Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137

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Review article

Treatment of bimalleolar fractures in elderly

François Loubignac ∗
Service de chirurgie orthopédique et traumatologique, hôpital Sainte-Musse, Toulon, France

a r t i c l e i n f o a b s t r a c t

Article history: Geriatrics continues to evolve as a specialty by adapting itself to increasingly older patients. Mus-
Received 12 June 2020 culoskeletal injuries are common in these patients, who can maintain their physical capacities and
Accepted 21 December 2020 autonomy for a long time, but whose bone solidness is frequently reduced by osteoporosis. Falls increase
with age and because of certain medical conditions. Trauma in the geriatric population involves specific
Keywords: risks; thus, the treatment must be adapted not only to the fracture, but to the local conditions and the
Ankle patient. Ankle injuries are particularly frequent in general traumatology but even more in geriatric trau-
Autonomy
matology. They can lead to complete loss of autonomy if the treatment is delayed and/or not adapted to
Fracture fixation
Failure
the local conditions or the patient. The functional prognosis is brought into play, along with the patient’s
Complications life due to loss of autonomy and general complications occurring in patients who are bed-ridden. The
Elderly treatment of bimalleolar ankle fractures in older adults requires rigorous analysis at all points, which
starts by evaluating the cutaneous status and viability of the soft tissues upon admission. The benefit-
risk balance of the various treatment options will be assessed with the main goal being that patients
recover their autonomy. This article will review this topic by answering 7 questions: 1) What are the dis-
tinctive features of elderly? Dependence on others, comorbidities, bone and soft tissue fragility are the
main ones, explaining these high-risk situations and frequent complications. 2) When should a bimalle-
olar ankle fracture be treated surgically? The surgery must be done early, preferably within 8 hours of
the injury occurring, once the comorbidities have been controlled. The local conditions (skin and soft
tissue damage) must be evaluated carefully as they determine the treatment. Errors are not allowed in
these patients, who are often fragile and in precarious health. Definitive fixation is preferred if the skin
status allows it, but one must keep temporary external fixation in mind as an option. 3) Is there still a
role for conservative treatment of displaced fractures? This will produce good results when it is well
done; however, the indications are rare and must be selected carefully. The main risks are secondary
displacement and skin lesions inside the cast, which are sources of infection. 4) Is fixation with anatom-
ical locking plates an advance? This is definitely an advance for these fragility fractures, which are often
comminuted, as it allows return to weight bearing in certain conditions. However, the implantation rules
must be followed exactly, and it is preferable to use thinner plates. 5) Does transplantar Steinmann pin
fixation still have a role? It has few indications, limited to salvage situations (catastrophic local condi-
tions, very poor general condition). External tibiocalcaneal fixation, alone or in combination, is a better
option. 6) Is immediate transarticular fixation with a retrograde or antegrade locked nail a reasonable
option? Fixation can be done by retrograde nailing or antegrade nailing. It is proposed to patients who
are not very autonomous with a poor cutaneous status and/or severe osteoporosis. It is preferable to
transplantar nailing. 7) Is immediate protected weight bearing, with or without fixation, possible? This
can be considered on a case-by-case basis depending on the extent of the trauma, patient compliance
and treatment carried out.
Level of evidence: V, Expert opinion.
© 2021 Elsevier Masson SAS. All rights reserved.

1. Introduction

The life expectancy continues to increase in industrialized coun-

tries. In France in 2020, more than 4 million inhabitants were more
than 80 years of age and there are now a few dozen centenarians
[1]. Geriatrics continues to evolve as a specialty by adapting itself
∗ Auteur correspondant. 54, avenue Sainte-Claire-Deville, CS 31412, 83056
to increasingly older patients. However, we will limit this study
Toulon, France.
E-mail address: francois.loubignac@laposte.net
to adults over 75 years of age, because it is at this age that the

