Surgery for Ankle Fracture

What is Surgery for Ankle Fracture?

If you have a serious or unstable ankle fracture, your surgeon may decide a cast will not be enough to help your bones heal. He or she will then discuss with you your need to have surgery.

Surgery for ankle fractures usually involves ‘open reduction and internal fixation’. This is a term used by doctors and surgeons to describe operations where the skin is cut to reach the fractured bones (‘open’), the bones are re-aligned (‘reduction’), and screws or plates are used to keep the fragments of bones together (‘fixation’).

Your surgeon may also need to repair other tissues around your ankle, including tendons and muscles that may have been torn during your injury.

Surgery can take 30 mins to several hours, depending on the type of fracture and any complications that arise during surgery. Usually, you will be under general anaesthetic or asleep.

The rehabilitation after ankle fractures can take anywhere between twelve to twenty-four weeks, depending on how severe the breaks are and how well the bones heal. During this time, your physio and surgeon will recommend exercises for you and ask you to gradually increase how much weight you place on your foot.

Who is this operation for?

Only those fractures which are too unstable to heal within a cast are recommended for surgery. Subtle fractures and breaks where the bones do not move apart (undisplaced) can be treated with immobilisation in a cast or walking boot.

Aside from this, your surgeon will only recommend an operation if he/she thinks you can withstand the stress of surgery. Some things you may need to discuss with your medical team include:

  • Heart or lung conditions. If you have underlying disease affecting your heart or lungs you may require extra care and even extra tests to ensure you will be able to keep breathing while under general anaesthetic.
  • Blood supply to your injured ankle. Some people, in particular diabetics and smokers, have poor blood vessels in their legs. This may make your surgeon concerned about the ability of your ankle to heal after the operation. In general, only those with very bad blood vessels will not be able to have surgery.

What are the benefits of the operation?

Surgery to repair fractures is often very successful and provides good stability and functionality of the joint in the future*. Your surgeon aims to provide you with an ankle that is just as flexible and strong as your uninjured ankle, and you to get back to all your former activities, including running and sports.

*The likely outcomes of surgery will vary depending on the severity of the fracture. A shattered ankle (‘comminuted’) with multiple fragments of bone is less likely to return to normal function than an ankle with only two fracture lines. You should discuss the likely outcomes in your case with your surgeon, both before and after you have the surgery.

Risks of not having the surgery

Ankles that are healed with a cast only tend to have higher rates of post-traumatic arthritis and are more likely to have ongoing stiffness and pain.

What if I can’t have an operation?

Sometimes it’s not possible for you to have an operation. When this occurs your surgeons can still help stabilise your ankle and relieve your pain by correcting the position of the bones then applying a cast. When this is done, you will need to return to your surgeon’s office for review X-Rays to check the bones have not moved. If, after a month, the bones are healing well and have not moved the cast can be removed.

During the time you are wearing the cast, you will not be able to put any weight on your foot at all, and will need to keep your leg elevated as often as possible.

Complications

After any fracture, there is a risk that there will be long-term stiffness and decreased function in the joint. In ankle fractures, there is also a risk of arthritis developing later in life. Other complications of ankle fractures include:

  • Instability – this can be in the ankle joint itself, resulting in a tendency to dislocate the ankle, or in the set of ligaments on the outer surface. This can lead to recurrent sprains and strains of the ankle, or ‘Chronic Ankle Instability’.

The risks and complications of surgery include:

  • Infection. In any surgery, there is a risk that the incision or underlying tissue may become infected. If the skin overlying your ankle has become broken during the fracture the risk of infection is much higher. Your surgeon will prescribe antibiotics to help prevent infection developing, and any signs of redness, swelling and fever will be watched carefully by the doctors caring for you. Rarely, infection can develop in the bone causing osteomyelitis.
  • Bleeding. There is usually minimal bleeding during surgery for ankle fractures. Your surgeon may however discuss the possibility of needing blood transfusions during the operation to replace lost blood, but this is unusual.
  • Blood clots (DVT).
  • Compartment Syndrome. This occurs when swelling around the ankle compresses blood vessels and nerves leading to injury to the muscles in the foot. It is extremely painful and may require further surgery (fasciotomy) to relieve the swelling. It is fortunately very rare in ankle fractures, especially when the injured foot has been kept elevated to reduce swelling and the cast has been reviewed.

