INTRODUCTION

Background

Ankle fractures occur frequently, with an estimated annual incidence of approximately 168 per 100,000 individuals [1]. About 60% to 70% of these fractures are unimalleolar, 15% to 20% are bimalleolar, and 7% to 12% are trimalleolar fractures, often in combination with a Volkmann fracture [2]. Typically, older women sustain low-energy trauma leading to these fractures, whereas young men are more commonly affected by injuries related to sports accidents [1]. To categorize ankle fractures, several classification systems have been developed, with the Danis-Weber and Lauge-Hansen systems being the most widely used [2,3]. Unstable fractures, such as Weber type B or C fractures and bimalleolar fractures (with or without a Volkmann fracture), usually require surgical intervention. Unlike pilon fractures, which involve the distal tibial plafond and often require initial stabilization with an external fixator before definitive surgery, malleolar fractures can be treated either with primary definitive fixation or with temporary stabilization in a cast or external fixator. The treatment approach depends largely on the condition of the soft tissues and the trauma mechanism, and outcomes are generally known to worsen with increasing comminution in both pilon and malleolar fractures [4].

The standard treatment for unstable ankle fractures, including bimalleolar fractures, is open reduction and internal fixation (ORIF) with plates and screws [5]. In some cases, tension band techniques using Kirschner wires may be employed [6]. When syndesmotic rupture is present, syndesmotic screw fixation is the preferred technique [7]. The goal of surgical management is to restore the anatomical alignment of the ankle mortise and maintain the functional integrity of the syndesmosis, thereby optimizing long-term functional outcomes [5,7–14]. If the alignment between the distal tibia and fibula is not fully restored, abnormal loading on the tibiotalar joint can result in severe pain, significant functional impairment, and an increased risk of posttraumatic arthritis over time [15,16]. However, achieving precise anatomical reduction is not always possible. Factors such as comminuted fractures, fracture-dislocations, syndesmotic injury, associated medial or posterior malleolar fractures, poor bone quality, and technical challenges may contribute to postoperative malreduction, which is a known risk factor for posttraumatic osteoarthritis [15,17].

Closed management with manipulation avoids surgical risks but often results in inferior long-term outcomes [18,19]. In contrast, superior results in the treatment of bimalleolar ankle fractures are typically achieved by emphasizing anatomical reduction, stable internal fixation, restoration of full fibular length, and early, pain-free mobilization. Restoring the anatomical alignment of the bones and ligaments is essential because the margin for error in managing these fractures is small [20]. Numerous studies have shown that ORIF provides advantages over closed treatment [21]. ORIF facilitates more efficient recovery and allows for simpler rehabilitation without a cast, early mobilization, and earlier weight-bearing, all of which contribute to improved functional outcomes [19].

Current literature indicates that precise anatomical reduction and stable internal fixation significantly improve recovery and reduce complications, including posttraumatic arthritis. However, despite these advantages, there remains limited prospective evidence focusing specifically on bimalleolar ankle fractures treated with ORIF, particularly regarding postoperative mobility, pain management, and radiological healing. Therefore, this study aims to address this gap by prospectively evaluating the clinical, functional, and radiological outcomes of patients undergoing ORIF for bimalleolar ankle fractures.

Objectives

The primary objectives of this study were to assess the clinical outcomes of patients with bimalleolar ankle fractures treated by ORIF, including pain levels, range of motion, and functional recovery. Additionally, the study aimed to evaluate radiological outcomes of ORIF in terms of fracture healing, alignment, and restoration of ankle joint stability, and to investigate complications associated with ORIF in the treatment of bimalleolar ankle fractures. Finally, the research sought to identify factors such as age, sex, comorbidities, and fracture type that may influence radiological outcomes following ORIF for bimalleolar ankle fractures.

METHODS

Ethics statement

The study protocol was reviewed and approved by the Institutional Review Board of SRM Institute of Medical Sciences (No. DNB/48/2022). Written informed consent was obtained from all participants before their enrollment in the study. This study was conducted in accordance with the principles of the Declaration of Helsinki.

Participants

The study population consisted of patients diagnosed with bimalleolar ankle fractures. A consecutive sampling approach was used, in which all eligible patients who met the predefined inclusion criteria were enrolled sequentially until the target sample size was reached. In total, 40 patients with bimalleolar ankle fractures were included. All participants underwent ORIF according to the institution’s standardized surgical protocol.

The inclusion criteria were patients over 18 years of age, of either sex, with radiological confirmation of a bimalleolar fracture involving either ankle, assessed as fit for surgical intervention, and willing to provide written informed consent. Fracture patterns were classified using the Weber system to differentiate type B and C fractures. Only closed fractures were included. Exclusion criteria consisted of patients under 18 years of age, individuals unwilling to participate, those with open fractures, cases involving syndesmotic disruptions requiring trans-syndesmotic screw fixation or associated ligamentous injuries (to maintain cohort homogeneity), patients deemed unfit for surgery or anesthesia, and individuals with a history of previous bimalleolar, pilon, or trimalleolar fractures.

