Comparison of Two Surgical Approaches for Trimalleolar Ankle Fracture Fixation

Abstract

Ankle fractures account for 10% of all presenting fractures, with research quoting the involvement of the posterior malleolus in around 7% of cases. Trimalleolar fractures are estimated to have greater long-term complications due to the significant disruption to the articular surface of the joint and the reduced weight-bearing potential associated with this. Despite the well-documented role of the posterior malleolus in ankle fractures, its fixation is often a matter of debate. One barrier to this is the potential need for an additional surgical incision. Our study compared two surgical approaches to trimalleolar ankle fracture fixation: One through an extended posterolateral and medial approach (2-incision approach) and one through a combined posterolateral, direct lateral, and medial approach (3-incision approach). Thirty-eight open reduction and internal fixation of trimalleolar ankle fractures were performed by the senior author in a single institution between January 2017 and January 2020. Fifteen underwent a 2-incision approach and 3 separate incisions were used in 23 cases. Outcomes of the two different surgical methods included a postoperative functional score (Ankle-Hindfoot American Orthopedic Foot and Ankle Society), postoperative complications, and evaluation of postoperative radiographs. Twenty-three patients were recruited to the 3-incision group and 15 to the 2-incision group. The utilization of 3 separate incisions for the fixation of trimalleolar fractures showed fewer complications than a 2-incision approach. Further, smoking was positively correlated with reported complications. All other perioperative variables did not reach statistical significance. In our study, a 3-incision approach showed a tendency for lower complication rates in the surgical treatment of trimalleolar ankle fractures compared with a 2-incision approach. In our opinion, a direct approach to the 3 malleoli through individual incisions allows better visualization of the fracture site, including intercalary and incisura fragments, enabling better reduction and avoiding unnecessary destructive tissue handling. Level of Evidence: Diagnostic Level 2. See Instructions for Authors for a complete description of levels of evidence.