigidly on a classification
system, but rather that fracture classification serves as one data
point in the overall comprehensive evaluation of the fracture.

The anatomy of the ankle has been thoroughly reviewed and documented by multiple authors.⁷⁶,¹⁷¹,¹⁹⁸
The ankle is a three-bone joint composed of the tibia, fibula, and
talus. The talus articulates with the tibial plafond superiorly, the
posterior malleolus of the tibia posteriorly, and the medial malleolus
medially. The lateral articulation of the talus is with the lateral
malleolus portion of the fibula. The joint is considered a saddle joint
with the talar dome being wider anteriorly then posteriorly. This
wedge-shaped footprint of the talar dome creates a situation whereby
the dorsiflexed position creates a stable bony articulation while the
plantarflexed position is more mobile and is stabilized by ligamentous
structures. As the ankle dorsiflexes, the wider anterior talus forces
the fibula to externally rotate through the syndesmosis (Fig. 57-10).

The tibiotalar articulation is considered to be highly congruent. Ramsey et al.¹⁸³
developed a static cadaveric biomechanical model and found that even a
1-mm lateral talar shift within the mortise decreases the joint contact
area by 42%. Further research has expanded on this finding. Clarke et
al.³⁹ developed an axially loaded
cadaver ankle model testing tibiotalar stability in bimalleolar ankle
fractures. Their findings showed that with a 6-mm lateral displacement
of the lateral malleolus, there was no significant change on the
contact area of the ankle as long as it was axially loaded. However,
once the deltoid ligament was sectioned, all ankles showed a
significant decrease in tibiotalar contact area. This result was
consistent with the observation that the pattern of instability was not
a straight lateral translation but rather anterolateral rotation
underneath the tibial plafond. In a follow-up study, Michelson and
Waldman¹³⁹ used a similar
unconstrained axially loaded cadaver model to assess instability in SER
fracture models. This study confirmed that in an axially loaded,
isolated lateral fibula fracture without medial malleolus or deltoid
ligament disruption, there was no appreciable loss of tibiotalar
contact and that the deltoid ligament, specifically

the deep portion, served as a main checkrein to anterolateral rotation of the ankle.¹³⁶

In another study assessing PER ankle injuries, Michelson et al.¹⁴²
applied their unconstrained axially loaded cadaver ankle model to show
that in the face of intact medial structures, even a syndesmotic injury
is not destabilizing. In this iteration of the cadaver experiment, when
the medial osteoligamentous structures were disrupted along with a high
fibular fracture and a disrupted syndesmosis, the talus dislocated from
the mortise. When the medial structures were intact, the talus remained
reduced. Solari et al. also demonstrated the importance of the medial
malleolus in the stability of Weber C fractures in a cadaver study
evaluating the need for syndesmotic screws.²⁰⁵
In this study, the rotational component of instability was assessed
specifically. A Weber C fracture pattern where the medial malleolus
alone was treated attained 56% of total rotational talar stability,
isolated lateral malleolus fixation attained 36% stability, and
fixation of the lateral malleolus and medial malleolus (without
syndesmotic fixation) attained 76% of total stability. Their conclusion
was that the medial malleolar osteoligamentous complex is the single
most important contributor to ankle stability in Weber C fracture
patterns.

The anteromedial aspect of the distal tibia is composed
of the medial malleolus to which the fibers of the deltoid ligament are
attached. When discussing the anatomy and function of the medial
malleolus, it is important to understand its close interrelationship to
the deltoid ligament, which originates from it. The most accurate
description of what we will refer to as the MMOLC was provided by
Pankovich et al. and Skie et al. in cadaveric studies.¹⁷¹,²⁰³

The osseous component of the MMOLC is the medial
malleolus, which is composed of the anterior and posterior colliculi
separated by the intercollicular groove. The anterior colliculus is the
narrower and most distal portion of the medial malleolus and serves as
the origin of the superficial deltoid ligaments. The intercollicular
groove and the posterior colliculus, which is broader than the anterior
colliculus, provide the origin of the deep deltoid ligaments. The
insertions of the deltoid ligaments (medial tubercle of the talus,
navicular tuberosity, and the sustentaculum tali) can also be
considered part of the MMOLC.

The deltoid ligament, which is divided into superficial
and deep, comprises the rest of the MMOLC. The superficial deltoid,
originating from the anterior colliculus, has three main components.
The naviculotibial ligament is most anterior portion of the superficial
deltoid inserting on the dorsomedial navicular. The strongest portion
of the superficial deltoid is the calcaneotibial ligament, which
inserts at the sustentaculum tali. The most posterior structure of the
superficial deltoid is the superficial talotibial ligament, which
inserts at the medial talar tubercle.