Data collection

Data collection was conducted prospectively from January 2023 to January 2024. Upon enrollment, baseline demographic and clinical information, including age, sex, mechanism of injury, fracture side and type, and comorbidities, was recorded for each participant. Preoperative evaluation included a detailed clinical examination and radiological assessment to confirm the diagnosis and classify the fracture pattern.

Standardized perioperative and postoperative forms were used to document surgical details such as the time from injury to surgery, operative findings, fixation techniques employed, and any intraoperative complications. All participants underwent ORIF following institutional protocols.

Follow-up assessments were conducted at 6, 12, and 24 weeks postoperatively. At each visit, patients underwent clinical evaluation for pain, swelling, wound condition, range of motion, and weight-bearing ability. Radiological evaluation was performed using standardized anteroposterior and lateral ankle radiographs to assess fracture alignment and union. Functional outcomes were measured at each follow-up using the Baird-Jackson scoring system. Adverse events and complications, including wound infection, implant prominence, delayed union, and other procedure-related issues, were recorded at every follow-up.

Statistical analysis

Statistical analysis was performed using established methods to evaluate the clinical, radiological, and functional outcomes of bimalleolar ankle fractures treated with ORIF. Continuous variables, such as patient age and time to radiological union, were summarized as means with standard deviations. Associations between categorical variables, including complication rates, sex, fracture type, and categorical functional outcomes, were evaluated using the chi-square test. To further explore potential predictors of favorable outcomes, multivariate regression analysis was performed. A significance level of P<0.05 was considered statistically significant. Additionally, 95% confidence intervals and effect sizes (Cohen d for continuous variables) were calculated to complement the interpretation of P-values. All data were entered into Microsoft Excel (Microsoft Corp) and analyzed using IBM SPSS ver. 21.0 (IBM Corp).

RESULTS

Table 1 presents the demographic and clinical characteristics of the study participants. Most patients were 20–40 years old (45.0%), followed closely by those aged 41–60 years (42.5%), while a smaller proportion were 61–80 years old (12.5%). The cohort consisted of 18 men (45.0%) and 22 women (55.0%), indicating a slight predominance of female participants.

With respect to the side of injury, right-sided ankle fractures were more common and accounted for 25 cases (62.5%), whereas left-sided injuries comprised 15 cases (37.5%). Regarding the mechanism of injury, slips and falls were the predominant cause (n=23, 57.5%), exceeding road traffic accidents (RTAs), which accounted for 17 cases (42.5%).

Analysis of fracture types showed that the supination-external rotation (SER) pattern was the most frequently observed (n=22, 55.0%). This was followed by pronation-abduction (PAB) fractures (n=7, 17.5%), pronation-external rotation (PER) fractures (n=6, 15.0%), and supination-adduction (SAD) fractures (n=5, 12.5%). Overall, these demographic and clinical data reflect a diverse patient population, with a higher prevalence of right-sided involvement and slips and falls as the most common mechanism, and SER as the predominant fracture pattern among individuals undergoing surgical treatment for bimalleolar ankle fractures.

The mean operative time was 1.31±0.17 hours and the mean duration of hospital stay was 4.20±0.94 days (Table 1).

Fig. 1 illustrates the time to union among the study participants. The average time to union was 14.70±2.20 weeks. Union was achieved within 12–14 weeks in 18 participants (45.0%), 15–17 weeks in 17 (42.5%), and 18–20 weeks in 5 (12.5%).

Table 2 presents the factors affecting the time to union among study participants. Age showed no significant effect on time to union (P=0.562). Sex demonstrated borderline significance (P=0.077), suggesting a potential influence on union time. Neither the side of injury nor fracture type significantly affected time to union (P=0.954 and P=0.130, respectively). Although sex showed a marginal association with union time (P=0.077), this trend did not reach statistical significance, and no clinical conclusions were drawn. Other variables, including age, side, and fracture type, were not significant predictors.

Fig. 2 presents the Baird-Jackson score outcomes for the study participants. Most patients, 28 (70.0%), achieved an excellent outcome, while 10 (25.0%) demonstrated a good outcome. Only two patients (5.0%) had a fair outcome. These results indicate that the majority of patients experienced favorable functional recovery following treatment.

