JOT - 2026-09-18 - Journal Article
Outcomes of early vs delayed medial malleolar fixation in the treatment of open ankle fractures.
Hughes IX, Baka DR, Wright BJ, Dibato JE, Gentile PM, Hwang R, Graf KW, Mashru RP, Dolch HJ
Topics
Key Takeaway
Early fixation of open ankle fractures involving the medial malleolus carries a 22% infection rate versus 9% with delayed fixation, reaching statistical significance (p=0.049) in bimalleolar and trimalleolar subgroups.
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Summary
This retrospective single-center study compared early versus delayed ORIF for open ankle fractures involving the medial malleolus (AO/OTA A2–C3) across 99 patients. Early fixation reduced LOS (7.8 vs 12.8 days, p=0.0004) and mean operations (1.3 vs 2.4, p<0.0001) but was associated with a numerically higher infection rate (22% vs 9%, p=0.09) that reached significance in the bimalleolar/trimalleolar subgroup (22% vs 7%, p=0.049). Union rates, antibiotic use, time to weight bearing, and pain scores did not differ significantly between groups.
Key Limitation
The non-randomized assignment to early versus delayed fixation almost certainly reflects surgeon judgment about wound quality and injury severity, meaning the groups are not comparable and the observed infection rate difference may reflect case selection rather than a true effect of timing.
Original Abstract
OBJECTIVE
To investigate outcomes after early versus delayed fixation of clean open ankle fractures involving the medial malleolus.
METHODS
Design: Retrospective review.
SETTING
Single-center academic Level I trauma center.
PATIENT SELECTION CRITERIA
Patients undergoing open reduction and internal fixation from November 2016 to July 2024 for an open ankle fracture involving the medial malleolus (AO/OTA A2-C3).
OUTCOME MEASURES AND COMPARISONS
Infection rate, length of stay, number of operations, and return to the operating room were compared between early and delayed fixation groups.
RESULTS
The early fixation group consisted of 55 patients (67% female; mean age 55.8 ± 21.1 years), while the delayed fixation group consisted of 44 patients (68% female; mean age 57.5 ± 15.9 years). Infection rates were 22% in the early group and 9% in the delayed group (p=0.09). Early, compared to delayed, fixation was associated with a shorter length of stay (7.8 vs. 12.8 days; p=0.0004), lower external fixation rate (11% vs 82%) and fewer operations (1.3 vs. 2.4; p<0.0001). Wound care was initiated more frequently in the early fixation group (56% vs 27%; p=0.0037). However, there were no statistically significant differences in union rates, antibiotic use, time to full weight bearing, pain scores, or symptomatic nonunion (P>0.05). A post hoc analysis excluding isolated medial malleolus fractures demonstrated a higher infection rate in the early fixation cohort (22% vs 7%; p=0.0487).
CONCLUSION
Early fixation was associated with a higher observed infection rate, particularly in bimalleolar and trimalleolar fractures, although this difference did not reach statistical significance in the overall cohort. Early fixation may be appropriate in select cases to reduce hospital resource utilization. However, surgeons should use caution when considering early fixation of higher energy injuries such as open bimalleolar and trimalleolar ankle fractures.
LEVEL OF EVIDENCE
Therapeutic Level III.