The deep deltoid is composed of two structures. The deep
anterior talotibial ligament, originating from the intercollicular
groove deep to the calcaneotibial ligament, inserts on the medial
talus. The deep posterior talotibial ligament originates from the
intra-articular aspect of the posterior colliculus and inserts on the
medial talus. This ligament is the strongest and thickest ligament of
the deltoid complex. This intra-articular ligament is not accessible
from outside the joint. Also important to consider is the close
approximation of the posterior tibial and flexor hallucis tendons to
the deltoid ligament as their tendon sheaths are essentially contiguous
with the insertions of the deltoid ligament complex (Fig. 57-11).

The distal lateral border of the tibia is concave with
anterior and posterior tubercles. The anterior tubercle (Chaput
tubercle) is the origin of the AITFL, and the posterior tubercle is the
origin of the deep component of the posterior inferior tibiofibular
ligament (PITFL). The anterior tubercle overlaps the fibula, and this
relationship is the basis of the radiologic interpretation of the
status of the syndesmosis. The more superficial fibers of the posterior
tibiofibular ligaments are also attached to the posterior tubercle and
are typically not injured in trimalleolar fractures. This serves to
tether the posterior malleolus to the lateral malleolus and is the
basis for the observed indirect reduction

of the posterior malleolar fragment with restoration of fibular length.

The posterior malleolus comprises the posterior lip of
the tibial plafond. The posterior malleolus is important as it serves
as the point of origin of the posterior inferior tibiofibular ligaments
of the syndesmosis (Fig. 57-12). The degree of
articular involvement associated with a posterior malleolus fracture
helps to determine the stability of the ankle joint as it prevents
posterior translation.¹⁹⁹ This fact,
however, was challenged by two cadaveric studies that demonstrated no
talar instability with posterior malleolus fractures involving up to
40% of the articular surface if there was no lateral-sided injury to
the fibula or posterior ankle ligaments.⁸³,¹⁸²
The posterior malleolus has also been noted to contribute significantly
to the weight-bearing surface with a loss of 35% of contact pressure
seen with a fracture involving half the joint surface.⁸⁰,¹⁸²

The lower end of the fibula makes up the lateral
malleolus. The lateral malleolus extends distally farther than the
medial malleolus, a property that is used to assess length and forms
the basis of the talocrural angle described previously. The lateral
malleolus is secured to the talus as well as tibia via a multiple
ligamentous structures as described earlier. The main ligamentous
complex of the ankle is the syndesmosis, which secures the fibula to
the tibia. The four components of the syndesmosis include the AITFL,
which runs from Chaput tubercle on the tibia to Wagstaffe tubercle on
the fibula; the PITFL, which runs from Volkmann tubercle and attaches
to the posterolateral aspect of the fibula. Distal to the PITFL is the
inferior transverse tibiofibular ligament (ITL). The ITL is thick and
cartilaginous and forms a structure akin to a labrum in the posterior
ankle joint. The fourth component of the interosseous membrane is the
tibiofibular interosseous membrane, which thickens and becomes the
tibiofibular interosseous ligament (see Fig. 57-12).

The talus (Fig. 57-13) is
largely covered by articular cartilage and has no musculotendinous
attachments. It has a limited blood supply, which will be discussed in
a later chapter. The medial and lateral facets, which articulate with
the medial malleolus and lateral malleolus respectively, are contiguous
with the articular surface of the dome. In general, the talar dome is
rarely injured during ankle fractures as its bone is considered more
dense than that of the tibial plafond bone. It is more typically
injured during an axial loading mechanism. The dome of the talus is
trapezoidal, being broader anteriorly and narrower posteriorly, and
this greatly affects ankle stability. In dorsiflexion, there is
significant stability from the bony conformity of the joint. In
plantarflexion, it is the ligamentous structures that help stabilize
the joint. The medial deltoid ligament fibers that attach to the talus
have been discussed. On the lateral side, it is the three lateral
collateral ligaments (LCLs) that help stabilize the

lateral
malleolus to the talus. The weakest of the LCLs is the ATFL, which is
essentially a thickening within the ankle capsule running from the
anterior-inferior portion of the lateral malleolus to the capsular
attachment on the talus. This ligament is highly susceptible in ankle
sprain injuries and is almost universally affected in this situation.
The calcaneofibular ligament (CFL) is stronger than the ATFL and
originates at the lower segment of the anterior border of the lateral
malleolus inserting on the calcaneus deep to the peroneal tendons. The
CFL resists ankle inversion in a dorsiflexed ankle. The posterior
talofibular ligament (PTFL) is the strongest of the three LCLs and
originates on the medial surface of the lateral malleolus extending
horizontally to the posterior surface of the talus. The PTFL functions
to prevent a posterior rotatory subluxation of the talus.

