Radiographic evaluation of the normal ankle joint in children and adolescent

Background

The purpose of this study was to determine the reliability of numerous radiographic measurements of the skeletally immature ankle joint, timing of ossification of medial malleolus and appearance of tibial incisura and differences in the values of radiographic measurements based on age and sex.

A comprehensive analysis of patients with malreduced ankle fractures undergoing re-operation

Purpose

The present study aimed to determine the most common surgical errors resulting in early re-operation following ankle fracture surgery.

Methods

We performed a chart review to determine the most common types of malreductions that led to early re-operation following ankle fracture surgery. From 2002 to 2011, we identified 5,123 consecutive ankle fracture operations in 5,071 patients. Seventy-nine patients (1.6 %) which underwent re-operation due to malreduction detected in postoperative radiographs. These patients were compared with an equal number of age- and sex-matched controls which did not need further surgery.

Results

The most common indication for re-operation was syndesmotic malreduction (47 of 79 patients, 59 %). Four main types of errors related to syndesmotic reduction or fixation were identified, with the most common being fibular malpositioning within the tibiofibular incisura. Other indications for re-operation were fibular shortening and malreduction of the medial malleolus. Fracture dislocation, fracture type, posterior malleolar fracture, associated medial malleolar fracture, duration of index surgery, and fixation of an associated medial malleolar fracture with other than two parallel screws were also associated with re-operation. Correction of the malreduction was successfully achieved in the majority (84 %) of cases needing further surgery.

Conclusion

Early re-operation after ankle fracture surgery was most commonly caused by errors related to syndesmotic reduction or failure to restore fibular length. In the majority of cases, postoperative malreduction was successfully corrected in the acute setting.     

Miniarthrotomy assisted percutaneous screw fixation for displaced medial malleolus fractures – A novel technique

Aim

To describe here a technique of miniarthrotomy assisted percutaneous screw insertion for displaced Herscovici type B and C medial malleolar fractures.

Method

Incision was made centred over the superomedial angle of the ankle mortise, about half a cm medial to tibialis anterior. Arthrotomy was done and reduction obtained. Percuntaneously, two 4 mm cancellous cannulated screws were inserted through medial malleolus.

Results and conclusion

This approach allows direct visualization of reduction, removal of entrapped soft tissue and preservation of saphenous vein and nerve.     

A clinical evaluation of alternative fixation techniques for medial malleolus fractures

Background

Medial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site.

Setting

Saint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO.

Methods

After IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation.

Results

Seven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12–208 weeks). There were no screw removals for painful hardware and no cases of non-union.

Conclusions

Headless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.     

Screw-only fibular construct for Weber B ankle fractures: A retrospective clinical and cost comparison to assess feasibility for resource-limited settings

IntroductionAnkle fractures are one of the most common injuries sustained worldwide, with the majority being isolated lateral malleolus fractures. The majority of the world's population live in Low and Middle Income Countries (LMIC), where implant cost may limit surgical treatment of ankle fractures. We investigate if Weber B ankle fractures could be effectively treated with a lower-cost technique using two screws between the fibula and the tibia to neutralize an interfragmentary lag screw.MethodsAfter IRB approval, consecutive patients from January 1, 2020 to December 31, 2020 with Weber-B ankle fractures were treated using AO technique (AOT) with plate osteosynthesis neutralizing an interfragmentary screw. Syndesmotic injuries, as well as injuries to the medial malleolus or foot were treated according to the surgeon's preferences. From January 1, 2021 to December 31, 2021 these injuries were treated with a screw-only technique (SOT) with two fibula pro tibia screws to neutralize an interfragmentary screw. Patient demographics including age, sex, BMI, smoking status, associated rheumatoid arthritis, and associated diabetes mellitus were recorded. The primary outcome variable was a stable radiographic mortise at six weeks post-surgery, secondary outcome variables included clinical union, infection, hardware removal, and implant cost for lateral malleolar fixation charged to the hospital.ResultsSeventeen AOT and 10 SOT constructs were included. Demographic characteristics were similar between groups. All fractures maintained a stable mortise with clinical union at 6 weeks without infection. There was a statistically significant difference in hardware removal (17.6% AOT, 50% SOT, p = 0.012). The average implant cost to the hospital of the lateral malleolar fixation was significantly less in the SOT group ($592 (SD $229)), compared to the AOT group ($1,949.97 (SD $562)), (p < 0.0001).ConclusionWe introduce proof of concept of a novel lower-cost fixation strategy for Weber B ankle fractures that maintained a stable mortise with clinical union at six weeks post-surgery. However, there was a significantly higher rate of hardware removal following fixation with a screw-only construct.     