https://doi.org/10.1016/j.otsr.2021.103137
1877-0568/© 2021 Elsevier Masson SAS. All rights reserved.
F. Loubignac
functional status and potential comorbidities drive the treatment
choices [1]. Musculoskeletal injuries are common in these patients,
who can maintain their physical capacities and autonomy for a long
time, but whose bone solidness is frequently reduced by osteoporo-
sis. The ankle is the fifth most common fracture site in elderly after
the spine, proximal femur, wrist and proximal humerus [1]. Ankle
injuries typically occur after a low-energy fall and mostly in women
[2]. The types of trauma featured in this study are limited to the
most common ankle fractures in this age group [1,3] – bi- or tri-
malleolar fractures with or without dislocation – excluding tibial
pilon fractures or peritalar dislocations. These fractures are unique
because the subcutaneous location of the malleoli increases the risk
of wound healing complications and deep secondary infection [2].
Elderly have thin, fragile skin, varicose veins, or even varicose ulcers
or arthritis that increase the risk of complications. The treatment
of ankle fractures is tricky in this context. They are a surgical chal-
lenge, with the primary objective of allowing autonomous walking
by ensuring bone healing [1].
This article will review this topic by answering 7 questions:
• What are the distinctive features of elderly ?
• When should a bimalleolar ankle fracture be treated surgically?
• Is there still a role for conservative treatment of displaced frac-
tures?
• Is fixation with anatomical locking plates an advance?
• Does transplantar Steinmann pin fixation still have a role?
• Is immediate transarticular fixation with a retrograde or ante-
grade locked nail a reasonable option?
• Is immediate protected weight bearing, with or without fixation,
possible?
2. What are the distinctive features of elderly?
The context in which these fractures occur is very specific,
because in these patients, they can be life threatening and the
functional prognosis comes into play. The ankle has no protective
muscular layers to soften the energy of the trauma and absorb the
local post-traumatic inflammation and oedema. The skin of elderly
is often very thin or very atrophic (like cigarette paper) with pre-
carious terminal vascularization, especially at the medial malleolus
[1,2]. These features are often potentiated by comorbidities con-
tributing to vascular or nerve problems (diabetes, arthritis, stasis
dermatitis, varicose ulcers) and sometimes lifestyle factors (smok-
ing, excessive drinking). Skin healing in the ankle region in older
adults is often problematic with a risk of secondary skin necrosis
after the surgical incision, which can potentially lead to secondary
infections [1,2]. Surgeons must be especially aware of the skin con-
dition upon admission, but also during the treatment course. In fact,
the local skin condition determines the treatment choice and can
be a starting point for a complication.
2.1. Old age (or the fourth age) starts after 75 years
Older or even much elderly after 80 years of age can be split into
three categories [1,3]:
• independent elderly who are in good general health make up 65%
of older patients; we can treat them as adults under 60 years of
age;
• fragile elderlywho make up 20% of older patients; in principle,
this sub-group includes all those beyond 85 years of age and those
between 75 and 85 of age who have a deficit and/or disability due
to age-related conditions. They have a higher risk of falling and
health deterioration that can cause them to become dependent
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Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137
on others, with a higher risk of dying than independent older
patients;
• dependent elderly make up 15% of the elderly population and
need the help of a third-party every day to complete activities
of daily living; senile dementia, especially Alzheimer’s disease, is
one cause of this dependency.
2.2. Geriatric assessment: The assessment involves several tests
• Katz score: six-point autonomy scale [3];
• Parker and Palmer score: nine-point functional scale [4];
• MMSE® : mini mental state examination for cognitive disorders
(5 items) [5];
• MNA® : mini nutritional assessment for the nutritional status (12
items) [6];
• Mini-GDS® : geriatric depression scale short-form (15 items) for
mood disorders [7].
All these tests are used to classify the elderly into one of the
three subcategories mentioned above. This allows for a prognos-
tic approach that is mainly based on the Parker score; however,
the ASA score can be used to evaluate comorbidities and thus, the
patient’s medical condition [8].
2.3. Is there a specific fracture classification for elderlys ?
No, because they present with the same fractures as younger
people. The historical French classification introduced by Duparc
and Alnot [1] is easy to use clinically. It consists of three groups
based on the location of the fracture and the injury mechanism. Sev-
eral types of specific fractures have been described for the posterior
malleolus (Volkmann and Cunéo-Picot). The Weber classification
developed by the AO/OTA [9] is most useful in the context of sci-
entific studies and publications. For our purpose, it is limited to
fracture types 44-A1, A2 and A3; 44-B1, B2 and B3, 44-C1 and C2.
Abduction fractures (Weber C) are the most problematic because
they are often open at the medial malleolus with the talocrural joint
sometimes being exposed [2,9].
2.4. Impact of aging on bone and treatment implications
In patients over 65 years of age, osteoporosis is found in more
than 70% of cases, contributing to a potential fragility fracture
[1,3]. Senile osteoporosis is responsible for significantly diminished
bone mass, adding to postmenopausal osteoporosis. Thus, the frac-
ture risk is increased in women starting at 75 years and in men
over 80 years of age [1]. Aging is also responsible for muscle loss
(sarcopenia) and alteration in the nerve fibers with reduced pro-
prioception and increased risk of falling. The management of these
fragility fractures is technically more demanding because the fix-
ation is more difficult to complete and less stable because of the
increased porosity and thinning of the bone cortices (corticocan-
cellous de-differentiation) [1,10,11]. Complications are more likely,
especially mechanical complications such as fixation failure and
secondary displacement (4% to 13% of cases) [12] but also biological
complications (delayed union and non-union) [12–14]. In princi-
ple, any fixation device that is used does not need to be removed
in elderly [15].
3. When should a bimalleolar ankle fracture be treated
surgically?
Musculoskeletal trauma in elderlygenerally requires rapid treat-
ment for local and general reasons. The time to surgery has been
studied in the context of proximal femur fractures: the ideal
F. Loubignac Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137