There are four tendon groups that cross the ankle joint:
posterior, medial, anterior, and lateral. The posterior and medial
tendon groups function to plantarflex and invert the ankle and are
innervated by the tibial nerve (Fig. 57-14).
The anterior and lateral tendons are primarily powered by the peroneal
nerve and work to dorsiflex and evert the ankle. The posterior group is
comprised of the Achilles and plantaris tendons. The medial tendon
group is composed of the tibialis posterior, flexor digitorum longus,
and flexor hallucis longus (FHL), and they are transmitted past the
ankle under the lacinate ligament, which forms the roof of the tarsal
tunnel.

The peroneus longus and brevis tendons comprise the
lateral compartment and are transmitted past the ankle under the
superior peroneal retinaculum posterior to the fibula. At the level of
the lateral malleolus, the peroneus brevis is directly in contact with
the fibula and is therefore anterior and medial relative to the longus
tendon. Rupture of the superior peroneal retinaculum during ankle
injuries can cause a subluxation of the tendons that might not be
evident until stability has been re-established at the ankle joint. The
anterior tendons are transmitted under

the
extensor retinaculum proximal to the ankle and under the Y-shaped
inferior extensor retinaculum just distal to the ankle joint.

Two neurovascular bundles traverse the medial side of
the ankle. Superficial to the anterior border of the medial malleolus
and the lacinate ligament lies the saphenous vein and nerve. These
structures are often injured with approaches to fixation of the medial
malleolus, and one should take care to avoid them, especially at the
proximal extent of the incision. The second neurovascular structure at
the medial side of the ankle is the posterior tibial artery and tibial
nerve, which passes under the laciniate ligament within the tarsal
tunnel and is consistently found between the flexor digitorum longus
and the flexor hallucis longus. The lateral side of the ankle transmits
the superficial peroneal nerve anteriorly at a point approximately 10
cm from the tip of the lateral malleolus 50% of the time and
approximately 5 cm from the tip 20% of the time; therefore, great care
must be taken to protect this superficial structure during approaches
to the lateral malleoleus.⁸⁹ Also on
the lateral side, roughly located halfway between the lateral border of
the Achilles tendon and posterior border of the lateral malleolus lies
the sural nerve, which assumes a more anterior position within the 5 mm
of the posterior aspect of the lateral malleolus, at the tip.⁸⁹
The anterior ankle contains the deep peroneal nerve and anterior tibial
arteries, which are transmitted under the superior and inferior
extensor retinaculum between the extensor hallucis longus and extensor
digitorum longus. A safe interval for an anterior approach to the ankle
is between tibialis anterior and the extensor hallucis longus with
medial retraction of the neurovascular bundle.

The approach to the lateral fibula is relatively
straightforward with several specific considerations to keep in mind.
The posterior location of the fibula relative to the tibia is easier to
approach when a small bump is placed underneath the operative side
buttock to internally rotate the lower extremity slightly. Also, a
sterile bump is useful to keep the ankle elevated and open up more
degrees of freedom for angling of the drill and screws. The level of
the fracture site is palpated or localized under fluoroscopy; this
determines the center of the incision and the approach. The superficial
peroneal nerve pierces the lateral peroneal fascia and traverses the
lateral compartment into the anterior compartment approximately 10 cm
proximal to the tip of the lateral malleolus, although it can be found
within 5 cm in 20% of ankles.⁸⁹ A
relative safe zone is directly over the center of the fibula extending
to a distance of 5 cm from the tip of the lateral malleolus, above
which a more careful dissection is advised. Skin flaps should be kept
thick to prevent any undue trauma and decrease the risk of skin
breakdown. Distally, the incision can be angled slightly anteriorly to
allow visualization of the anterolateral joint and the AITFL. This
structure can be repaired through this approach, although it is rarely
indicated once fibular and syndesmotic fixation has been achieved.
Dissection should be kept to a minimum at the bone, and the periosteum
should be elevated only at the level of the fracture. Placement of
clamps may be facilitated by creating strategic perforations in the
anterior fascia over the anterior border of the fibula to allow entry
of the clamp medially without unnecessarily performing a wide
dissection of that area.

