Management of ankle fractures. Long-term results and intramedullary nailing of high risk patients

Thesis event information

Date and time of the thesis defence

Place of the thesis defence

Oulu University Hospital, Lecture Hall 1, Zoom link:

Topic of the dissertation

Management of ankle fractures. Long-term results and intramedullary nailing of high risk patients

Doctoral candidate

Licentiate of Medicine, M.D. Sini Karkkola

Faculty and unit

University of Oulu Graduate School, Faculty of Medicine, Orthopaedics and traumatology

Subject of study

Orthopaedics and traumatology


Docent Minna Laitinen, University of Helsinki


Professor Juhana Leppilahti, University of Oulu

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Management of ankle fractures. Long-term results and intramedullary nailing of high risk patients.

Deciding between surgery and nonoperative treatment is a key question when evaluating patients with ankle fractures. In short-term follow-up, the stability-based classification can reliably predict the need for surgery, but little is known of possible long-term problems.

When surgery is needed, older patients with comorbidities pose a particular challenge, as high rates of complications are associated with plate fixation. The introduction of mini-invasive fibular intramedullary nailing (IMN) has lowered the complication rates, but the efficacy of IMN in high-risk patients remains uncertain.

The aims of this thesis were 1) to assess the long-term functional and radiological outcomes, complications and development of osteoarthritis (OA) after stability-based treatment of ankle fractures; 2) to assess the long-term functional outcomes after treatment of isolated medial malleolar fractures (IMMF); and 3) to evaluate the safety of fibular IMN in patients at high risk for wound complications.

The primary outcome measure was the Olerud-Molander Ankle Score (OMAS) and secondary outcome measures included the RAND 36 health questionnaire and complication rates. After a mean follow-up of 12 years, the mean OMAS was 92 for 85 patients with stable ankle fractures treated nonoperatively and 84 for 75 patients treated surgically. No patients with fractures deemed stable needed surgery during follow-up. Development of OA was common (56%) in patients with unstable fractures.

After a mean of 9.5 years after treatment of 113 patients with IMMF, the mean OMAS was 87 for nonoperatively and 85 for operatively treated patients, but the initial fracture displacement (≥ 2 mm) was an independent risk factor for lower scores in both groups. The quality of life was similar to the normal population in both studies. No infection complications occurred after a minimum of 2 years of follow-up in 41 high-risk ankle fracture patients treated by meticulous soft tissue evaluation, possible staged treatment with additional soft tissue procedures and IMN.

In conclusion, the stability classification reliably guides the choice between operative and nonoperative treatments. Unstable fractures and IMMFs with > 2 mm displacement are more severe injuries and have poorer functional outcomes. Fibular IMN with possible staged treatment provides a safe choice for high-risk patients if surgery is needed.
Last updated: 1.3.2023