Hardware in the medial malleolus: is it intra-articular?

This paper is a radiographic approach to ascertain if the hardware at the medial malleolus is intra-articular. A human tibia was removed from a skeleton and pins were placed in the medial malleolus representing pins that would be intra- and extra-articular (in the mortise). Radiographs were obtained at precise rotation intervals. Those pins that were placed intra-articularly could not be made to appear otherwise. The pin that was placed extra-articularly was visualized on a single view to be extra-articular. Therefore, if hardware can be demonstrated to be extra-articular on any one view then it is not intra-articular.     

Radiographic evaluation of the position of implants in the medial malleolus in relation to the ankle joint space: anteroposterior compared with mortise radiographs

BACKGROUND: Displaced transverse fractures of the medial malleolus are commonly treated with open reduction and internal fixation with two screws or wires. A mortise radiograph is often used to verify the position of the implants relative to the joint space. However, because the medial and lateral talomalleolar spaces are normally not parallel, the mortise projection (which is colinear with the lateral space) does not provide an accurate radiograph of the medial joint space. METHODS: In ten cadaveric ankles, two wires were inserted into the medial malleolus, as is done for fixation of a fracture, and the distance of the wires from the joint space was measured on an anteroposterior radiograph, on mortise radiographs made with the foot in 15 and 30 degrees of internal rotation, and on anatomical cross section. RESULTS: The measurement on the anteroposterior radiograph exceeded the anatomical measurement in only two specimens, and the discrepancy was 0.5 millimeter in both instances. Measurement of the osseous thickness between the joint surface and the posterior wire on the mortise radiographs always revealed a lower value than the measurements on the anteroposterior radiograph and the anatomical cross section of the same specimen. There was a false appearance of intra-articular placement of the posterior wire on the 15-degree mortise radiographs of four specimens and on the 30-degree mortise radiographs of eight specimens. CONCLUSIONS: These findings demonstrate that the mortise projection provides an oblique radiograph of the medial joint space that can inaccurately reflect the true position of fixation implants in the medial malleolus. Because an anteroposterior radiograph is made with the articular surface of the medial malleolus tangential to the beam, it provides a more accurate representation of implants in the medial malleolus.     

Therapie der Sprunggelenksluxationsfrakturen vom Pronationstyp

Objective

Early reduction of the dislocation and anatomic reconstruction of axial alignment, ankle mortise and articular congruity with special focus on syndesmotic stability.

Indications

Fracture–dislocations resulting from pronation injuries to the ankle with a highly incongruent and unstable mortise and either considerable internal pressure on the soft tissues by the displaced fragments or open soft tissue damage.

Contraindications

General contraindications to surgery: closed reduction and cast immobilization or external fixation.

Surgical technique

Early preoperative closed reduction of complete dislocations is achieved through longitudinal traction and movements contrary to the original fracture mechanism. A cast or joint-spanning external fixator is applied temporarily. Ideally, definite anatomic reduction of the posterior tibial fragment, the distal fibula and medial malleolus and stable internal fixation is achieved within the first hours after the injury. Congruity of the ankle mortise and syndesmotic stability is controlled intraoperatively and a syndesmotic screw is inserted if necessary. In these cases, the correct positioning of the distal fibula within the tibial incisura is verified with three-dimensional fluoroscopy or postoperative computed tomography scanning.

Postoperative management

Early range of motion exercises of the ankle and subtalar joints are initiated the second postoperative day or after soft tissue consolidation and removal of the external fixation. Patients are mobilized with partial weight bearing (20 kg) in a cast or special boot for 6 weeks postoperatively. The syndesmotic screw is then removed in most cases and weight-bearing is rapidly increased.

