Ankle Fracture Fixation: Medial or Lateral First?

Published:November 15, 2018DOI:


      In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a time-tested and common surgical approach, current surgical practice does not always follow the established dogma. Medial-first fixation may be a worthwhile alternative to lateral-first fixation in select instances. We performed a retrospective, cohort study in an urban level I trauma center to compare medial malleolus-first fixation of unstable ankle fractures with lateral malleolus-first fixation. Patient demographics, injury characteristics, and radiographic metrics including pre-, intra-, and final postoperative talocrural angles, medial clear space, and tibiofibular overlap were assessed. Complications were also reviewed. A total of 280 adult patients with operative bimalleolar ankle fractures from January 2010 to January 2015 met inclusion criteria. There were more open fractures (23.2% vs 9.4%, p = .01) and less isolated injuries in the medial-first group (59.2% vs 71.0%, p = .02). There were less isolated operative procedures (80.3% vs 89.1%, p = .04) and more intramedullary screw placement of the lateral malleolus (11.2% vs 4.3% p = .02) in the medial-first fixation group. There was also a strong trend in identifying more posterior tibial tendon injuries in the medial-first group compared with the lateral-first group (3.5% vs 0%, p = .06). There were no significant differences in fluoroscopy times or radiographic variables in the preoperative, intraoperative, or most recent postoperative images between either group. This approach demonstrates equivalent radiographic outcomes to lateral-first fixation and may be appropriate in select cases.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Foot and Ankle Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Daly PJ
        • Fitzgerald Jr, RH
        • Melton LJ
        • Ilstrup DM
        Epidemiology of ankle fractures in Rochester, Minnesota.
        Acta Orthop Scand. 1987; 58: 539-544
        • Mont MA
        • Sedlin ED
        • Weiner LS
        • Miller AR
        Postoperative radiographs as predictors of clinical outcome in unstable ankle fractures.
        J Orthop Trauma. 1992; 6: 352-357
        • van den Bekerom MP
        • Mutsaerts EL
        • van Dijk CN
        Evaluation of the integrity of the deltoid ligament in supination external rotation ankle fractures: a systematic review of the literature.
        Arch Orthop Trauma Surg. 2009; 129: 227-235
        • Koval KJ
        • Egol KA
        • Cheung Y
        • Goodwin DW
        • Spratt KF
        Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture? A preliminary report.
        J Orthop Trauma. 2007; 21: 449-455
        • Hoelsbrekken SE
        • Kaul-Jensen K
        • Mørch T
        • Vika H
        • Clementsen T
        • Paulsrud Ø
        • Petursson G
        • Stiris M
        • Strømsøe K
        Nonoperative treatment of the medial malleolus in bimalleolar and trimalleolar ankle fractures: a randomized controlled trial.
        J Orthop Trauma. 2013; 27: 633-637
        • Jones CR
        • Nunley 2nd, JA
        Deltoid ligament repair versus syndesmotic fixation in bimalleolar equivalent ankle fractures.
        J Orthop Trauma. 2015; 29: 245-249
        • Miniaci-Coxhead SL
        • Martin EA
        • Ketz JP
        Quality and utility of immediate formal postoperative radiographs in ankle fractures.
        Foot Ankle Int. 2015; 36: 1196-1201
        • Yablon IG
        • Heller FG
        • Shouse L
        The key role of the lateral malleolus in displaced fractures of the ankle.
        J Bone Joint Surg Am. 1977; 59: 169-173
        • Phillips WA
        • Schwartz HS
        • Keller CS
        • Woodward HR
        • Rudd WS
        • Spiegel PG
        • Laros GS
        A prospective, randomized study of the management of severe ankle fractures.
        J Bone Joint Surg Am. 1985; 67: 67-78
        • Donken CC
        • Al-Khateeb H
        • Verhofstad MH
        • van Laarhoven CJ
        Surgical versus conservative interventions for treating ankle fractures in adults.
        Cochrane Database Syst Rev. 2012; CD008470
        • Ostrum RF
        • Avery MC
        Open reduction internal fixation of a bimalleolar ankle fracture with syndesmotic injury.
        J Orthop Trauma. 2016; 30: S43-S44
        • Regier M
        • Petersen JP
        • Hamurcu A
        • Vettorazzi E
        • Behzadi C
        • Hoffmann M
        • Großterlinden LG
        • Fensky F
        • Klatte TO
        • Weiser L
        • Rueger JM
        • Spiro AS
        High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: medium-term follow-up of 100 cases.
        Injury. 2016; 47: 757-761
        • Jasqui-Remba S
        • Rodriguez-Corlay RE
        Muscular tendinous junction rupture of the posterior tibial tendon after closed bimalleolar ankle fracture.
        BMJ Case Rep. 2016 Feb 3; (doi:pii:bcr2015214028.10.1136/bcr-2015-214028)
        • Monto RR
        • Moorman 3rd, CT
        • Mallon WJ
        • Nunley 3rd, JA
        Rupture of the posterior tibial tendon associated with closed ankle fracture.
