Operative Management of AO Type 44 Ankle Fractures: Determinants of Outcome

The consequences of inadequate treatment of ankle fractures can be disastrous. We assessed the radiologic and functional outcomes, postoperative quality of life (QOL), and its determinants for patients treated operatively for AO type 44 ankle fractures. Evidence is lacking concerning the management of posterior malleolus fractures and syndesmotic injuries. Our retrospective adult cohort study included 432 AO/OTA type 44 ankle fractures (431 patients). The median follow-up period was 52 months. Outcomes were assessed from the medical records, radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) ankle scale (functional outcome), and EuroQol EQ-5D questionnaires. The median AOFAS scale score was 88; 27.9% of patients reported restricted mobility and 40.4% pain or discomfort. In 8.8%, radiographic failure was observed. The presence of posterior malleolus fractures was significantly associated with poor functional outcomes, and a postoperative step-off correlated with radiologic failure, poor functional outcome, and poor postoperative QOL. Late syndesmotic screw removal was associated with worse EQ-5D time trade-off QOL scores. A substantial number of patients experienced functional impairment, discomfort, and pain. Syndesmotic injury was associated with ankle joint failure and poor functional outcomes. Our data indicate that all displaced posterior malleolus fracture fragments affecting the posterior articular tibial surface in patients aged ≤65 years require anatomic reduction.