Results

The presence of a dislocation at the time of injury represents a negative prognostic factor in malleolar fractures. Higher rates of posttraumatic arthritis are also observed with trimalleolar fracures, especially fractures of the posterior tibial rim, cartilage damage, and syndesmotic disruption. Irrespective of the fracture classsification, good to excellent results can be obtained in 75–89?% of cases with anatomic reconstruction of the ankle mortise and the articular surfaces. Proper reduction of the distal fibula into the tibial incisura is of utmost importance in cases of frank syndesmotic diastasis.     

Safe zone for the placement of medial malleolar screws

BACKGROUND: Hardware placement for fracture fixation can put soft-tissue structures at risk for injury or abutment. The prominence of the hardware is a frequent cause of pain after the fixation of ankle fractures. This study was designed to assess the risk of injury or abutment of the posterior tibial tendon with the placement of medial malleolar screws. METHODS: Ten unmatched cadaveric limbs that had been disarticulated at the knee were used, and the medial malleolus was exposed by dissection of the skin. With use of fluoroscopy and direct visualization of the deep fascia, three Kirschner wires were placed through the tip of the medial malleolus and directed parallel to the medial articular surface. The first wire was placed in the center of the anterior colliculus. Two additional wires were placed parallel and posterior to the initial wire at 5-mm intervals. The wires were overdrilled, and 4.0-mm screws were inserted over the Kirschner wires. The specimens were dissected to inspect for trauma and the proximity of the screws to the posterior tibial tendon. The medial malleolus was divided into three zones on the basis of anatomic landmarks. Zone 1 is the anterior colliculus; Zone 2, the intercollicular groove; and Zone 3, the posterior colliculus. RESULTS: Screws placed in Zone 1 (the anterior colliculus) did not contact the posterior tibial tendon in any specimens. Screws placed in Zone 2 (the intercollicular groove) were, on the average, 2 mm from the posterior tibial tendon. Screws placed in Zone 3 (the posterior colliculus) resulted in tendon abutment in all ten specimens and in tendon injury in five of the ten specimens. CONCLUSIONS: Screws inserted posterior to the anterior colliculus place the posterior tibial tendon at significant risk for injury or abutment.     

Arthroscopic assessment of medial malleolar reduction

Introduction

Ankle fractures treated with open reduction internal fixation are fixed in an effort to reestablish anatomic bony alignment and avoid a malunion, thereby diminishing the risk of post-traumatic arthritis. For a medial malleolar fracture, an articular step-off is likely more related to the risk of post-traumatic arthritis than is a cortical step-off. However, the external cortical alignment is often used to judge the adequacy of reduction, as the articular component of the fracture is not as readily visualized. Arthroscopy has been used in various articular fractures as an aid to diagnosis and treatment. The current study prospectively assessed both the quality of medial malleolar reduction on the articular side using arthroscopy and the adequacy of using cortical cues to guide the articular reduction.

Methods

Twelve consecutive patients were enrolled in this prospective diagnostic study. All patients had medial malleolar fractures that required fixation. The outcome variables of interest were extra-articular fracture displacement and articular surface displacement.

Results

After reduction and provisional fixation, 10 of the 12 patients had an anatomic reduction based on cortical cues. On arthroscopy 7 of the 12 patients had an anatomic reduction. Four of the patients had a slight gap (<1 mm) at the anterior edge of the fracture. The last patient had an anterior gap just under 2 mm. Two patients had impaction of the medial malleolus that made reduction difficult and was recognized during arthroscopy after obtaining a reduction based on cortical cues.

Conclusion

The cortical reduction of the medial malleolus often matched up with the articular reduction. However, in some patients, impaction of the medial malleolus made it so that the two did not match up. There are some cases in which extra-articular cues are insufficient to evaluate for intra-articular reduction.     

Improving accuracy and confidence in distal radius volar plate screw placement through supplemental radiography: examining specialty, education, and experience levels

Background

The purpose of this study was to assess the extent to which a supplemental radiographic view increases accuracy and confidence ratings when determining screw placement in volar plating of distal radius fractures for evaluators of different specialties and experience levels.

Methods

Thirty-four distal radius fractures treated with volar plate fixation were imaged using standard AP and lateral, and supplemental lateral tilt views. Each case was then evaluated for penetration of distal screw tips into the articular space. Sixty-five physicians then completed a two-phase analysis and survey of these cases. In the first phase, presentation consisted only of AP and lateral views; in the second, the lateral tilt view was added. Participants were asked to determine whether distal screws penetrated the joint and rate their confidence in the determination. Assessments were scored for correctness; changes in accuracy and confidence levels between phases were analyzed using paired t tests. Comparisons between groups were performed by ANOVA.

