Surgery for ankle and foot fractures

When surgery is recommended

For background, see ankle and foot fractures. Surgery is generally recommended when:

• the bones are displaced (out of their normal position)
• the ankle or a joint is unstable or dislocated
• several bones are broken
• a fracture has not healed with non-surgical treatment
• the skin has broken over the fracture (an open fracture), which is treated urgently^[1,5]

For some injuries the question isn’t only whether the bone is broken but whether the joint is stable. Ligament injuries that accompany a fracture, for example damage to the syndesmosis that holds the two lower-leg bones together above the ankle, are assessed at the same time.^[2,6]

How the operation is planned

Planning starts with X-rays and, for complex fractures, CT, which shows the pieces of bone in three dimensions.^[1] If the ankle is very swollen or the skin is blistered, surgery may be delayed for days, with the leg splinted and elevated, until the soft tissues are ready; operating through swollen skin raises the risk of wound problems.

What the operation involves

• Realignment (reduction). The surgeon returns the bones to their normal position.
• Fixation. The bones are held with screws, a plate and screws, or a rod or nail, depending on the fracture type and location.^[1] Ankle fractures can involve the outer bone (lateral malleolus), the inner bone (medial malleolus) and the back of the shin bone (posterior malleolus), and each is fixed according to its pattern.^[2]
• Syndesmosis fixation, when the ligaments between the two shin bones have been injured. Traditionally this uses a screw across the joint; newer flexible fixation devices have been developed. A systematic review of eight studies found no functional difference between them at final follow-up and lower reoperation rates with the flexible devices in three studies, so flexible fixation may be a reasonable alternative.^[6]
• Other regions. A fractured fifth metatarsal may be fixed with a screw placed inside the bone. Lisfranc injuries may be treated with plates and screws or with fusion of the midfoot joints (see Lisfranc surgery).^[7,8,9] High-risk stress fractures, such as those of the navicular, may need surgical fixation.^[10]

Most fracture operations are done at a hospital or ambulatory surgery center under regional or general anesthesia, and some patients stay overnight depending on the injury and their health.

Recovery

Most ankle fractures take at least six weeks for early healing and 10 to 12 weeks for complete healing.^[1] Putting weight on the fracture too early risks a nonunion or a malunion, so the timing is set by your surgeon for your fracture and your fixation.^[1]

A Cochrane review of rehabilitation after ankle fractures, with 53 studies, found that starting weight-bearing early (within three weeks of surgery) probably leads to somewhat better ankle function than delaying it, although the difference was small and not clinically meaningful, and that after surgery a removable ankle support may lead to better function than a non-removable one.^[4] Physical therapy helps restore motion, strength and balance. Lisfranc injuries can take six months to a year to reach full activity.^[9] See recovery after foot and ankle surgery.

Risks

Complications can include stiffness, swelling, infection, arthritis in the joint, malunion, nonunion, hardware that is prominent or bothersome, and injury to nerves or blood vessels. Smoking and diabetes raise the risk of surgical problems.^[1] In a meta-analysis, people with diabetes had about twice the overall complication risk after an ankle fracture and about three times the risk of infection, with a higher risk when surgery was performed.^[3] Blood clots in the leg veins are a risk after a lower-limb injury and immobilization, and your surgeon will discuss whether preventive measures are appropriate for you.^[11,12]

Questions to ask before deciding

• Is this fracture stable, and would treatment without surgery be reasonable?
• What fixation do you plan, and might it need to be removed later?
• When can I put weight on the foot, and when can I drive and return to work?
• How do my health conditions and smoking affect the risks and timing?

When to seek care