treatment time is within the first 24 hours, and especially within

48 hours [1,2,10]. For bimalleolar fractures, the treatment must be
even faster given how quickly skin damage sets in, thus preferably
within 8 hours for a closed fracture and 6 hours for an open fracture
[10,16,17]. Definitive fixation is preferred when the skin condi-
tion allows it. However, if additional examinations are needed, if
the patient is undergoing long-term anticoagulant therapy (anti-
vitamin K, DOAC), or if the skin condition is not suitable for fracture
fixation, the surgery must be delayed. Skin lesions frequently occur
above the medial malleolus, often with opening of the ankle joint
itself, which requires extensive lavage.
Temporary damage control orthopedics is indicated here with
a cast (two-part boot) in cases of moderate and likely reversible
skin damage or external tibiocalcaneal fixation in cases of severe
skin lesions. The construct will span the tibia and calcaneus, with
two pins in the calcaneus to prevent its rotation into equinus and
one pin in the first ray to prevent equinus, in cases when definitive
fixation is delayed due to local or general reasons.
This allows the skin’s condition to be checked regularly with
application of cold packs (but not directly against the skin due to the
risk of burns) until surgery can be performed [1,2,10,17]. One must
do everything possible to prevent postoperative infections, since
inflammatory arthritis of the ankle is very bad [18,19], especially
in this older population.
In summary:

• the surgery must be done as quickly as possible, once the comor-

bidities are addressed;
• evaluating the skin’s condition is essential to the treatment deci-
sion. It must be rigorous and repeated as needed;
• temporary external fixation is a valid option, although definitive
internal fixation must be done as soon as possible.
4. Is there still a role for conservative treatment of
displaced fractures?
The role of conservative treatment is limited. It is mainly indi-
cated in cases of non-displaced or minimally displaced fractures or
when anesthesia is contraindicated (very rare). Conservative treat-
ment is contraindicated in the presence of skin lesions (laceration,
abrasion, blister) or when there is a concurrent dislocation, even
if reduced. One can sensibly use this strategy in a patient who has
minimal autonomy, typically lives in a nursing home and who has
been fully informed, along with their family [10,20]. Even if the
conservative treatment is limiting, it produces good results when
it is well conducted (very close clinical and radiological follow-
up) in this carefully selected population. The displacement must
be reduced with fluoroscopy guidance by performing the inverse
movement to the one that caused the injury initially. The ankle
should not be immobilized in an extreme reduced position as
this can lead to an abnormal posture that is difficult to correct
with rehabilitation. Immobilization is done with a split short leg
cast. It is important to achieve good tibiotalar alignment on AP
and lateral views even if the fractured malleoli are not perfectly
reduced. A slight equinus (± varus) is sometimes necessary to pre-
vent secondary displacement. In fact, immobilization in a functional
position contributes to early secondary displacement. At 48 hours,
once the oedema has resolved, and if the fracture is still well
reduced on imaging, the short leg cast will be made circular. Disap-
pearance of the oedema and resorption of the fracture hematoma
will result in the cast being too big, which increases the chances of
secondary displacement or even the development of skin lesions.
The cast’s effectiveness must be checked every 7 to 10 days; it must
be redone if it has become too big [16,17]. The complications associ-
ated with conservative treatment are skin lesions (necrosis and/or
Fig. 1. Failure on the 10th day of conservative treatment with evidence of skin
lesions requiring surgical revision (percutaneous fixation combined with external
fixation).
sores) and secondary fracture displacement in nearly 25% of cases
[19–21].
Rigid braces, such as the commercially available walking boots,
do not immobilize the fracture properly, leading to a risk of sec-
ondary displacement and skin damage [22,23]. Resin splits are also
not recommended, as they are too rigid. Thus, a short leg cast
remains the preferred option.
Ambulation with supported weight bearing on the cast can be
done using a walker starting in the 3rd week, as long as regular
radiological and clinical follow-ups are being done and there was
no talocrural dislocation initially [22,23]. However, a wheelchair
is often required. Starting at week 6, immobilization is changed
to a flexible ankle splint (Aircast® ) that allows for return to com-
plete weight bearing over the next 2 to 4 weeks and the start of
physiotherapy [20].
If secondary displacement and/or skin damage occur during
conservative treatment, surgical treatment must be considered.
This typically consists of an external fixator, although some cases
can be treated by transplantar pinning (Fig. 1) [23,24]. Prophylac-
tic anticoagulant therapy must be continued up to the 6th week
[1,2,10]. Over time, tibiotalar osteoarthritis can develop (typically
centered), but it is often well tolerated [21].
In summary:
• conservative treatment is rarely indicated for displaced fractures;
• it must comply with strict rules and requires close clinical and
radiological monitoring;
• the biggest risks are skin damage and secondary displacement;
• assuming regular radiological and clinical monitoring, it will
provide satisfactory clinical results in carefully selected cases
(non-displaced or minimally displaced fractures, anesthesia con-
traindications, no dislocation, no skin lesions or wound, fragile
patients who are not or minimally autonomous).