Results

Supplementation increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years post-fellowship experience than those with more.

Conclusions

A supplemental view of the distal radius combined with AP and lateral views significantly improves the ability of all evaluators, regardless of specialty or training level, to correctly assess placement of fixation screws. The greatest improvements are seen for resident trainees.     

Intraoperative evaluation of dorsal screw prominence after polyaxial volar plate fixation of distal radius fractures utilizing the Hoya view: a cadaveric study

Background

The irregular nature of the dorsal surface of the distal radius makes it difficult to detect prominent screws with volar plate fixation for distal radius fractures using standard fluoroscopic images. This study evaluates the accuracy of a new radiographic method, the Hoya view, for the assessment of dorsal cortical screw penetration with volar plate fixation.

Methods

Eight cadaveric upper extremities underwent application of a volar distal radius plate with polyaxial locking screws placed distally. Utilizing a mini C-arm, lateral and Hoya views were obtained with notation of any dorsal cortical screw prominence. Dissection of the cadavers was then performed for direct visualization of screw prominence. The screws were then exchanged sequentially for screws 2-mm longer than their initial measurements with repeated imaging and direct visualization.

Results

The Hoya view revealed that 9.4 % of the screws penetrated the dorsal cortex with an average screw prominence of 1.08 mm (range 0.5–2 mm). None of the six prominent screws were detected with lateral views. With the Hoya view, six of six prominent screws were identified. With locking screws exchanged for screws 2-mm longer, 76.6 % of the screws had violated the dorsal cortex; of these, 24.5 % were detected with lateral imaging versus 100 % with the Hoya view.

Conclusions

This study supports the intraoperative use of the Hoya view to evaluate screw length and dorsal cortical screw penetration in volar plate fixation of distal radius fractures. However, this view may be difficult to obtain in patients with limitations in elbow or shoulder range of motion.     

Realignment-lengthening osteotomy for malunited distal fibular fracture

Purpose

Persistent displacement of ankle fractures increases the stresses on the articular cartilage and leads to degenerative arthritis. Correction of the ankle mortise restores the normal ankle biomechanics and should prevent the development of degenerative joint disease.

Methods

Seventeen patients were treated for symptomatic ankle joint due to malunited distal fibular fracture. There were eleven male and six female patients. Their ages ranged from 23 to 54 years (median 34 years). The procedure included transverse fibular osteotomy for restoration of the lateral malleolar alignment, acute distraction of the osteotomy to restore the fibular length with interpositional graft and reduction of subluxation of the distal tibio-fibular articulation. Internal fixation of the osteotomy was performed with plate and screws and trans-syndesmotic screws.

Results

Fibular lengthening was performed in all cases and ranged from six to 12 mm (median eight millimetres). The American Orthopaedic Foot and Ankle Society score preoperatively ranged from 40 to 74 (median 60) and at follow up ranged from 50 to 95 (median 79). Progression of ankles arthrosis occurred in one patient leading to ankle arthrodesis as a secondary procedure. Results were satisfactory in 12 cases (70.6 %), and unsatisfactory in five cases (29.4 %) due to stiffness and pain in the ankle joint. The follow-up ranged from 24 to 45 months (median 31 months).

Conclusion

Corrective osteotomy of fibular malunion produces considerable improvement provided that the patient does not have significant degenerative changes before surgery. The use of athrodiastasis of the ankle as a secondary procedure may be of value to improve the outcome.     

Radiographic effects observed in the coronal view after medial malleolar osteotomy at total ankle arthroplasty in rheumatoid arthritis cases