Before the operation

If you come in to the Emergency Department, the ED doctors will make sure you are stable, perhaps giving you some fluids and oxygen as well as pain relief, before sending you to get X-Rays of your foot.

The orthopaedic surgeons will need to see you to assess your ankle and your general health before deciding if you can be taken straight to surgery. Some tests that may be ordered to check you’re fit for surgery include:

  • Blood tests
  • Chest X-Ray
  • Urine test
  • ECG

If your fracture is complicated by breaks in the skin or infection you may need to have wash outs of your wound in the emergency department before surgery is considered.

You will be asked not to eat anything until the plan for surgery is confirmed. In the meantime, you will be kept comfortable and possibly taken up to the ward.

Tip

Carry a list of your medications with you including the name, dosage and how often you take it

Make sure you tell your doctor if you:

  • Have heart, lung or blood conditions
  • Have ever taken prednisolone or other steroids
  • If you are taking warfarin or aspirin

About the Operation

The exact details of the operation will vary depending on the type and severity of your fracture. Often the most important point is whether or not your fracture has been open (with the skin broken by the accident) or closed (skin intact) as this will have a major impact on when your surgery can be done.

  • Open fractures. When your surgeon is concerned about the condition of your skin and soft tissue, he or she may need to delay your surgery until your wound is clean and the swelling has gone down. While waiting for this, you will need a metal framework placed around your leg to hold the fractured bones in place. This is called ‘external fixation‘. Once the skin is ready, internal fixation can be done to finally fix the fracture.
  • Closed fractures. If your surgeon is satisfied that your ankle is ready, you can go straight to the operating theatre to have ‘internal fixation‘. In this type of operation, your surgeon opens your ankle, places screws across the fractured bones then stitches your skin closed and puts on a cast.

However some common components of surgery include:

  • Hardware – including screws, plates and K-wires. Orthopaedic hardware is used to hold bones in position while they heal. Some hardware, like K-wires, may be designed to be removed once the bones have healed. Often, hardware needs to be left in the body permanently.
  • Repair of soft tissues – any tendons, ligaments and muscles around the joint that have been injured may require specific repair. This can involve stitching torn tissue back together, or trimming away damaged or infected tissue.

The surgical process itself will involve taking you to the operating theatre and putting you to sleep (general anaesthetic). Your surgeon will then make a cut (incision) in your skin and carefully part the soft tissues to reach the bone. From here, he or she can look at the soft tissues around the bones before positioning hardware that will join the bones together.

The position and type of hardware used will vary. In simpler fractures, a number of screws and K-wires can be drilled through the ankle bones. In more complicated fractures, your surgeon may need to use ‘plates’. These are flat pieces of metal that are lined up along the bone. Small screws are then drilled through the plate into the bone to hold it in place.

After the Operation

After you wake up from the general anaesthetic you will be taken back to the ward. At this time, pain killers from the operation will still be working, keeping your leg numb and pain free. Depending on the type of fracture, your surgeon may have applied a cast during the surgery or have wrapped thick bulky bandages around your ankle.

Once you are back on the ward, you will be asked to keep your leg elevated as much as possible. You may also be asked to wear thick white stockings to prevent blood clots forming in your leg (DVT).

You should be able to eat and drink very soon after the operation, however you may feel nauseous from the anaesthetic. Once you’re ready, you will be encouraged to get up and move around (without putting weight on your foot).

Before you are discharged from hospital, your doctors need to be satisfied you can take care of yourself, including getting to the bathroom and eating and drinking.

What about pain?