In Fig. 3, the relationship between injury type and fracture union time demonstrates varied patterns across fracture categories. For PAB, most cases (57.1%) united within 15–17 weeks, with 14.3% uniting within 12–14 weeks and 28.6% within 18–20 weeks. In SAD, 60% achieved union in 12–14 weeks, 40% in 15–17 weeks, and none in 18–20 weeks. For SER, 50.0% of cases united within 12–14 weeks, 36.4% within 15–17 weeks, and 13.6% within 18–20 weeks. For PER, union times were evenly distributed, with 50% uniting in 12–14 weeks and 50% in 15–17 weeks, with none in 18–20 weeks. These results reflect differences in union times across fracture patterns, although statistical analysis confirmed no significant association.

As shown in Fig. 4, fractures with lower injury severity demonstrated a higher proportion of excellent and good outcomes compared to more complex patterns. For PAB, 57.1% had an excellent outcome, 28.6% had a good outcome, and 14.3% had a fair outcome. In SAD, 80% achieved an excellent outcome, 20% a good outcome, and none had a fair outcome. For SER, 72.7% achieved an excellent outcome, 22.7% a good outcome, and 4.5% a fair outcome. In PER, 66.7% demonstrated an excellent outcome, 33.3% a good outcome, and none a fair outcome.

Fig. 5 illustrates that patients sustaining low-energy RTA injuries achieved slightly better functional recovery compared to those injured through high-energy impacts. For RTA, most cases (76.5%) demonstrated an excellent outcome, 17.6% a good outcome, and 5.9% a fair outcome. For slips and falls, 65.2% achieved an excellent outcome, 30.4% a good outcome, and 4.3% a fair outcome. These results indicate favorable functional recovery across both injury mechanisms, with a slightly higher proportion of excellent outcomes in RTA cases.

Fig. 6 presents the complications observed among the study participants. A substantial majority (n=36, 90.0%), experienced no complications. Two participants (5.0%) developed superficial wound infections, and another two participants (5.0%) experienced implant prominence. These findings demonstrate that complications were relatively uncommon in the study population.

Overall, the results highlight the clinical relevance of achieving anatomical reduction and align with existing literature emphasizing the benefits of early mobilization.

DISCUSSION

This study highlights that the surgical treatment of bimalleolar fractures with internal fixation results in positive functional outcomes in most cases. In the majority of patients, anatomical reduction and proper alignment of the ankle mortise were successfully achieved, which facilitated early mobilization and rehabilitation. These factors are essential for promoting a favorable recovery process.

Age distribution

In this study, the mean age of the participants was 44.1±14.3 years. In comparison, Deshpande and Dudhanale [22] reported a mean age of 40.5 years for men and 37.1 years for women; Beris et al. [23] and Shah and Arif [24] reported mean ages of 30 and 37.4 years, respectively. These findings suggest that ankle fractures are more common in middle-aged individuals, likely due to active lifestyles combined with age-related decreases in bone density and balance.

Sex distribution

In this study, 45% of participants were male and 55% were female. In contrast, Deshpande and Dudhanale [22] reported that 80% of patients were male and 20% were female. Shah and Arif [24] observed a distribution of 60% male and 40% female, while Beris et al. [23] reported a higher proportion of women, with 38% male and 62% female. These variations indicate that the sex distribution of ankle fractures differs across studies, potentially reflecting differences in demographic characteristics or geographic factors.

Injuries

In this study, 63% of fractures occurred on the left side and 37% on the right. These findings are comparable to those of Deshpande and Dudhanale [22], who documented 62% of fractures on the left and 38% on the right. Conversely, Shah and Arif [24] reported a predominance of right-sided fractures (62.5%). Although the factors contributing to side dominance are unclear, this variability may relate to individual biomechanics or the specific mechanism of trauma.

Regarding the cause of injury, slip and fall injuries accounted for 58% of cases in this study, followed by RTA at 42%. Deshpande and Dudhanale [22] similarly found slips and falls to be the most common cause (60%), followed by self-falls (30%) and falls from height (10%). In contrast, Patel et al. [25] reported RTA as the leading mechanism in 63.3% of patients. These differences highlight substantial variability in injury patterns across studies, which may be influenced by regional factors, occupational exposures, and lifestyle differences.

Fracture classification

In this study, there were 7 PAB, 6 PER, 5 SAD, and 22 SER cases. In the study of Deshpande and Dudhanale [22], the classification showed a similar pattern, with 2 PAB, 7 PER, 3 SAD, and 18 SER cases. Although the relative frequencies vary slightly between studies, the overall distribution remains broadly comparable, with SER consistently observed as the most frequent fracture type.

Radiological outcomes

In this study, the average time to union was 14 weeks. Delayed surgery has been associated with complications such as infection and delayed union; however, these complications were minimized in the cohort described by Deshpande and Dudhanale [22] due to timely surgical intervention. This underscores the importance of prompt operative management to reduce complication rates and optimize healing.