3
F. Loubignac
Fig. 2. Talocrural fracture-dislocation: A. Initial radiographs. B. Postoperative radio-
graphs.
5. Is fixation with anatomical locking plates an advance?
Fixation with a locking plate is recommended for
metaphyseal–epiphyseal fractures [1,10,11]. In the ankle, it is
indicated for fibular fractures. Medial or posterior malleolar frac-
tures are most often treated by direct screw fixation or lag screw
tightening for the posterior malleolus, or by wire cerclage for the
medial malleolus since the medial skin is often very thin, making
it impossible to use a plate.Tibiofibular diastasis on intraoperative
fluoroscopy may require one or two tibiofibular screws [10]. A
locking plate provides high quality stabilization due to the locking
of the screws in the plate, independent of the bone quality and
thereby, osteoporosis [24,25]. An additional short-leg posterior
splint is often needed for 2 to 3 weeks, while allowing for early
rehabilitation. Return to weight bearing protected by a brace
(Aircast® ) is possible when strict fracture fixation rules were
followed: at least two or three locking screws on either side of the
fracture site, always bicortical and near the fracture site when it
is comminuted [11,24]. The use of a locking plate has a learning
curve and there are large numbers of failures if these rules are
not followed [24–26]. The reduction must be anatomical since the
plate aims to provide stable and solid support to achieve fracture
union while restoring the anatomical alignment and correct joint
line. If the geometry of the fracture line allows it, the fracture site
can be compressed by the screws inserted before the plate, which
neutralizes the torsional and compressive stresses [11,24]. AO
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Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137
locking plates (LCP-DCP) are too thick and must not be used here.
In fact, they increase the risk of skin necrosis because the skin over
and around the malleoli is so thin [12,26]. The thinner 1/3 tubular
plates (LCP) are preferred (Fig. 2A–Fig. 2B) [26]. Locking plates
have been widely studied and compared to conventional plates
(standard plate or dynamic compressive plate) [27–30] but the
literature results are inconsistent. According to some authors, the
superiority of locking plates is clear, mainly in cases of severe frac-
ture comminution and/or the presence of bone fragility, without
increasing the complications [27,28]. Other authors [29] do not
believe they are superior, but their studies involved fewer patients
and younger patients (less than 60 years of age). Gauthé et al. [31]
reported the results in 477 elderly (women over 60 years and men
over 70 years), of which 310 were treated with conventional plates
and only 15 with locking plates. The functional outcomes were
satisfactory with no evidence that locking plates were superior,
given the small sample size. Another internal fixation method can
be used at the fibula: nailing with a large-diameter K-wire (Rocher
nail or the like). This is an alternative for distal fibular fractures
especially when the skin condition contraindicates a plate. But
it can be difficult to achieve good reduction and rotation is not
controlled, which may lead to a rotational malunion that is highly
arthrogenic [10,32].
In summary:
• internal fixation is the best treatment if the local conditions allow
it, especially in an active elderly with no cognitive disorders;
• fixation with a locking plate is certainly an advance, as it helps to
overcome fracture comminution and/or osteoporosis;
• it can facilitate early return to weight bearing;
• it must be done early on, while following strict rules;
• thin locking plates are preferable to prevent skin complications;
• there are not many published studies on this topic, but the results
are promising.
6. Does transplantar Steinmann pin fixation still have a
role?
Certain authors recommend Steinmann transplantar nailing
in very old adults (beyond 90 years) who are minimally or not
autonomous, in salvage situations where the skin condition is
catastrophic and an external fixator will not be tolerated (poor skin
vitality and/or major osteoporosis with a risk of early movement
of the external fixator pins and thus fixation failure) [33,34]. The
ankle is stabilized by two, 5 mm Steinmann pins inserted retrograde
into the sole of the foot through the subtalar then talocrural joints,
until the inferior third of the tibia’s medullary cavity with multiple
fluoroscopy controls (Fig. 3A–Fig. 3B). The talus must be perfectly
aligned under the tibial pilon without generating any equinus. If
possible, the two nails must be parallel on AP view and superim-
posed on the lateral view [33,34].
A supplementary short leg brace is needed to reduce the risk of
nail migration. Early return to weight bearing, even with an appro-
priate orthotic device, is not recommended because it can cause nail
migration and increase infection risk [33–35]. The pins are removed
after 2 months, although this can be difficult. The literature empha-
sizes the complications more than the functional outcomes of this
“salvage” fixation, which provides temporary trans-articular tibio-
talarcalcaneus fixation [34,35]:
• Morgan-Jones et al. [34] and then Meijer et al. [35] reported com-