Once the anaesthetic has worn off completely (after about 24 hours), you will be given a combination of drugs to keep you comfortable. These can sometimes make you nauseous or constipated, however your doctors can prescribe medications to help with this too.

You will be given a prescription for pain tablets when you leave the hospital. Your doctor may also recommend using over-the-counter pain relief like panadol and nurofen to supplement the prescription medication.

Recovery and Rehabilitation

Your recovery and rehabilitation will depend on the type of fracture and the method used to treat it.

You should expect a number of weeks of rehabilitation and gradual return to normal walking. However, even after the period of formal rehabilitation you should be careful with your ankle and avoid putting major stresses across the joint.

In the first two weeks after surgery

During your first week, you should try to keep your leg elevated as much as possible to reduce the swelling in your foot. This may mean placing a number of pillows under your foot while you sleep to keep your ankle high.

While on the ward and at home, you should not put any weight on your injured leg at all. Your physio will give you crutches and show you how to walk and get up and down stairs without putting any weight through your injured ankle.

You can begin to wriggle your toes and stretch and flex your knee to keep the joints supple. After the first week, your physio may recommend a series of exercises for your toes. These help to stretch and strengthen muscles that run just above and beside your ankle. Your physio may also recommend exercises to keep the muscles in your thigh active and strong.

Warn your surgeon/physio if you notice:

  • Your toes tingling or turing blue
  • Tingling around the top of the cast near your knee
  • Extreme or worsening pain in the ankle
  • Any rubbing or irritation from your cast

Your surgeon may ask you to return for a follow-up appointment after the first or second week. At this session, your surgeon can:

  • Assess your comfort and make sure the cast is placed correctly
  • Take review X-Rays to check that the bones are still in the correct position and the hardward has not moved or become loose.
  • Depending on when the XRays are taken, your surgeon may be able to tell if the bones are beginning to heal.

After four weeks

At this stage, the bone has healed significantly but is still not as strong as normal bone. This means that:

  • You may be able to switch to a different cast or to a walking boot.
    • If your fracture is minor you may be taken out of the cast altogether.
  • If you are taken out of a cast, you may be able to begin carefully flexing and extending your ankle – make sure you do not force yourself to stretch beyond what your joint can tolerate.
  • Some patients may be able to being partial weight-bearing. This means leaning against a table, chair or walking aid and carefully transferring some of your weight onto the toes of your injured foot.
    • You must not begin doing this unless your surgeon and physio have advised that it is safe.
    • If you are able to begin weight-bearing, your physio may show you a new way of using your crutches that transfers some of your weight to your injured leg each time you take a step.

Your surgeon will take this opportunity to look over your ankle for any signs of skin infection or damage to blood vessels and nerves.

After six-eight weeks

At this point your ankle will be much more stable, and you will be able to gradually begin or increase your level of weight-bearing and remove your cast/walking boot.

Your physio will teach you new exercises to further stretch the joints and keep the muscles in your leg strong. These may include proprioceptive exercises (see exercises in phyiotherapy), or exercises designed to retrain your body to balance.

When will I finish rehabilitation?

Generally, patients finish formal rehabilitation after 12 weeks. This is only when XRays have demonstrated adequate healing of the bones and your physio is satisfied with your progress.

The end of rehabilitation does not automatically equal a return to full function. Over the months following your surgery, you should notice an ongoing improvement in the strength and function of your ankle.

F.A.Q.s | Frequently Asked Questions

When can I return to sports?

This is a question you will need to discuss with your surgeon and physio. In general, rehabilitation following ankle surgery takes around 12 weeks, however you may need to avoid major stressors to your ankle for some time after this.

Bone normally takes around twelve weeks to heal properly, but the process of strengthening new bone can take months.

Are there important things I need to tell my doctors?

  • Redness, swelling or warmth around the cut
  • Leakage from the cut
  • Fever and chills.
  • Further surgery planned for the future i.e. dental work, bladder catheterisation, examinations of the bowel, bladder, rectum or stomach.