![]() ![]() Patients with trimalleolar ankle fractures or ankle fracture-dislocations are at significantly increased risk of having an OCL compared to low-energy fractures. 17, 24, 38 A significant correlation has been shown between ankle fracture severity and the incidence of talar OCLs. 54 One hypothesis to potentially explain the suboptimal outcomes in these patients is related to injury-associated traumatic OCLs and intra-articular loose bodies, which have been reported to occur in up to 20% to 79% of ankle fractures. 37, 48 Therefore, anatomic reduction of all ankle joint surfaces and fracture fragments is critical to achieving optimal clinical outcomes and minimizing persistent symptoms after surgery.Ī recent systematic review of 1822 operatively treated ankle fractures identified 20% of patients who failed to achieve good to excellent outcomes despite anatomic fracture reduction. 47, 48 Studies have demonstrated that as small as a 2-mm lateral talar shift decreases the contact surface area of the tibiotalar joint up to 56% and results in a load increase from 650 to 1590 N/cm 2 for a 75-kg person. Contact pressures across the ankle joint have been shown to be up to 3.9 times body weight during heel rise and stance phase, and the average tibiotalar contact area is estimated to be 4.4 cm 2. Fracture malreduction and/or OCLs can lead to altered contact forces and joint mechanics in the ankle resulting in early-onset post-traumatic arthritis. Many patients who sustain ankle fractures continue to have persistent ankle pain and swelling months after surgery despite appropriate operative fixation. This review will examine recent evidence regarding operative indications and operative management of ankle fractures with a focus on arthroscopic-assisted ankle open reduction internal fixation (ORIF), deltoid ligament complex repair, indications for posterior malleolar fracture fixation, fibula intramedullary nailing, and flexible syndesmotic fixation. In recent years, operative management of ankle fractures has evolved to improve anatomic reduction of the ankle joint, address soft tissue injury around fracture fragments, prevent ankle subluxation, minimize operative incisions, and improve syndesmotic stability. Other predictors of poor outcomes include associated osteochondral lesions (OCLs), fracture pattern severity (including posterior malleolar involvement), syndesmotic malreduction, persistent medial ankle instability, and increased postoperative infection rates in diabetics and elderly individuals. Despite these general indications, a recent systematic review found that even in appropriately reduced ankle fractures, only 80% of operatively treated patients had good to excellent outcomes. Open unstable patterns, or those with significant articular malalignment, often require operative intervention to prevent malunion, nonunion, and early post-traumatic arthritis. ![]() 13, 17, 51 Closed stable fractures with appropriate alignment of the ankle mortise and fracture displacement <2 mm can be treated nonoperatively with immobilization and protected weight bearing. Ankle fractures are one of the most common orthopedic injuries in the world, with an incidence between 157 and 187/100 000 people reported in the literature.
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