INFLUENCE OF SURGICAL APPROACH IN TRIMALLEOLAR ANKLE FRACTURES ON FIBULAR FRACTURE REDUCTION, COMPLICATION, AND REVISION RATES

Introduction: Trimalleolar ankle fractures are complex injuries requiring surgical intervention to restore anatomical alignment and joint stability. The Mason and Molloy algorithm has advanced the use of the posterolateral approach, supplemented by a posteromedial approach in rotational and posterior pilon variants. While fixation of the posterior malleolus has received increasing attention, accurate fibular reduction remains a critical outcome determinant. This study evaluates complication and revision rates associated with different surgical approaches, with a focus on fibula reduction quality. Methods: A retrospective review of prospectively collected data was performed across a major trauma centre and affiliated trauma unit from 2019 to 2024. Patients undergoing fixation of the posterior malleolus and fibula were included. Exclusion criteria were age >70, bilateral injuries, and open fractures. A total of 960 trimalleolar ankle fractures with minimum 6-month follow-up were analysed. Patients were divided into three groups, with 320 fractures in each, based on surgical approach and fibular fixation technique: (1) posterolateral approach with posterior fibula fixation through the same approach, (2) posterolateral approach with direct lateral fibula fixation through the same approach, and (3) posteromedial approach with lateral fibula fixation through a separate direct approach. Outcomes assessed included fibular reduction (Pettrone criteria), wound complications, revision surgery, and sural nerve injury. Results: Lateral fibular fixation via a posterolateral approach showed a higher rate of lateral wound complications which was statistically significant. Posterior fibular fixation resulted in statistically significant higher malreduction rates. Revision rates were lowest in the posteromedial group which also had fewer sural nerve injuries. Conclusion: The posteromedial approach with direct lateral fibular approach and fixation offers improved fibular reduction, with fewer wound complications and lower revision rates compared to posterolateral techniques.