BackgroundWhen soft tissue balance is not acceptable at total ankle arthroplasty (TAA) for rheumatoid varus deformity, medial malleolar osteotomy has been performed. At the same time, the shape of the ankle joint changes after soft tissue balancing with such an osteotomy, however there is few information for the radiographic findings after the osteotomy. Thus, radiographic changes in the coronal view of such cases were investigated.MethodsJSSF-RA foot and ankle scale and SAFE-Q scores were determined along with pre/postoperative radiographic parameters of the ankle joint in 70 ankles (65 patients) with rheumatoid arthritis followed for a mean of 7.9 years (range, 2–16 years) after TAA. Seven ankles were excluded because those underwent lateral or lateral/medial malleolar osteotomy. Twenty-seven ankles underwent medial malleolar osteotomy, and compared with 36 ankles without osteotomy.ResultsAll ankles achieved bone union after medial malleolar osteotomy, and the tibial medial malleolus (TMM) angle was significantly decreased [30.3°–19.1°] following significant valgus correction [TC angle: −2.7° to 0.5°]. The gap due to medial soft tissue tightness was significantly improved by medial malleolar osteotomy [4.95° to 0.7°]. Lateral malleolar fractures sometimes occurred (19%: 5/27 ankles) at valgus correction, but they healed completely without any internal fixation.ConclusionMedial malleolar osteotomy was useful in rheumatoid varus ankle for not only controlling the soft tissue balance, but also providing a stabilized shape of the ankle joint. Lateral malleolar fractures were caused by valgus correction following medial malleolar osteotomy in some cases, but all fractures were completely healed without any internal fixation.     

The Role of Far Cortical Endosteal Fixation for the Treatment of Medial Malleolus Fractures: A Biomechanical Study

The traditional method for fixation of medial malleolus fractures has been with partially threaded (PT) lag screws extending beyond the physeal scar. The purpose of this study was to evaluate the biomechanical strength of an innovative method of fixation for medial malleolus fractures using a fully threaded (FT) lag screw that extends to the far endosteal cortex. Medial malleolus fractures were simulated in 12 matched cadaver pairs. A single PT 4.0-mm cancellous lag screw was placed in 1 ankle. The contralateral ankle of the same matched pair received an FT 3.5-mm cortical lag screw that extended to the far lateral tibial cortex and achieved endosteal purchase. Final torque of both screw configurations was recorded, and radiographs were taken to confirm appropriate screw placement. Average torque for the PT cancellous screws was 5.02 ± 2.34 in-lb. Average torque for the FT cortical screw was 7.63 ± 3.86 in-lb (p = .002). Visual and radiographic inspections revealed no displacement of the fracture site with use of the FT endosteal lag screw. Our results indicate superior biomechanical torque with far endosteal fixation with use of an FT cortical lag screw versus a traditional PT cancellous lag screw in a cadaver model. Far endosteal fixation is an alternative surgical option for medial malleolus fractures that provides added strength compared with PT lag screws and may obviate downsides associated with bicortical fixation.     

Ankle mortise stability in Weber C fractures: indications for syndesmotic fixation

A Weber type C ankle fracture was sequentially reproduced in 12 cadaver lower extremities and an external rotation torque was applied at each interval. The fractures were then repaired in staged fashion and the rotational stability of the mortise evaluated. Maximum external rotation of the talus within the mortise averaged 7.7 degrees in the intact ankle and increased by 311% to 31.8 degrees after creation of a Weber C injury. Rigid fixation of the fibular fracture restored 32% of the rotational stability, whereas isolated fixation of the medial malleolus reconstituted 57%. Fibular fixation combined with a syndesmotic screw restored 51% of original stability, and the addition of medial malleolar fixation improved stability to 101%. Bimalleolar fixation without a syndesmotic screw yielded 73% of the original rotational stability. The results of this study suggest that when rigid medial and lateral osteosynthesis can be achieved, syndesmotic fixation may not be necessary.     

胫骨pilon骨折受伤机制的有限元分析

目的 探讨胫骨pilon骨折发生过程中胫腓骨及远端关节面的应力分布规律。方法 选择1名健康男性志愿者建立胫腓骨及距骨的三维有限元模型,根据骨折发生特点设定工况,在中立位、背伸、跖屈、内翻、外翻5种不同工况下从距骨远端向近端进行静力加载,并将模型与地面进行碰撞。结果 在静载荷下,中立位应力主要分布于踝间线以前的内踝、胫骨踝穴顶前缘及外踝,背仲位应力主要分布于外踝及胫骨踝穴顶前部,跖屈位应力分布于胫骨踝穴顶后部,内翻位应力主要分布于外踝关节面及胫骨踝穴顶外侧部,外翻位应力主要分布于外踝关节面。在碰撞情况下,中立位应力分布与静载荷下一致,背伸立应力主要分布于踝间线以前,跖屈位应力主要分布于胫骨踝穴顶之踝间线后部及外踝关节面,内翻立应力主要分布于胫骨踝穴顶外部及外踝,外翻位应力主要分布于内踝、外踝及踝间线前部。腓骨关节面存静载荷作用下均处于高应力分布状态,在碰撞过程中亦最早接受应力分布。结论 腓骨是胫骨pilon骨折发生中最早受累且受累较重的部位。胫腓骨远端关节面在骨折发生中存在4个主要应力分布区,此4个应力区向近端延伸为内、外、前、后4个柱。     

