Broken Ankle Surgery (Ankle Fracture Fixation): Who Needs It, the Operation and Recovery

Does a broken ankle need surgery?

The usual story is a fall, after which the person cannot put weight on the ankle and foot, and that tells me the injury may be more than a simple sprain. In some cases I ask for a plain X-ray first, to see what the bone shows.

If a case is genuinely borderline, I set out both options, surgery and treatment without an operation, with the advantages of each, and match the choice to what the person does in daily life. For some injuries, such as a partial tear of a ligament (see my ankle ligament surgery page) or a hairline crack in a bone, I explain that an operation carries its own risks. In that person’s situation those risks may not be worth taking, so treatment without surgery may be the better course. When surgery is most essential, I explain that declining it can leave a persistent limp and pain.

In my experience, older patients have their own demands, especially with weaker muscle tone and balance, and they need much more care. With diabetes, recovery is slower, and with age and with diabetes the recovery timeline and what to expect need to be planned for. Someone with diabetes who needs an operation will still need it, with proper care of their blood sugar. I tell patients that age and diabetes are factors that cannot be changed, and that the only thing in our control is to make sure that their blood sugar is under control in the 2 or 3 months after surgery, which helps them get better.

How the injury is assessed, and what must not be missed

First, the broken part has to be identified correctly. When surgery is planned, I often ask for a CT scan, either before admission or once the patient is admitted, because it shows the bone’s anatomy most clearly. From the CT scan and the X-rays I identify the pattern of the fracture, and we discuss which implant, plate or screws, will give the most stable fixation.

In one study of 145 ankle fractures treated with surgery (Sahin and colleagues), adding a CT scan to the X-rays made the doctors assessing them agree far more consistently on the fracture type (agreement, measured with a statistic called kappa, rose from 0.464 to 0.804) ^[1]. The treatment plan was also revised in 47.6–52.0% of cases ^[1]. That study measured agreement and planning, not how patients recovered ^[1].

In my practice, an ankle fracture can come with an injury to the ligament between the two leg bones (the syndesmosis) that also needs fixing. That injury can be fixed in the same operation if it has been identified, which is why proper X-rays, CT and MRI scans matter (ligament surgery on its own is on my ankle ligament surgery page).

Cartilage injuries are one thing I wish people would not neglect (see my ankle arthroscopy page), because cartilage is very precious: it needs careful treatment and should not be missed.

What the operation does: plates, screws and the ligament between the leg bones

The pattern of the fracture, the patient’s age and the patient’s demands together decide which implant I use. The syndesmosis can be fixed in the same operation when it is injured, if the injury has been identified.

Two methods used to hold that ligament joint while it heals are a stitch-and-button device (suture button) and a screw (syndesmotic screw) ^{[2] [3]}. AO codes, such as 44-C and 44-B below, name fracture types in a standard fracture classification. In a randomised trial of 113 adults with one fracture type (AO 44-C) (Ræder and colleagues), a single suture button was compared with one screw ^[2]. No clinically relevant difference in functional outcomes was detected between the two at 2 years, and CT measures of how well the joint was held were similar ^[2]. A 95% confidence interval (95% CI) is the range within which the true figure is likely to lie. A pooled analysis of eight randomised trials (569 patients) found fewer implant failures with the suture button (odds ratio 0.06, 95% CI 0.02–0.23; an odds ratio below 1 means the problem was less likely with the suture button) ^[3]. It also found less implant irritation (odds ratio 0.31, 95% CI 0.11–0.89) and fewer repeat operations (odds ratio 0.43, 95% CI 0.22–0.83) ^[3]. So, in that trial, the two held the joint similarly at 2 years, and in the pooled trials the suture button caused fewer hardware problems; neither finding shows that one gives a better result for the ankle ^{[2] [3]}. The pooled trials included ligament ruptures as well as ankle fractures, with follow-up of 12 to 60 months ^[3].

In a retrospective study of one fracture type (classified as AO 44-B) from the FAIR study group, locking plates were associated with more breakdown of the wound on the outer side of the ankle than one-third tubular plates (24 of 362 against 21 of 674) ^[4]. They were also associated with more infection (30 of 362, 8.3%, against 34 of 674, 5.0%) ^[4]. The study could not establish that the type of plate caused the difference ^[4].

Some fractures also break the back of the shin bone at the ankle (the posterior malleolus) ^[5]. In a retrospective study of 79 people with fractures involving three parts of the ankle bones (trimalleolar fractures; Aravindan and colleagues), fixing the posterior malleolus directly (38 people) was associated with operations about 53 minutes longer (95% CI 35.9–70.1) and with more wound complications (26.5 percentage points more, 95% CI 6.9–43.6) than leaving it unfixed (41 people) ^[5]. Whether to fix this fragment directly is debated and depends on the fracture, and the studies on this page give no figure for the benefit of fixing it.

In one retrospective cohort (Simske and colleagues, 265 patients), 26 of the 54 patients operated through an approach from the back of the ankle (48%) had an injury to the sural nerve, the nerve on the outer side of the foot and ankle ^[6]. That is 9.8% of all 265 patients, and 62% of those injured recovered fully within 6 months ^[6].

The first weeks after surgery

When you go home, I explain the routine care: keep the foot raised, move the joints, use a walker or crutches, and how to get about at home, for example to the bathroom or the dining table. I choose the fixation to be stable enough to get you moving and back on your feet. I think every activity puts its own demand on the ankle and foot, which needs to be understood, and rehabilitation has to be matched to it. I always explain to patients that swelling is the last thing to go, and that their rehabilitation, which focuses on stretching to get back the flexibility of the calf muscles, helps them reduce the swelling themselves.