In cases where a posterior fibula plate is templated for and planned, a modification of the lateral approach is required.²³³
Here, the incision over the fibula is centered vertically over the
posterior border of the lateral malleolus. This approach takes the
surgeon away from the danger of damaging the superficial nerve;
however, the sural nerve becomes a more proximate structure that is at
risk of being damaged. This dissection also does not allow ready access
to the anterolateral joint if fixation of Chaput tubercle is desired, a
fact that must be recognized before selecting posterior plating. The
approach is taken down the posterior border of the fibula and outside
the peroneal tendon fascial envelope. Occasionally, through this
approach, a portion of the superior peroneal retinaculum is divided and
may be reapproximated at the end of the procedure. The plate is affixed
directly posteriorly and the screws are aimed anteriorly, providing for
bicortical purchase throughout the length of the plate without danger
of intra-articular penetration. A large sterile bump as well as
significant internal rotation of the lower extremity facilitates aiming
of the screws posterior to anterior.

In cases when a large posterior malleolar fragment requires fixation, a posterior approach may be desired.²³³
For large laterallybased fragments where the posterior malleolus does
not extend to the medial malleolus, a direct posterior approach is
helpful. The patient is ideally placed in the prone position, and a
longitudinal incision is undertaken on the lateral side of the Achilles
tendon. Here, the sural nerve is at risk for injury as it passes
through the middle of the operative field. The sural nerve is located
subcutaneously in the areolar fat tissue and can be easily cut. Careful
dissection will mobilize the nerve laterally as the interval between
the peroneal tendons and the Achilles (superficially) and FHL tendon
(deep) is approached. The approach extends down to the posterior
malleolus on its lateral side and the posterior aspect of the
syndesmosis. Care must be taken to visualize and cauterize a branch of
the peroneal artery that lies on the posterior aspect of the
syndesmosis. Through this interval, both the fibula as well as
posterior malleolus can be instrumented and reduced. On the fibula, a
posterior plate is placed while the medial malleolus can be repaired
with either a plate or posterior to anterior directed lag screws. The
medial malleolus can be easily approached via a separate incision in
the prone position.

The medial approach to the ankle is used to secure
medial malleolar fractures and can also be used to approach
mediallybased posterior malleolus fragments. Two types of medial-sided
incisions are commonly used. A curvilinear incision (“hockey stick
incision”) can be made based over the anteromedial aspect of the medial
malleolus centered over the joint “axilla” and curving either
anteriorly or posteriorly around the tip of the medial malleolus. The
structures at risk with this approach are the saphenous vein and nerve
at the proximal incision and the posterior tibial tendon at the distal
extent of the incision. This incision is ideal for visualization of the
medial joint axilla and therefore allows fixation of medial impaction
fractures, medial comminution, and evaluation of osteochondral injuries
of the talus should they be present. The main limitation of this
incision

is
that it is not extensile distally. An alternative and commonly used
incision is a straight vertical incision over the midsubstance of the
medial malleolus. This incision, although extensile, is limited in its
ability to allow visualization of the medial joint axilla.

Although rarely used in conjunction with rotational
ankle fractures, an anterior approach may sometimes be desirable
specifically in situations where a full posterior exposure of the
posterior malleolus is not advised (because of soft tissue
constraints). In this scenario, the posterior malleolus can be clamped
and lagged from anterior to posterior. The interval used here is
between the anterior tibialis tendon and the extensor hallucis longus
tendon (Fig. 57-15).

Another helpful approach that is infrequently used is a
modification of the lateral approach for the purposes of minimally
invasive extraperiosteal plating of the lateral malleolus, which has
been specifically described for pronation abduction injuries but can be
applied to other fibula fractures.²⁰¹,²³⁰ In this approach, the plate is used as a bridge-plate construct, avoiding direct reduction of the fracture fragments.

The underpinnings of current indications in the
treatment of ankle fractures lie in an understanding of ankle
biomechanics and the evolution of this understanding. During the 1930s
and through the 1960s, the vast majority of ankle fractures were
treated nonoperatively. If surgery was indicated, the recognized
standard fixation technique for bimalleolar ankle fractures was an open
reduction of the medial malleolus and closed reduction of the lateral
malleolus. The teaching was that an anatomic reduction of the medial
malleolus was sufficient to reduce the talus and re-establish a stable
and congruent mortise and that the integrity of the medial malleolus
was considered to be the chief determinant of ankle stability. Several
outcome studies, however, indicated unsatisfactory long-term results
for surgically treated displaced ankle fractures. The poor long-term
outcome of ankle fractures prompted further critical analysis of the
approach to treatment of these fractures.⁴⁶,⁹⁰,¹⁹⁰