内倾型后踝骨折的诊断与治疗

 目的 探讨内倾型后踝骨折的特点及治疗方法。方法 回顾性分析2007年5月至2010年12月治疗的75例资料完整的后踝骨折患者资料,筛选出后踝骨折线延伸至内踝的损伤（内倾型后踝骨折）13例,男8例,女5例;年龄15～75岁,平均40.3岁;坠落伤6例,车祸伤4例,扭伤3例;均合并腓骨骨折;12例伴关节软骨面损伤。患者术前临床均表现为踝部及足背部肿胀、畸形、活动受限。正位X线片示骨折线呈冠状位走行,其中10例形成双边征。根据Haraguchi CT分型：Ⅰ型8例（61.6%,8/13）,Ⅱ型3例（23%,3/13）,Ⅲ型2例（15.4%,2/13）。采用后内侧入路切开,骨折复位后空心钉固定。术后随访切口及骨折愈合情况;采用Baird-Jackson评定标准评价术后疗效。结果 13例患者均获得随访,随访时间8～45个月,平均16个月。术后X线片均示胫骨远端关节面移位＜1 mm,踝穴增宽＜1 mm,骨折达到或者近似解剖复位。13例患者骨折均愈合,愈合时间为12～20周,平均15.1周;切口均为一期愈合。术后Baird-Jackson评分为93～100分,平均96.3分;其中优10例,良3例,优良率为100%（13/13）。末次随访,无一例患者出现感染、骨折再移位、骨不连、螺钉松动及断钉现象。踝关节功能恢复良好,且无需借助辅助工具即可行走。结论 大部分内倾型后踝骨折伴有关节软骨的损伤,这可能是旋转应力合并垂直应力共同作用的结果,需要早期行切开复位内固定治疗,采用后内侧切口治疗具有一定的优越性。     

Selective fixation of the medial malleolus in unstable ankle fractures

BackgroundWhilst the lateral malleolus appears to be crucial in controlling anatomical reduction of the talus, the role of the medial malleolus is less clear. Medial sided complications including infection, damage to local structures and symptomatic hardware are not without morbidity. This study compares the outcomes of patients with bimalleolar or trimalleolar ankle fractures who underwent fibular nail stabilisation with or without medial malleolar fixation.MethodsFrom a prospective single-centre trauma database, we identified 342 patients over a nine-year period who underwent fibular nail insertion to stabilise a bimalleolar or trimalleolar ankle fracture. Isolated lateral malleolar fractures were excluded. Demographic data, clinical outcomes, radiographic evaluation, return to work and sport, and patient reported outcomes, including Olerud-Molander Ankle Score (OMAS), EuroQol-5D (EQ-5D) and Manchester-Oxford Foot Questionnaire (MOXFQ) were collected.ResultsThis study included 247 patients with a mean age of 66.7 years (range, 25–96 years), of whom 200 were female (81%). Medial malleolar fixation was not performed in 54 cases (22%). There was no significant difference between groups with respect to failure of fixation (p = 0.634) or loss of talar reduction (p = 0.157). No patient required surgery for a symptomatic medial malleolar non-union. Medial sided complications occurred in 32 (16%) of the fixation group, of whom 20 (10%) required further surgery. At a mean mid-term follow-up of 4.8 years (range, 8 months – 9 years) there was no significant difference between the non-fixation and fixation groups with respect to the median OMAS (85 vs 80; p = 0.885) or median EQ-5D (0.80 vs 0.81; p = 0.846). Patient satisfaction was not significantly different between the two groups (85/100 vs 87/100; p = 0.410).ConclusionNon-operative management of the medial malleolar component of an unstable ankle fracture treated with a fibular nail may reduce the rate of post-operative complications without compromising the patient reported outcome.