A Cochrane review of rehabilitation after ankle fracture (Lewis and colleagues, 2024) found that starting to put weight on the ankle early probably produces a small improvement in early ankle function (a difference of 3.56 points on a function score, 95% CI 1.35–5.78; 5 studies, 890 people; moderate-certainty evidence) ^[7]. The trials were in adults whose ankle fracture had been treated with surgery; early weight-bearing generally meant starting within 3 weeks, compared with waiting about 6 weeks, and function was measured over the first 6 months or less ^[7]. The review notes that this difference was not clinically meaningful ^[7].

After surgery, a removable ankle support improved ankle function compared with a support that could not be removed (a difference of 6.39 points, 95% CI 1.69–11.09; 6 studies, 677 people), but this evidence is of low certainty, and the range of the result spans both an unimportant and a possibly important improvement ^[7]. For unplanned return to the operating theatre, there may be little or no difference between the two (risk ratio 1.20, 95% CI 0.39–3.71; low-certainty evidence) ^[7].

Getting back to work, the commute and daily life

The commonest fear is not getting back to the level of activity before the injury. Office workers who commute by local train want to know how soon they can be back at work, and older people fear not walking again; the fears differ with age. When you leave hospital, I also explain how you can go back to work.

In my experience, rehabilitation very often stops at walking. But getting on and off a Mumbai local train is as demanding as a football pitch, and it needs a great deal of balance and joint position sense (proprioception).

In a study that followed 142 adults aged 18 to 65 for a year after surgery for an ankle fracture (Ramadi and colleagues), 74 of the 81 people who had been working (91.4%) were back at work by 6 months ^[8]. By 1 year, 68 of 70 (97.1%) were back at work ^[8]. At 1 year, 49 of 94 (52.1%) had returned to the activities they did before the fracture ^[8]. These figures use different groups of people ^[8]. Being back at work is not the same as being back to normal.

What to expect at six months and a year: more than the bone healing

The recovery of function is the most important part, and in my experience it invariably gets missed. Everyone expects to be back to normal, and we also aim to get people back to normal, so that they do not remember which ankle was operated on. But many factors decide how far recovery goes, starting with how hard the impact was and the type of injury. In my experience, after a high-impact injury with damage to the cartilage, people rarely get fully back to normal, compared with simple fractures where the cartilage, ligaments and capsule are intact. At six months, it is the stiffness and pain that surprise people and stop them getting back to normal.

In the same one-year study, a weight-bearing lunge test, which measures how far the ankle bends forward under load, showed an average side-to-side difference of 3.22 cm (standard deviation 2.68 cm); this is a distance, not an angle ^[8]. Stiffness was still reported by about 7 in 10 people (69 people; the paper gives this as 72% to 73.4% in different places) ^[8]. Stiffness and reduced bending of the ankle were still common and measurable at one year ^[8].

I think the commonest problem is stiffness, with a mild limp that persists, and in my experience it usually recovers with good physiotherapy that works on joint movement and strengthening. The study’s one-year figures above and my experience differ, and both are given here as they are ^[8].

Risks of ankle fracture surgery

Because an ankle fracture runs into the joint, it can lead to arthritis later (see my ankle arthritis page), and I discuss this before surgery; the chance depends on how complex the fracture is. In one study, advanced arthritis seen on X-ray (Kellgren–Lawrence grade 3–4) was found in 36.3% (37 of 102) of people about 18 years after an ankle fracture (range 12–22 years); only 102 of 372 were followed up, and this is arthritis seen on X-ray, not arthritis that causes symptoms ^[9].

In a 2003 retrospective study, 120 people treated for an ankle fracture came back for review, 56 treated with surgery and 64 in a cast ^[10]. Painful symptoms from injury to a nerve on the top of the foot (the superficial peroneal nerve) were reported more often after surgery (21%) than after a cast (9%) ^[10]. That is a finding from a 2003 study, not an estimate of the risk in modern surgery ^[10]. Failure of the outer leg bone to join (fibular non-union) after a twisting (rotational) ankle fracture appears to be uncommon, reported at around 0.3% to 1.1% in older retrospective series ^[11]. The review itself notes that the true rate is hard to determine, and its evidence is old and made up entirely of case series ^[11].

In adults whose leg is temporarily immobilised after an injury, a blood-thinning injection (low-molecular-weight heparin, LMWH) reduced the odds of any clot compared with no treatment (odds ratio 0.52, 95% credible interval 0.37–0.71); another drug, fondaparinux, also reduced the risk, with a different estimate ^[12]. This evidence covers a wider group than ankle-fracture surgery, and “any clot” includes clots that caused no symptoms ^[12].

Wound problems with locking plates, and injury to the sural nerve when the back of the ankle is approached, are described in the section on the operation above ^{[4] [6]}. Stiffness and lasting swelling are covered under the first weeks after surgery and what to expect.

When to call me after surgery

The warning signs I ask you to watch for after you go home are fever, swelling, throbbing pain, cough, pain, difficulty breathing, or a reaction to any of the medicines. Swelling that makes the dressing feel uncomfortable is not normal, and it needs attention. Throbbing pain with swelling should not be ignored, because it is sometimes caused by bleeding inside or another problem. Do not ignore any fever, because fever is a telltale sign of infection. If you have sudden difficulty breathing, go to the nearest hospital emergency department straight away. To contact us: Dr. Kini, +91 99208 61187, or the clinic, +91 98207 89797.

Before your first visit

Bring any previous X-rays, ultrasound, MRI or CT scans, blood tests and earlier consultation notes, so that I can see what has already been done.

Common questions