The present study found no significant association between union time and age, sex, or the side of injury. Regression analysis indicated that age had no significant effect on union time (P=0.562). Sex showed borderline significance (P=0.077), suggesting a possible influence, although this did not reach statistical significance. Neither the area of injury nor the fracture type significantly affected the time to union (P=0.954 and P=0.130, respectively). These findings suggest that while sex may exert a minor influence, age, side of injury, and fracture pattern were not meaningful predictors of healing time in this cohort.

Functional outcomes

In terms of functional outcomes, 8 participants had an excellent outcome, 10 had a good outcome, and 2 had a fair outcome. In the study by Deshpande and Dudhanale [22], 40% of patients had an excellent outcome, 40% had a good outcome, 13.3% had a fair outcome, and 6.7% had a poor outcome. These findings are consistent with those of Shah and Arif [24], who documented excellent outcomes in 57.5% of cases. The consistently high rates of good-to-excellent outcomes across studies reinforce the importance of accurate anatomical reduction, stable fixation, and early mobilization in maximizing functional recovery.

Complications

In this study, a large majority of participants (36.9%) experienced no complications. Two participants (5%) developed superficial wound infections, and another two (5%) experienced implant prominence. These findings indicate that complications were relatively uncommon. In comparison, Deshpande and Dudhanale [22] reported a higher complication rate of 40%, including superficial infections (20%), deep infections (6.7%), nonunion (6.7%), lateral shift (3.3%), and talar shift (3.3%). Shah and Arif [24] similarly reported four superficial infections and one deep infection.

Despite these complications, approximately 90% of patients in these studies achieved favorable outcomes. These findings are consistent with prior literature showing high success rates with ORIF of bimalleolar fractures [25]. Stable fixation and early rehabilitation are essential for promoting optimal joint recovery and preventing long-term disability.

Limitations

No prior power calculation was undertaken, as this was an exploratory observational study; however, the sample size of 40 participants was adequate for descriptive and comparative purposes but limits broader generalizability. Several limitations should be acknowledged. First, the relatively small sample restricts extrapolation of the findings to the wider population of individuals with bimalleolar fractures. The single-center design may have introduced selection bias, limiting external validity. Additionally, the observational nature of the study precludes randomization and may allow unmeasured confounding variables to influence outcomes. The 24-week follow-up period, while adequate for short- to medium-term evaluation, may not capture long-term complications or functional deficits. Furthermore, the study relied on the Baird-Jackson scoring system, which, although validated, may not fully encompass patient-reported outcomes or health-related quality-of-life measures. Future studies with larger, multicenter cohorts and longer follow-up durations are recommended to validate these findings and to better define factors influencing recovery after bimalleolar ankle fractures. Longer-term follow-up beyond 12 months would help identify later complications such as posttraumatic arthritis or implant-related discomfort. Incorporating patient-reported outcome measures, such as the Foot and Ankle Disability Index or 12-Item Short Form Survey, may provide additional insight into subjective recovery and quality of life.

Conclusions

This study assessed the clinical, radiological, and functional outcomes of patients with bimalleolar ankle fractures treated with ORIF. The findings indicate that most patients experienced favorable functional recovery, with the majority achieving excellent or good outcomes and an average union time of 14 weeks. No significant associations were found between union time and factors such as age, sex, or fracture side. Postoperative complications were infrequent, occurring primarily as superficial infections or implant prominence. These results suggest that accurate anatomical reduction, stable fixation, and early mobilization play important roles in supporting recovery following ORIF for bimalleolar fractures. The outcomes observed in this study are consistent with existing evidence and emphasize the value of ORIF and timely rehabilitation in achieving satisfactory post-injury function.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Data curation: RS, MASN; Formal analysis: HAS; Investigation: KVSV, VS, RS; Methodology: MASN, HAS, VS; Project administration: KVSV, VS; Resources: KVSV, VS, RS, MASN; Supervision: KVSV, VS; Validation: VS, HAS; Visualization: KVSV, VS, HAS; Writing–original draft: RS, HAS; Writing–review & editing: KVSV, VS, HAS; All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Distribution of time of union.

Fig. 2.

Baird-Jackson score outcomes.

Fig. 3.

Relationship between type of injury and fracture union time. PAB, pronation-abduction; SAD, supination-abduction; SER, supination-external rotation; PER, pronation-external rotation.

Fig. 4.

Relationship between type of injury and functional outcome. PAB, pronation-abduction; SAD, supination-abduction; SER, supination-external rotation; PER, pronation-external rotation.

Fig. 5.

Relationship between mechanism of injury and functional outcomes. RTA, road traffic accident.

Fig. 6.

Complications among study participants.

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References

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