plications in 35% to 55% of cases (infection in 1/3 and loss of
reduction in 2/3);
F. Loubignac
Fig. 3. Transplantar Steinmann pin fixation: A. Initial radiographs. B. Postoperative
radiographs.
• Morgan-Jones et al. [34] reported the outcomes of eight such pin
fixation procedures in salvage situations with acceptable results
despite secondary talocrural osteoarthritis;
• Meijer et al. [35] compared fixation with Steinmann pins (9 cases)
to external tibiocalcaneus fixation (6 cases) in adults over 60 years
of age: the radiographic results were comparable, but the func-
tional outcomes were better with the external fixator.
The functional outcomes with transtalar Steinmann pin fixation
are fair and the complication rate is high. Fixation with a tibiocalca-
neus external fixator alone or in combination with closed fixation
(intramedullary Rocher fibular nail and tibial malleolar cannulated
screw) is preferable because early full weight bearing is more likely
with an external fixator [36].
In summary:
• vertical transtalar Steinmann pin fixation has limited indications
in patients who are minimally or not autonomous and/or in sal-
vage situations because of skin lesions or when it is impossible to
apply an external fixator (thin skin, severe osteoporosis). Com-
plications are very frequent;
• external fixation alone or in combination with percutaneous fixa-
tion is preferred as it yields better functional outcomes, although
still average.
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Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137
7. Is immediate transarticular fixation with a retrograde or
antegrade locked nail a reasonable option?
7.1. Retrograde locked intramedullary nailing
Given the treatment challenges of bimalleolar ankle fractures in
elderly and the frequent complications associated with plate fixa-
tion, a retrograde fixation technique was introduced in 1997 using
a locked intramedullary transplantar nail [36]. This technique is
aimed at older minimally autonomous patient whose clinical con-
dition makes it impossible to perform internal fixation. It allows for
a definitive treatment, avoids external fixation and its associated
risks, but it sacrifices the subtalar and tibiotalar joints irreversibly
(Fig. 4A-Fig. 4B). It has a learning curve because of the risk of neuro-
logical and vascular injury and the difficulty of restoring anatomical
alignment [36,37].
• Galmiche et al. [38] did a retrospective study of 37 patients with
a mean age of 82 years. Twenty-nine times, this technique was
used with an unstable fracture and in more than 50% of cases,
initial skin damage was a contraindication for open fixation. In
nine cases, the nailing was performed after failure of another fixa-
tion method. Nearly 15% of patients had a postoperative infection
and 17% developed a nonunion. The authors concluded that this
fixation method should be reserved to older, bed-ridden, or min-
imally autonomous patients whose clinical conditions does not
allow for open fracture fixation.
• Georgiannos et al. [39] reported the outcomes of a prospective
study of older patients (mean 78 years) in which 43 received ret-
rograde tibiocalcaneus nailing and 44 received open fixation with
a conventional plate. There were much fewer complications in the
nailing group (8% versus 33%).
• Persigant et al. [40] did a prospective study in 14 patients over
65 years of age who had limited autonomy (Parker score ≤ 5,
ASA ≥ 2) but who could still walk over 500 m. A long retrograde
nail was inserted percutaneously into the fracture site and locked
with four screws on either side of the talocrural joint line (1 in the
talus, 1 in the calcaneus and 2 in the superior metaphysis of the
tibia). Immediate weight bearing was allowed with a removable
walking boot during the first 21 postoperative days. The com-
plication rate was 20% including one case of ankle osteoarthritis
with tibial pandiaphysitis. At 1 year of follow-up, the Parker score
(5) was lower by a half-point relative to the initial score; fracture
union had been achieved in all cases without malunion (defined
as an alignment defect greater than 10◦ ).
• Elmajee et al. [41] did a review of literature with seven stud-
ies that met the inclusion criteria, with data collected up
to September 2019. The functional scores were only mini-
mally improved postoperatively with a high complication rate,
although fracture union was achieved in 90% to 100% of cases.
They concluded that in fragility fractures, this technique allows
for early functional recovery. While it increases the risk of
septic arthritis, this immediate double trans-articular fixation
allows for immediate weight bearing and thus faster return
to walking, which reduces the risk of complications related to
being confined to bed and helps patients recover the auton-
omy they had before the fracture more quickly and more
easily [40,41].
7.2. Antegrade intramedullary nailing
Antegrade intramedullary nailing is also a possibility given the
recent improvements in intramedullary locked nails where the dis-
tal locking can now be done very close to the joint.
The nail is sunk into the medullary cavity of the tibia then into
the body of the talus, where the locking is done, thereby sparing
F. Loubignac Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137

