ABSTRACT
The weakened mechanical strength of bone, as well as the suboptimal biology, may jeopardize the results of a traditional approach to ankle fractures in elderly patients. A different strategy should be considered for ankle fractures in patients with poor bone quality and osteoporosis. Previous osteoporotic fractures, insufficient trauma with or without a pronation abduction mechanism may be indicative of an osteoporotic ankle fracture. Stable and close osteoporotic ankle fractures should be treated conservatively in nonambulatory or demented individuals and in patients with multiple comorbidities; close follow-up is warranted due to the risk of loss of fixation. Internal or external fixation, provisional or auxiliary fixation with Steinmann pins, as well as ankle arthrodesis are valid alternatives for operative cases. Currently, there is not sufficient evidence to support the widespread use of locking plates for the management of osteoporotic ankle fractures. Multiple syndesmotic screws (comb technique) can compensate for unsatisfactory fixation of the lateral malleolus due to poor bone stock. Cement augmentation is an alternative that can be considered to improve screw grip strength. Tension band fixation of the medial malleolus and one-screw fixation for smaller fragments yield good results. In addition, intramedullary fixation of the lateral malleolus, although technically demanding, might achieve anatomical reduction and works well for patients with risks for wound healing complications. Arthrodesis of the hindfoot and ankle with a retrograde nail can be used as a salvage procedure for severe osteoporotic ankle fractures. In summary, the personality of the fracture, patient comorbidities, and the quality of bone stock, should shape the treatment plan in patients with osteoporotic ankle fractures.
