Unstable Rotational Ankle Fractures Treated With Anatomic Mortise Repair and Direct Posterior Malleolus Fixation

Introduction: The purpose of this study was to evaluate patient outcomes following a standardized algorithmic approach to ankle mortise stabilization, following rotational fracture, utilizing direct repair of the posterior malleolus in the prone position. Methods: Eighty consecutive patients with unstable rotational ankle fractures that involved the posterior malleolus were analyzed. All underwent direct repair of the posterior malleolus regardless of size through a posterolateral approach. Electronic records were retrospectively reviewed for demographic information, initial injury and operation details, healing status, and complications. Preoperative and postoperative radiographs were obtained to assess the initial injury and healing was determined both by radiographic and clinical progress at follow-up visits. Results: Average posterior malleolus fragment width was 8.1 +/- 3.7 mm (range = 2.1-19.9 mm) and percentage of the articular surface was 23.6% (range = 7.1%-56.7%) on the lateral radiograph. Overall, 80/80 (100%) patients healed their ankle fractures by a mean 2.9 +/- 1.1 months. Only 1 (1.3%) patient required transsyndesmotic fixation following posterior malleolus repair. Mean range of ankle motion was as follows: dorsiflexion 20 degrees +/- 10 degrees, plantarflexion 34 degrees +/- 10 degrees, inversion 8 degrees +/- 4 degrees, and eversion 7 degrees +/- 4 degrees. Seventy-nine patients (98.8%) had an anatomic mortise reduction. Nine patients (11.3%) had a superficial wound complication, 3 patients (3.8%) had dysesthesia in the sural nerve distribution, and 1 patient (1.3%) lost reduction of the medial malleolus. Conclusion: Patients who undergo direct repair of the posterior malleolus in the prone position can expect a high rate of healing with superficial wound breakdown being the biggest problem, which was associated with an ankle fracture dislocation. Posterior malleolus fixation may obviate the need of transsyndesmotic stabilization.Levels of Evidence: Retrospective Level IV