The dogma of the medial malleolus being the main
stabilizer of the ankle joint was first challenged by Yablon et al.,
who conducted a combined anatomic and clinical study of unstable ankle
fractures.²⁵⁰ In the anatomic arm of
the study, cadaver ankles underwent stress testing after an isolated
deltoid ligament division, isolated medial malleolus fracture, isolated
division of the fibular collateral ligaments, and a short oblique
distal fibula osteotomy with all ligaments intact. Stress testing of
these sectioned specimens revealed that both an incompetent deltoid
ligament and a medial malleolar fracture contributed little to ankle
instability. Both of the lateral lesions of the ankle, however (lateral
malleolus fracture or ligament disruption), caused marked ankle
instability. In the clinical arm of the study, 42 patients with
bimalleolar ankle fractures and 11 patients with a lateral malleolus
fracture and tear of the deltoid ligament (indicated by talar shift)
were treated operatively. The 11 patients with a fibula fracture and
deltoid ligament tear were treated with isolated fibular plating and
all fractures were anatomically

reduced.
Of the 42 patients with bimalleolar fractures, the first 17 were fixed
with medial malleolar fixation only. Intraoperative radiographs
revealed inadequate talar reduction in 14 of these cases, at which
point all hardware was removed and the fibula alone was plated. All
patients achieved reduction of the talus after lateral malleolar
fixation. The authors concluded that the lateral malleolus is the
keystone for ankle stability after ankle fracture.

A study by Svend-Hansen et al.²¹⁵
corroborated the poor results associated with isolated medial malleolar
fixation in bimalleolar ankle fractures. Twenty-nine patients with
either SER4 or PER3/PER4 fractures were treated with isolated medial
malleolar fixation and closed reduction of the lateral malleolus.
Sixteen of the 29 patients in this series had unsatisfactory results
with development of ankle arthritis within the 4.8-year average
follow-up period. They attributed the poor results to malunions of the
fibula and lack of talar reduction by medial malleolar fixation alone.

Another indication of poor results of ankle fractures treated by isolated medial malleolus fixation was provided by Joy et al.⁹⁵
A total of 118 unstable ankle fractures were enrolled and all underwent
initial closed reduction. If closed reduction was judged inadequate,
open reduction was undertaken. Forty-six ankles underwent operative
fixation of the medial malleolus or suture repair of the deltoid
ligament without fibular fixation in any of the fractures. During a
follow-up period of 1 to 7.5 years, the authors looked at radiographic
criteria of reduction as well as subjective and objective evaluation of
function. In the 46 operatively treated fractures, 22 (46%) were
considered to have poor results, with similar results in the closed
treatment group. An analysis of the factors most predictive of a poor
result showed a correlation with degree of talar displacement, severity
of fracture, and presence of deltoid ligament ruptures. This study
concluded that isolated medial malleolar fixation and treatment of the
MMOLC was inadequate in restoring a normal tibiotalar relationship,
having results similar to nonoperative treatment.

A landmark study by Pettrone et al.¹⁷⁷
would expand on our knowledge of ankle fractures. In this study, the
authors established radiographic criteria for evaluating the adequacy
of lateral malleolar reduction and syndesmotic disruption and then used
these criteria to assess ankle fractures treated by medial malleolar
fixation versus bimalleolar fixation. One hundred and forty-six
displaced ankle fractures were analyzed after they were treated closed,
treated with open bimalleolar fixation, or treated with medial
malleolar fixation alone. Analysis revealed that the overall result was
most affected by the degree of medial and lateral malleolar
displacement, integrity of the syndesmosis, and the patient’s age. They
concluded that the relative orders of importance for structures that
require restoration are the lateral malleolus, medial malleolus,
deltoid ligament, and finally the syndesmosis. Their analysis also
revealed that bimalleolar open reduction and internal fixation (ORIF)
of both SER4 and PER3/ PER4 fractures fared significantly better than
closed treatment and significantly better than reduction of the medial
malleolus alone. As a matter of fact, the data showed a trend toward a
worse outcome for isolated medial malleolar fixation compared with
closed treatment. Their conclusions were that anatomic reduction of
bimalleolar fractures correlated with superior outcome and that the
prognosis worsened as the number of deranged structures increased
following treatment.

Phillips et al.¹⁷⁸
reported a prospective study of 49 SER4 and PER4 ankle fractures with
an acceptable closed reduction who were randomized to operative
treatment or continuation of nonoperative treatment. A second arm of
the study assessed the treatment of 22 SER4 and PER4 ankle fractures
with unacceptable closed reductions randomized to bimalleolar or medial
malleolar fixation. Their conclusions stated that bimalleolar ORIF
provided far superior results than closed treatment of ankle fractures
and that patients with a medial malleolar fracture (as opposed to just
a deltoid ligament rupture) fared significantly worse when treated
closed. In the second arm of the study, bimalleolar fixation appeared
to have superior results to medial malleolar fixation alone; however,
this did not reach statistical significance.

