Background: Fixation of posterior malleolar (PM) fragments remains a controversial topic in ankle fracture management. Our objective was to examine the incidence of severe adverse events (AEs) associated with surgical management of patients with ankle fractures involving the posterior malleolus before increased use of direct PM fragment fixation.Methods: This is a retrospective cohort study including patients from a level III trauma center in the Capital region of Denmark. Adult patients (age >18 years) with ankle fractures involving a PM fragment treated surgically with a minimum of 18 months follow-up were included. The main outcome measurements were adverse events (graded using the Orthopaedic Surgical Adverse Events Severity (OrthoSAVES) System) requiring revision in the first 12 months after surgery. Results: In 75 out of 421 included patients (17.8%), PM fragments were surgically fixed. During the first twelve months after surgery, 34 patients (8.1% (95% CI [5.9–11.1%])) experienced AEs requiring revision. 17 patients (4%) were revised due to deep infection, 10 patients (2.4%) due to malpositioned implants, and 3 patients (0.7%) due to postoperative loss of reduction. Additional causes of revision were impingement of intraarticular fragment, non-union, postoperative joint dislocation, and postoperative vascular insufficiency leading to transmetatarsal amputation. Conclusions: The incidence of AEs requiring revision within the first twelve months after surgery was 8.1%, and the overall risk of severe AEs seemed unacceptably high. If direct PM fragment fixation can decrease the risk of severe AEs, then a change of practice could be justified. Further prospective studies are needed to establish generalizability, safety and efficacy before direct PM fragment fixation can be recommended in clinical guidelines.

Background Recent systematic reviews support that non-operative management should be the standard treatment for all stable isolated lateral malleolar fractures (ILMFs), regardless of fibular fracture displacement. Surgical fixation of ILMFs carries a risk of adverse events (AEs), and many patients will later require implant removal. We wanted to estimate the incidence of AEs requiring revision after surgical fixation of “potentially stable” displaced ILMFs before non-operative treatment became standard care in our department. Materials and methods To identify patients with “potentially stable” ILMFs who had been treated surgically in a historical cohort, we retrospectively applied the stability-based classification system, introduced by Michelson et al., to a cohort of 1006 patients with ankle fractures treated surgically from 2011 to 2016. The primary outcome of this retrospective cohort study was the incidence of AEs that had functionally significant adverse effects on outcome and required revision in the first 12 months after surgery. AEs were graded and categorized using the Orthopedic Surgical Adverse Events Severity (OrthoSAVES) System. Results The study population comprised 108 patients with “potentially stable” displaced ILMFs; 4 patients (3.7% [95% CI (0.1–7.3%]) experienced AEs requiring revision in the first twelve months after surgery. There were 5 additional patients (4.6%) with functionally significant AEs where revision surgery was not indicated within the first twelve months after surgical fixation. A further 5 patients (4.6%) had AEs managed in the outpatient clinic (grade II); 36 patients (33.3%) required secondary implant removal due to implant-related discomfort. Conclusions Surgical fixation of ILMFs carries a risk of severe AEs, and many patients will subsequently need implant-removal procedures. Further prospective studies are required to ascertain whether non-operative treatment can lower the risk of AEs and the need for additional surgical procedures.