        Foot Ankle. 1991; 11: 400-403
        • Dodd AC
        • Lakomkin N
        • Attum B
        • Bulka C
        • Karhade AV
        • Douleh DG
        • Mir H
        • Jahangir AA
        • Obremskey WT
        • Sethi MK
        Predictors of adverse events for ankle fractures: an analysis of 6800 patients.
        J Foot Ankle Surg. 2016; 55: 762-766
        • SooHoo NF
        • Krenek L
        • Eagan MJ
        • Gurbani B
        • Ko CY
        • Zingmond DS
        Complication rates following open reduction and internal fixation of ankle fractures.
        J Bone Joint Surg Am. 2009; 91: 1042-1049
        • Belmont Jr, PJ
        • Davey S
        • Rensing N
        • Bader JO
        • Waterman BR
        • Orr JD
        Patient-based and surgical risk factors for 30-day postoperative complications and mortality after ankle fracture fixation.
        J Orthop Trauma. 2015; 29: e476-e482
        • Davidovitch RI
        • Egol KA
        The medial malleolus osteoligamentous complex and its role in ankle fractures.
        Bull NYU Hosp Jt Dis. 2009; 67: 318-324
        • Clarke HJ
        • Michelson JD
        • Cox QG
        • Jinnah RH
        Tibio-talar stability in bimalleolar ankle fractures: a dynamic in vitro contact area study.
        Foot Ankle. 1991; 11: 222-227
        • Solari J
        • Benjamin J
        • Wilson J
        • Lee R
        • Pitt M
        Ankle mortise stability in Weber C fractures: indications for syndesmotic fixation.
        J Orthop Trauma. 1991; 5: 190-195
        • Svend-Hansen H
        • Bremerskov V
        • Baekgaard N
        Ankle fractures treated by fixation of the medial malleolus alone. Late results in 29 patients.
        Acta Orthop Scand. 1978; 49: 211-214
        • Joy G
        • Patzakis MJ
        • Harvey Jr, JP
        Precise evaluation of the reduction of severe ankle fractures.
        J Bone Joint Surg Am. 1974; 56: 979-993
        • Wiss DA
        • Gilbert P
        • Merritt PO
        • Sarmiento A
        Immediate internal fixation of open ankle fractures.
        J Orthop Trauma. 1988; 2: 265-271
        • Okike K
        • Bhattacharyya T
        Trends in the management of open fractures. A critical analysis.
        J Bone Joint Surg Am. 2006; 88 (Review. PubMed PMID: 17142427): 2739-2748
        • Connors JC
        • Coyer MA
        • Hardy MA
        Irreducible ankle fracture dislocation due to tibialis posterior tendon interposition: a case report.
        J Foot Ankle Surg. 2016; 55: 1276-1281
        • Coonrad RW
        • Bugg EI
        Trapping of the posterior tibial tendon and interposition of soft tissue in severe fractures about the ankle joint.
        J Bone Joint Surg Am. 1954; 36-A: 744-750
        • Ermis MN
        • Yagmurlu MF
        • Kilinc AS
        • Karakas ES
        Irreducible fracture dislocation of the ankle caused by tibialis posterior tendon interposition.
        J Foot Ankle Surg. 2010; 49: 166-171
        • Jaffe D
        • Christian MW
        • Weber A
        • Henn RF
        Incarceration of the posterior tibial tendon in an isolated comminuted medial malleolus fracture.
        J Foot Ankle Surg. 2017; 56: 1312-1315
        • Stevens NM
        • Wasterlain AS
        • Konda SR
        Case report: irreducible ankle fracture with posterior tibialis tendon and retinaculum, deltoid ligament, and anteromedial joint capsule entrapment.
        J Foot Ankle Surg. 2017; 56: 889-893
        • Formica M
        • Santolini F
        • Alessio-Mazzola M
        • Repetto I
        • Andretta A
        • Stella M
        Closed medial malleolar multifragment fracture with a posterior tibialis tendon rupture: a case report and review of the literature.
        J Foot Ankle Surg. 2016; 55: 832-837
        • West MA
        • Sangani C
        • Toh E
        Tibialis posterior tendon rupture associated with a closed medial malleolar fracture: a case report and review of the literature.
        J Foot Ankle Surg. 2010; 49 (565.e9–565.e12)
        • Wardell RM
        • Hanselman AE
        • Daffner SD
        Posterior tibialis tendon rupture in a closed bimalleolar-equivalent ankle fracture: a case report.
        Foot Ankle Spec. 2017; 10: 572-576
        • Jain S
        • Haughton BA
        • Brew C
        Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes.
        J Orthopaed Traumatol. 2014; 15: 245-254
        • Hintermann B
        • Regazzoni P
        • Lampert C
        • et al.
        Arthroscopic findings in acute fractures of the ankle.
        J Bone Joint Surg Br. 2000; 82: 345-351
        • Loren GJ
        • Ferkel RD
        Arthroscopic assessment of occult intra-articular injury in acute ankle fractures.
        Arthroscopy. 2002; 18: 412-421
        • Adams SB
        • Reilly RM
        • Heubner JL
        • Kraus VB
        • Nettles DL
        Time-dependent effects on synovial fluid composition during the acute phase of human intra-articular ankle fracture.
        Foot Ankle Int. 2017; 38: 1055-1063