Further evidence supporting the lateral malleolus being
most responsible for ankle stability comes from two case reports that
describe a traumatic extrusion and loss of the medial malleolar
fragment secondary to an open fracture. In both cases, an effort was
made to repair the deltoid ligament. Lindenbaum et al.¹¹⁸
reports follow-up of 3 years showing no evidence of arthritis, range of
motion 5 degrees less than the contralateral side, and stability under
a lateral stress radiograph. In a second case report by Hernigou et al.,⁸⁵
20-year follow-up of a patient with similar absence of the medial
malleolus showed roughly equal range of motion in both ankles. This
patient’s radiographs, however, showed arthritic changes within the
joint. The hypothesis of the authors was that although ankle varus and
valgus stability is conferred by the lateral malleolus, the rotational
stability and articular congruency provided by the medial malleolus are
important for maintaining the ankle articulation and preventing
arthritis.

Based on these studies, the standard of care for
unstable ankle fractures changed during the 1970s and shifted attention
to an anatomic reduction of the fibula. As previously mentioned, much
of this shift was stimulated by the study of Yablon et al.²⁵⁰
and subsequent clinical studies. Several authors, however, have shown
that dorsiflexion and plantarflexion of the ankle is a complex motion
that involves some movements out of the plane of motion of the ankle
and therefore static models of ankle kinematics such as Yablon’s were
flawed. It has subsequently been suggested and shown that during axial
loading, the talus may seek its own position beneath the tibia, tending
to reduce the lateral subluxation force.¹³²,¹⁷³,²³⁵
It had also been shown that rotational stability of the talus within
the ankle is because of tension in the deltoid and lateral ligaments.
Excision of the lateral malleolus articular surface did not reduce
rotational stability, but division of the deltoid ligament caused a
twofold increase in rotational instability.¹⁵¹

Clarke et al.³⁹
developed an axially loaded cadaver ankle model testing tibiotalar
stability in bimalleolar ankle fractures. Their findings showed that
even with a 6-mm lateral displacement of the lateral malleolus, there
was no significant change on the contact area of the ankle as long as
it was axially loaded. However, once the deltoid ligament was
sectioned, all ankles showed a significant decrease in tibiotalar
contact area. This result was consistent with the observation that the
pattern of instability was not a straight lateral translation but
rather anterolateral rotation underneath the tibial plafond. In a
follow-up study, Michelson et al.¹³⁸
used a similar unconstrained axially loaded cadaver model to assess
instability in SER fracture models. This study confirmed that in an
axially loaded ankle,

isolated
lateral fibula fracture without medial malleolus, or deltoid ligament
disruption, there was no appreciable loss of tibiotalar contact and
that the deltoid ligament, specifically the deep portion, served as a
main checkrein to anterolateral rotation of the ankle.

In another study assessing PER ankle injuries, Michelson et al.¹⁴²
applied their unconstrained axially loaded cadaver ankle model to show
that in the face of an intact MMOLC even a syndesmotic injury is not
destabilizing. In this iteration of the cadaver experiment, when the
MMOLC was disrupted along with a high fibular fracture and a disrupted
syndesmosis, the talus dislocated from the mortise. When the MMOLC was
intact, the talus remained reduced. Solari et al.²⁰⁵
also demonstrated the importance of the medial malleolus in the
stability of Weber C fractures in a cadaver study evaluating the need
for syndesmotic screws. In this study, the rotational component of
instability was assessed specifically. A Weber C fracture pattern where
the medial malleolus alone was treated attained 56% of total rotational
talar stability, isolated lateral malleolus fixation attained 36%
stability, and fixation of the lateral malleolus and medial malleolus
(without syndesmotic fixation) attained 76% of total stability. Their
conclusion was that the MMOLC is the single most important contributor
to ankle stability in Weber C fracture patterns.

Based on these studies, it is safe to conclude that the
MMOLC is important for ankle fracture stability when considering the
ankle joint in a dynamic state. Clearly, all fracture patterns are
located on a continuum of severity and their treatment must be
individualized. It appears that although a near anatomic reduction of
lateral side of the ankle is important, it is only relevant when the
MMOLC is disrupted. Therefore, ankle injuries that do not present with
a medial-sided injury are likely stable and can be treated
nonoperatively. Displaced fibula fractures without any medial-sided
injury has been considered a possible indication for surgery, as it was
believed that the distal fibula is externally rotated. External
rotation of the distal fibula has been stated as a reason for ankle
symptoms and poor function after SER2 ankle fractures.²⁵¹
Michelson et al. refuted this notion with a CT study that found the
proximal fibula internally rotates relative to the distal malleolus
fragment and the relationship of the lateral malleolus at the ankle is
maintained.¹⁴⁰ This study provides evidence that ankle biomechanics are not altered in an SER2 type of injuries.