Fig. 4. Locked retrograde nailing: A. Short nail. B. Long nail.

the subtalar joint. This technique requires the use of a fracture
(traction) table, knee flexed at 90◦ with traction applied through a
transcalcaneus pin using fluoroscopy guidance but no tourniquet.
The nail is inserted through the superior metaphysis of the tibia
and lowered to the talus where the distal locking must be done
starting by a screw in the talus. After traction is released, this helps
to compress the talocrural joint by holding the compression by the
proximal locking on the superior metaphysis of the tibia. Then a
2nd or even a 3rd screw is inserted into the talus, or even better,
through the malleoli.

6
F. Loubignac
This innovative technique spares the subtalar joint and reduces
the infection-related complications of retrograde nailing. Immedi-
ate weight bearing is allowed, which contributes to faster recovery
of autonomy in these older patients. However, this technique is
difficult, still limited and has not been featured in any published
studies.
In summary:
• talocrural fixation by nailing is a valuable treatment option but
reserved to elderly who have minimal autonomy and whose clin-
ical condition makes internal fixation impossible. It allows early
return to weight bearing;
• retrograde nailing must be reserved to elderly who are not very
autonomous and whose skin condition makes it impossible to
consider open fixation given the safety risks;
• retrograde nailing is easier to perform but it sacrifices the subtalar
joint in addition to the talocrural joint. Antegrade nailing spares
the subtalar joint but is technically very demanding;
• nailing is better tolerated than external fixation and is preferable
if the surgeon has mastered this technique.
8. Is immediate protected weight bearing, with or without
fixation, possible?
In the course of a simple bimalleolar ankle fracture, without
associated dislocation or large skin lesions (44A1, 44B1, 44A2, 44B2,
44C1), good results have been reported in more than 80% of cases
in well-selected, autonomous and independent patients when early
return to weight bearing was allowed [10,22,23,42]. Furthermore, it
helps to limit osteoporosis secondary to the lack of weight bearing.
• for conservative treatment, only simple well-reduced fractures
without dislocation in a disciplined patient can be considered
for early return to weight bearing, as soon as the 3rd week, but
requires regular monitoring [10,20,22];
• Plate and screw fixation must be stable and have restored the
ankle’s anatomical alignment in the three planes in space. Except
for a fracture with dislocation, in a disciplined patient with a well-
reduced fracture and good quality fixation, some surgeons allow
weight bearing 15 days after the surgical procedure, when inflam-
matory processes have subsided [22,23]. A rigid ankle brace, or
even a two-piece padded walking boot, helps with this return to
weight bearing for 6 weeks, while allowing the skin healing to be
monitored regularly and radiographs to be made. After 45 days,
the patient wears a flexible ankle brace (Aircast® ) during the day,
which protects the free return to weight bearing and the start of
rehabilitation during the next 2 to 4 weeks [22,23]. Some sur-
geons start the physiotherapy in the 3rd week [2,10] but this is
typically delayed to 45 days since the risk is too high in elderly
whose osteoporosis reduces the fixation’s stability [11]. Rehabil-
itation typically helps to restore the ankle’s functional mobility
and walking autonomy [43]. This early weight bearing produces
faster return to walking, as a wheelchair does not need to be used,
which is often a requirement in elderlywhen weight bearing is not
allowed;
• Locked intramedullary nailing allows for very early and free
return to weight bearing;
• Conversely, with the Steinmann nailing procedure, no weight
bearing is allowed until all the hardware is removed [1,3,10].
In summary:
• the possibility of early weight bearing must be determined based
on the joint and bone lesions (simple fractures without dislo-
7
Orthopaedics & Traumatology: Surgery & Research 108 (2022) 103137
cation), the type of treatment done, the quality of the tibiotalar
centering achieved, and the patient’s cooperation;
• it allows for faster recovery of autonomy and reduces the com-
plications related to being bed-ridden.
Disclosure of interest
The author declares that he has no competing interest.
Funding
None.
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