Ankle Fracture Fixation: Medial or Lateral First?

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.