The diagnosis of a medial-sided injury can be difficult
when an osseous injury is not present. Koval et al. studied 21 Weber B
type ankle fractures that had a positive stress test. All ankles
underwent MRI to evaluate for a deep deltoid rupture. The study
reported no statistically significant correlation between MRI findings
at the deltoid ligament and a positive stress test as 19 of the 21
patients had only a partial tear of the deltoid ligament. Only the
patients with a full rupture of the ligament on MRI underwent surgery,
and all patients in this group had excellent outcomes.¹⁰³
Another study by Egol et al. found that the clinical signs of medial
tenderness and swelling were not sensitive for predicting medial
widening on stress views. Moreover, this study found that patients
without any medial signs of injury and a positive stress test who were
treated without surgery had good or excellent clinical results.⁵³
Deangilis et al. lent further support to these data as they found no
statistically significant relationship between the presence of medial
tenderness and deep deltoid ligament incompetence. Medial tenderness
was determined to have a 57% sensitivity and 59% specificity for
predicting a deep deltoid injury.⁵⁰

Indications for nonoperative treatment of ankle
fractures may continue to evolve. At this point, however, the main
criteria for surgery are a widened mortise and obvious signs of
instability on radiograph such as dislocation, subluxation, syndesmosis
widening, or joint impaction. Other patient-specific indications must
obviously be taken into consideration such as age, functional level,
comorbidities, and soft tissue considerations.

Closed Treatment of Stable Fractures. Clinical studies
have shown that isolated lateral injuries (SER2) are treated well
nonoperatively with excellent functional results.¹³,¹⁰⁶,¹⁹⁵,²⁵⁵
Long-term follow-ups of patients with SER2 fractures that were treated
nonoperatively have shown a near-complete recovery up to 20 and 30
years after the initial injury. Other studies where SER2 fractures were
treated operatively have shown equivalent results to nonoperative
treatment.²⁵²

The difficulty with identifying the injuries ideal for
closed injuries was detailed earlier. The practice of obtaining a
stress view has historical precedence for ruling out instability. Both
a manual stress view and a gravity stress examination have been
described as legitimate methods to stress the ankle mortise¹³⁰,¹⁷²,²⁰⁰; however, recent data have brought the utility of the stress view into question.⁵³,⁶⁸,¹⁰³,¹⁵⁷
Despite this, the practice of obtaining a stress view has become a
standard of care that should still be used but now should be
interpreted with greater caution.

Stable ankle fractures are therefore treated for 6 weeks
in a supportive brace with weight bearing allowed as tolerated.
Favorable results have been described with treatment using high-top
shoes, elastic support brace, air cast stirrup brace, or a walking boot.²⁹,¹⁹⁵,²⁵⁵
Physical therapy can be instituted throughout the recovery period
encouraging range-of-motion exercises. The therapy can be advanced to
full weight-bearing strengthening and proprioception training for
several weeks with almost uniform excellent results. The complication
rate from nonoperative treatment in stable ankle fractures is
negligible despite reports of rare fibular nonunions.⁵⁸,¹⁴³,¹⁸⁴

Closed Reduction of Unstable Fractures. Once an unstable
ankle fracture is identified, a closed reduction is indicated as the
first line of treatment. Clearly, ankle fracture-dislocations are a
sign of great instability and require more immediate attention and a
prompt closed reduction. Once a satisfactory closed reduction is
achieved, the patient should be given the option of proceeding with
operative or nonoperative treatment. The typical regimen of
nonoperative treatment is a long-leg cast, to neutralize rotational
forces at the ankle, for a period of 6 weeks and then advanced to
either a short-leg cast or walking boot.

Closed reduction typically requires some type of
anesthetic to facilitate relaxation of the limb and allow manipulation
as well as immobilization while maintaining optimal patient comfort.
Some advocate the use of anesthesia or a conscious sedation protocol to
achieve the reduction,¹⁹⁴ although performing an intra-articular block or hematoma block may require less nursing and ancillary support.⁶,⁶⁶,²⁴³
An intra-articular block is performed by placing the patient in a
supine position. The affected ankle is prepared with Betadine solution.
A 20-gauge needle is inserted into the medial aspect of the ankle
joint, medial to

the
tibialis anterior tendon. Once the joint is penetrated and hematoma is
aspirated, confirming appropriate placement of the needle, the joint
can be injected with 12 mL of 1% lidocaine without epinephrine. White
et al.²⁴³
compared an intra-articular hematoma block to conscious sedation in a
randomized prospective manner and reported a similar degree of
analgesia (Fig. 57-16).

Once adequate analgesia is obtained and the patient is
appropriately relaxed, a reduction maneuver is performed. The classic
closed reduction maneuver was originally described by Quigley in 1959
and has since come to be known as “Quigley’s maneuver.”¹⁸¹

The original description stated:

This reduction maneuver continues to be helpful in the
emergency department, allowing the physician to perform both the
reduction and casting with minimal assistance as the leg is hung from
an intravenous line pole while the reduction is performed and a
long-leg cast is applied. The mortise should be anatomically reduced;
otherwise, the reduction should be repeated (Fig. 57-17).

The complications associated with cast treatment are
well known. Maintaining the reduction in a cast can be exceedingly
difficult despite an initial congruent reduction, with one study
showing 34% rate of anatomic reduction with up to 26% rate of loss of
reduction.⁵⁷ Obstacles to
maintaining a reduction in a cast are body habitus, poor patient
tolerance of a long-leg cast, elderly and polytraumatized patients,
decreased swelling, and subsequent cast loosening. Closed treatment
requires close follow-up with nearly weekly radiologic examinations for
a period of 3 weeks. Quigley, in his original article, acknowledged
that certain fracture patterns such as those where the medial malleolar
fracture line is at the level of the plafond or above will have no
medial buttress and the talus will subluxe medially.¹⁸¹ The ideal treatment for unstable ankle fractures is arguably surgical.

Meticulous casting and splinting technique is required
to allow for optimal results. It is important to ensure that the cast
or splint is well contoured without any wrinkling of the cotton padding
that could exacerbate any soft tissue compromise that already exists.
The ankle must be kept in neutral and great care should be taken to
avoid an equinus posture. Certain fracture patterns are highly unstable
in neutral and can only be closed reduced in plantarflexion; this
should serve as an indication for operative fixation.

The first part of the decision algorithm for operative
treatment of ankle fractures should be the degree of instability that
is present. As previously discussed, our understanding of what
constitutes ankle instability continues to evolve; however, obvious
instability should receive surgical treatment. Other indications for
operative treatment are failure to hold a reduction in a cast,
syndesmosis diastases, articular surface incongruity as

marginal
plafond impaction injuries, comminution at the medial axilla of the
joint, and large displaced medial malleolar fractures. Special
considerations are surgical timing, open fractures, elderly patients,
and diabetic patients.

The prognosis for most rotational ankle fractures
appropriately treated is generally good. Multiple studies have
established that the adequacy of reduction on radiographs correlates
well with overall outcome.⁶²,⁹⁵,¹⁴⁹,¹⁷⁷
As discussed, stable ankle fractures that are treated in a closed
fashion have good to excellent results at various follow-up times with
the only subjective long-term symptom being swelling.¹⁵,¹⁰⁶
The outcomes of operatively treated unstable ankle fractures have also
been favorable as shown by multiple authors with up to 85% to 90%
excellent results.¹⁷,¹¹⁹
Although variability among postoperative weightbearing protocols exists
in the literature, outcomes seem to be favorable when an unstable
injury is identified and treated appropriately.⁵⁴,⁷⁴,¹¹²,²⁰² Surgery for unstable ankle fractures has even been shown to be a cost-effective endeavor.¹⁸

Studies on patient functional outcomes following ankle
fractures using validated outcome scores have been limited in the past.
In one study of 141 patients followed for 2 years after

operative
stabilization of an ankle fracture, 77% obtained a good or excellent
result, as measured with the Olerud-Molander score.¹¹⁰ Obremsky et al. have shown continued improvement in the SF-36 even 20 months after surgery.¹⁵⁹
Day et al. showed only 52% good or excellent outcome after bimalleolar
ankle fracture fixation with a follow-up of 10 to 14 years using the
Phillips scoring system.⁴⁹ With regard to driving, patients have been shown to return to baseline breaking function at 9 weeks status post ankle surgery.⁵⁵
A more recent study from our institution was conducted to identify
demographic and patient factors that are associated with functional
recovery. In this prospectively followed cohort of patients, the AOFAS
and SMFA scores were used for evaluation. The patient factors most
predictive of functional recovery were found to be patient age, gender
(males with better outcomes), the presence of diabetes mellitus, and
the ASA classification. The same study found that at the 1-year
follow-up, patients had largely returned to their preoperative baseline
function and were experiencing little to no pain.⁵⁶
Bhandari et al. found that modifiable social factors such as smoking
and alcohol consumption are important determinants of outcomes in
patients with operatively treated ankle fractures.¹⁹